Events

Lunch will be provided. RSVPs are not required, please email Anna Adelman with any questions

Over the last decade, the United States has fairly aggressively swung away from the rather free attitude towards opioid prescribing of the late 1990s and early 2000s towards a more restrictionist model in response to the “opioid epidemic.” Guidelines for prescribing opioids have tended to focus on acute pain and chronic, non-cancer pain. Cancer pain, however, has often been overlooked in guidelines. This panel will discuss that “cancer exceptionalism” concerning opioid prescribing leads to very different care in the two example cases.

Case 1
Jon is a 25-year-old graduate student recently diagnosed with relapsed metastatic bone cancer after he developed significant bony pain and shortness of breath. Jon opted to enroll in an early phase clinical trial investigating the role of a novel targeted agent. Jon’s pain is being aggressively treated by his oncologist and a dedicated palliative care team. Due to disease progression, Jon now has worsening pain and new areas of pain. As a result, he has found it challenging to attend graduate seminars and spend meaningful time with his family and friends. Jon is promptly seen by the members of his care team and prescribed a long-acting fentanyl patch with short-acting oxycodone for breakthrough pain. Additionally, non-opioid medications are rotated, and an appointment with an acupuncturist is coordinated. During the visit, the oncology social worker meets with Jon to provide psychosocial support and various outpatient and community resources.

Case 2
James is a self-employed, 25-year-old with sickle cell disease (SCD) complicated by significant avascular necrosis (AVN) of the hips and shoulder resulting in disability and pain. James is committed to growing his business and not to be deterred by SCD. His job requires that he be on his feet and carry heavy objects for many hours a day. James’ SCD is being managed with hydroxyurea and L-glutamine. Despite excellent medication adherence with improved laboratory markers, lately, James has endured intense bony and joint pains involving both the hips and shoulder.

Given his increased pain, James reluctantly goes to the emergency department (ED) affiliated with the hospital where he receives sickle cell care, hopeful that his acute on chronic pain can be effectively treated allowing him to return to work. When he is seen by the ED physician, James shares that in addition to ketorolac, an intravenous non-steroidal anti-inflammatory (NSAID), his pain most effectively responds to 5 mg intravenous morphine sulfate. He also shares that based upon his current level of pain, for his pain to adequately improve to allow him to be discharged and to get back to work, he likely will require several doses of intravenous morphine. He suggests to the ED physician that checking the EMR for the physician-approved individual pain plan would be ideal. The physician returns to his workstation, noting to a colleague his concern that in asking for specific medications and doses, James may be “drug-seeking.” The physician orders a dose of oral ibuprofen and oxycodone. Following the oral pain medications, James’ pain intensifies. Ultimately, an IV is placed and James receives ketorolac and two 3 mg doses of intravenous morphine. Due to unrelenting pain, James is hospitalized for ongoing care.

Questions

1. What is cancer exceptionalism?
2. Is cancer pain different than other forms of pain?
3. How do sociocultural accounts of cancer influence approaches to treating cancer pain?
4. Should responsible opioid prescribing guidelines differ by medical specialty?

Objectives

1. Analyze the effect of America’s opioid epidemic for patients suffering from cancer pain
2. Articulate the concept of “cancer exceptionalism”
3. Apply responsible opioid prescribing to patients suffering from cancer pain
4. Recognize that pain should be treated responsibly and appropriately irrespective of a patient’s diagnosis