No Disease, Chronic Pain, High Dose Opioids…What Do We Do?

Topic: Specific Patient Populations

Introduction:

Outpatient palliative care clinics are often expected to manage a broad spectrum of oncology patients. Oncology patients who have completed disease –specific treatment and no longer have any evidence of disease, present a particular challenge to the palliative care practitioner, especially with regard to their chronic opioid management. Typically, neuropathic pain related to surgery or chemotherapy is their predominant symptom complaint. The neuropathic pain experienced by patients may also be complicated by pre-existing chronic pain syndromes and a history of ‘chemical coping’.

Simply transitioning these patients to their primary care provider (PCP) or a chronic pain specialist may not be possible for a variety of factors. PCP’s may be reluctant to assume the responsibility of chronic pain management because they lack training ; are concerned about the medico-legal risks of prescribing opioids; or have time constraints . Our institution has additional challenges, including the absence of a robust chronic pain service, and community based pain clinics that focus on providing only interventional pain procedures. There are other social and financial barriers preventing our patients from obtaining access to the appropriate care. Many are un-insured or indigent, lack transportation or have a history of substance misuse.  We describe a case series of oncology patients managed in our ambulatory care clinic for chronic pain, with no evidence of disease, and complex psychosocial issues.

Methods:

A case series of 7 oncology patients (4 female, 3 male Caucasians), mean age 35 years, with no evidence of disease ≥ 12 months. Edmonton Symptom Assessment System (ESAS) scores at initial visit and last visit, morphine equivalent dose were analyzed.

Results:

Six patients unemployed, one employed without insurance coverage. Their chronic pain was described as arthralgia, odynophagia, myalgia, or neuropathic pain. All 7 patients had complex psychosocial issues including poor family support, marital or child custody problems, poor financial resources, or the recent death of spouse. All had documented depression and/or anxiety. Four of the seven had past and/or present polysubstance abuse. Initial Morphine Equivalent Daily Dose (MEDD) ranged 60mg to 1200mg, average 552mg. ESAS pain scores ranged 4 to 8/ 10 (average 6/10). An individualized plan was initiated for every patient and included access to an interdisciplinary team (psychologist, physical therapist, registered nurse, physician and nurse practitioner).By their last visit, patients’ MEDD range was 0 to 1035mg, median of 25mg. Pain ranged 0 to 8/ 10, average 4 /10. Four of the 7 were able to stop taking opioids with pain scores of 0/10. The other 3 had reductions. Average time between first and last visit was 4.14 months.     

Conclusions:
Oncology patients with no evidence of disease may be on high dose opioids, express high symptom burden, and experience a number of complex psychosocial issues. Although it is debatable whether the palliative care clinic is the optimal site for managing these patients, our case series shows that an interdisciplinary approach can successfully decrease opioid doses, and reduce pain even in those patients with a history of substance abuse.

Author

  • Wendy E. Thompson, NP
  • Virginia Commonwealth University Health System
  • 1250 E Marshall Street
  • Richmond, VA 23284
  • (804) 914-0074

Co-authors

  • Egidio Del Fabbro, MD
  • Hope Barner, RN
  • Jessica Tsukanov, DO
  • Wendy Thompson, NP

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