Pain is one of the most common symptoms experienced by patients with cancer, occurring in 20% to 50% of patients and often negatively impacting the individuals’ functional status and quality of life.1,2 Cancer pain can be caused by a variety of factors, including the underlying malignancy, cancer therapy, supportive care therapies, and diagnostic procedures. Approximately 80% of patients with advanced cancer experience moderate to severe pain, and typically require opioid therapy.1,3 Cancer-related pain also impacts disease survivors; 20% to 50% of patients report they continue to experience pain and functional limitations years after treatment.1,4,5
Untreated pain may lead to unnecessary hospital admissions and emergency department (ED) visits.1,6 Conversely, appropriate management of symptoms, including pain control, is associated with improved survival and can reduce unnecessary ED visits and hospital admissions. Pharmacists should play a pivotal role in managing pain in patients with cancer, in both the inpatient and outpatient settings. A pharmacist’s expertise is required for opioid medication selection, dosing and titration, drug-interaction evaluations, use of unique formulations/delivery methods, side effect management, counseling, and throughout transitions of care.
The Outpatient Setting
The outpatient practice setting offers flexibility in the various ways a pharmacist can be involved in cancer pain management. Pharmacists engaged in ambulatory practice can play an important role in optimizing medication therapy, monitoring outcomes, educating patients, and enhancing adherence.7
In the clinic, a pharmacist may be responsible for conducting comprehensive patient assessments to determine if opioid therapy is appropriate, as well as assessing the patient’s risk of nonadherence and abuse potential. It is critical to review the Prescription Drug Monitoring Program (PDMP) to verify other medications a patient is receiving and to ensure that they are only receiving opioid prescriptions from providers at one clinic. Because patients may see different providers at each clinic visit, it is critical to balance appropriate patient access to medications while minimizing the chances of misuse and abuse of high-risk opioid medications.
Medication Management and Monitoring Plan
Pharmacists should be involved in developing an opioid management and monitoring plan, including ensuring medication compliance, developing and reviewing pain contracts with patients, and implementing toxicology screens. In states where medical marijuana is legal, pharmacists and providers should discuss whether a patient is allowed to use marijuana to manage pain. Data indicates that patients are using marijuana to manage pain, and also that patients using marijuana may use fewer opioid medications.8,9
Ensuring Medication Access
Cancer pain is often managed with high doses and large quantities of opioid medications. Insurance restrictions on medication quantities, limited formulary options, and a preference for abuse-deterrent formulations are common barriers to medication access in the ambulatory setting (see TABLE 1 for a complete list of barriers). The pharmacist should play an integral role in ensuring access to opioid medications, and when necessary, conversion to different formulations or products that are on a patient’s insurance medication benefit plan. A continual line of communication between the clinic and the dispensing pharmacist is critical to address prior authorizations and any concerns or issues that arise.
Patients must receive appropriate counseling on safe use, handling, and disposal of opioid medications, as well as side effects, to ensure adherence to the treatment regimen. Counseling also should address any patient concerns or fears about using opioid medications to manage their pain. In situations where clinic staff lacks experience with a particular medication, such as methadone, a patient may be referred to the palliative care clinic to assist with pain management. Patients with a history of opioid abuse and misuse may also be referred to these specialists.10,11
The Inpatient Environment
Pharmacists in the inpatient setting have both operational and clinical roles in the management of cancer pain. Developing policies and procedures (P&Ps) and institutional opioid formularies are central to pharmacists’ operational responsibilities in the inpatient environment. Standardized products and unit dose packaging, as well as opioid prescribing and storage P&Ps, control costs and improve patient safety. Clinical duties encompass pain management, drug conversion, dose titration, and PCA and implanted pain pump management. (See TABLE 2 for considerations in opioid policies.)
Clinically, inpatient pharmacists play an active role in managing patients with acute pain crises or uncontrolled pain. Pharmacists are often the most adept providers at identifying what pain regimen the patient was on before admission, which is essential to determine both safe and efficacious opioid initiation within the hospital. The process often requires patient/caregiver interviews, review of pharmacy/medical records, and/or PDMP investigation. The use of PDMP in the inpatient environment not only identifies aberrant behavior, but also can identify the most up-to-date prescription history for patients who are unable to communicate.12
Many institutions do not allow patients to use their own opioid supply while in the hospital due to safety, storage, and liability concerns. For patients adequately maintained on a home pain regimen, it often falls to the pharmacist to convert a patient from their home products to the institution’s preferred formulary medications. New brand name opioid products on the market, such as Xtampza ER, which is not bioequivalent to oxycodone extended release tablets, require careful review when converting medications.13
Treating pain in a monitored setting, such as a hospital, allows for a rapid titration or analgesics. To ensure patient safety, pharmacists should be involved in calculating, double-checking, and verifying all opioid dose adjustments. The use of adjuvant analgesics, such as ketamine, lidocaine, and methadone, also warrants pharmacist involvement. Pharmacist review of drug-drug interactions (DDIs), lab and vital sign monitoring, and dose titration are important prior to and throughout therapy.
PCA and Implanted Pain Pump Management
It is not uncommon for patients with cancer to be on PCAs or implanted pain pumps at home. Inpatient pharmacy departments should have a protocol in place to streamline the process for continuing these devices when a patient is admitted. Pharmacists play a significant role in identifying the patient’s current PCA settings, developing an inpatient PCA plan, and coordinating the transition between the patient’s own device and the institutional device. While PCAs may be easily switched out for hospital devices, implanted pain pump management is significantly more complex. The pharmacist’s role in managing these devices often includes developing methods to make hospital staff aware of the device and the current settings, through placeholder medication builds or chart notes.
Transitions of Care
Even with optimal pain management within the clinic and inpatient setting, a patient’s transition between home, hospital, care facility, and hospice can be fraught with error. Pharmacists can reduce the risk of error through medication reconciliation, PDMP participation, and patient education.14 Appropriate medication reconciliation should be completed at every clinic visit, hospital admission and discharge, and facility stay to ensure accurate and timely documentation of pain regimens. With the increasing connectivity of electronic medical records (EMRs), complete medication reconciliation may now allow providers from a multitude of practice areas to safely provide care for a single patient.15 When EMRs are not available, PDMPs may provide necessary opioid histories. Lastly, continued patient and caregiver education may help ease transitions of care. Giving patients the tools to understand their medication regimens and side effects, and providing useful resources, can allow them to be their own advocates and often be the first person to identify errors.
Patients with cancer often require opioids to manage their pain, and the need for opioids may persist into the survivorship setting as well. To minimize inadequate prescribing as well as inappropriate use by patients, pharmacists should be involved in opioid management, regardless of the practice setting. Pharmacists may assist with patient assessment and counseling, rational prescribing, opioid dispensing and monitoring, toxicology screening, pain contract management, policy development, interdisciplinary pain committee involvement, and education of health care professionals.
Ashley E. Glode, PharmD, BCOP, graduated from Duquesne University School of Pharmacy in 2007 and is an assistant professor at the University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences. She works in the outpatient phase of the I/GI/sarcoma/head and neck clinic, providing patient education and clinical consults for cancer patients receiving standard of care or study treatment. Ashley teaches at the School of Pharmacy and conducts scholarly activity. Her professional interests include the use of complementary and alternative medicine, the pharmacist’s role in optimizing supportive care, and patient education.
Sarah Norskog, PharmD, BCOP, graduated from the University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences in 2014 and is an oncology clinical pharmacy specialist at the University of Colorado Hospital. She is a clinical pharmacy specialist for the Inpatient Medical Oncology Service and works with oncologists, hospitalists, and nursing to optimize medication therapy for patients with solid tumors admitted to the hospital. Sarah provides patient education and coordination of chemotherapy and also serves as the primary pharmacist for the palliative care service. Her professional interests include palliative care, immunotherapy toxicity management, and sarcoma.
- PDQ Supportive and Palliative Care Editorial Board. PDQ Cancer Pain. Bethesda, MD: National Cancer Institute. Updated August 30, 2017. www.ncbi.nlm.nih.gov/books/NBK65949. Accessed January 22, 2018.
- Fischer DJ, Villines D, Kim YO, et al. Anxiety, depression, and pain: differences by primary cancer. Support Care Cancer. 2010;18(7):801-810.
- Bruera E, Kim HN. Cancer pain. J Am Med Assoc. 2003;290(18):2476-2479.
- van den Beuken-van Everdingen MH, de Rijke JM, Kessels AG, et al. Prevalence of pain in patients with cancer: a systematic review of the past 40 years. Ann Oncol. 2007;18(9):1437-1449.
- Harrington CB, Hansen JA, Moskowitz M, et al. It’s not over when it’s over: long-term symptoms in cancer survivors—a systematic review. Int J Psychiatry Med. 2010;40(2):163-181.
- Mayer DK, Travers D, Wyss A, et al. Why do patients with cancer visit emergency departments? Results of a 2008 population study in North Carolina. J Clin Oncol. 2011;29(19):2683-2688.
- Ratka A. The role of a pharmacist in ambulatory cancer pain management. Curr Pain Headache Reports. 2002;6(3):191-196.
- Pergam SA, Woodfield MC, Lee CM, et al. Cannabis use among patients at a comprehensive cancer center in a state with legalized medicinal and recreational use. Cancer. 2017;123(22):4488-4497.
- Bradford AC, Bradford WD. Medical marijuana laws reduce prescription medication use in Medicare Part D. Health Affairs. 2016;35(7):1230-1236.
- Levy MH, Samuel TA. Management of cancer pain. Semin Oncol. 2005;32(2):179-193.
- Paice JA, Ferrell B. The management of cancer pain. CA Cancer J Clin. 2011;61(3):157-182.
- United States. Dept. of Health and Human Services. Centers for Disease Control and Prevention. Fact Sheet: Prescription Drug Monitoring Programs (PDMP). Centers for Disease Control and Prevention, August 2017. Web. 12 October 2017.
- Xtampza ER (oxycodone) [package insert]. Collegium Pharmaceuticals Inc: Canton, MA; 2017.
- Sourial M, Lese MD. The pharmacist’s role in pain management during transitions of care. US Pharm. 2017;42(8):HS-17-HS-28.
- King, J., Patel, V., Jamoom, E. W. et al. Clinical Benefits of Electronic Health Record Use: National Findings. Health Serv Res. 2014;49: 392–404.
Aberrant Behavior: A behavior outside the boundaries of the agreed-upon treatment plan that is established as early as possible in the doctor-patient relationship.
Abuse: A maladaptive pattern of prescription opioid use leading to clinically significant impairment and/or distress.
Addiction: Aberrant use of a controlled substance characterized by loss of control, compulsive use, preoccupation, and continued use despite harm.
Chemical Coping: The use of opioids to cope with emotional distress, characterized by inappropriate and/or excessive opioid use.
Diversion: Redirection of a prescription drug from its intended user to another individual.
Misuse: Inappropriate use of a drug, whether deliberate or unintentional.
Opioid-Induced Hyperalgesia: Paradoxical worsening of pain caused by treatment of pain with opioids; potential cause of loss of efficacy of opioids.
Physical Dependence: Condition in which abrupt termination of drug use causes withdrawal syndrome.
Pseudo-Addiction: Condition characterized by behaviors such as drug hoarding that mimic addiction but are driven by a desire for pain relief; usually signals undertreated pain or anxiety that future pain will be untreated.
Self-Medication: Use of a drug without consulting a health care professional to alleviate stressors or disorders such as depression or anxiety.
Substance Abuse: Maladaptive pattern of substance use leading to considerable impairment or distress.
Tolerance: Phenomenon in which analgesia decreases as the body grows tolerant to a given dosage of a drug, requiring an increased dose to achieve the same analgesic effect.
1. PDQ Supportive and Palliative Care Editorial Board. PDQ Cancer Pain. Bethesda, MD: National Cancer Institute. Updated August 30, 2017. www.ncbi.nlm.nih.gov/books/NBK65949. Accessed January 22, 2018.
2. National Comprehensive Cancer Network (NCCN). Clinical Practice Guidelines in Oncology. Adult Cancer Pain. Updated May 10, 2017. www.nccn.org/professionals/physician_gls/default.aspx. Accessed January 22, 2018.
3. Jackson LH, Iman SN, Braun UK. Opioids in cancer pain: right or privilege? J Oncol Practice. 2017;13(9):e809-e814.
Recommended Reading and Resources
Drug Enforcement Administration (DEA). Diversion Control Division. www.deadiversion.usdoj.gov. Accessed January 22, 2018.
Food and Drug Administration. Extended-Release (ER) and Long-Acting (LA) Opioid Analgesics Risk Evaluation and Mitigation Strategy (REMS). http://er-la-opioidrems.com/IwgUI/rems/home.action. Accessed January 22, 2018.
Kochhar R, Legrand SB, Walsh D, et al. Opioids in cancer pain: common dosing errors. Oncology (Williston Park). 2003;17(4):571-575;575-576,579.
Levy MH, Chwistek M, Mehta RS. Management of chronic pain in cancer survivors. Cancer J. 2008;14(6):401-409.
Levy MH, Samuel TA. Management of cancer pain. Semin Oncol. 2005;32(2):179-193.
National Alliance for Model State Drug Laws (NAMSDL). www.namsdl.org. Accessed January 22, 2018.
National Comprehensive Cancer Network (NCCN). Clinical Practice Guidelines in Oncology. www.nccn.org/professionals/physician_gls/default.aspx.
- Adult Cancer Pain
- Palliative Care
Paice JA, Ferrell B. The management of cancer pain. CA Cancer J Clin. 2011;61(3):157-182.
Paice JA, Portenoy R, Lacchetti C, et al. Management of chronic pain in survivors of adult cancers: American Society of Clinical Oncology Clinical Practice Guideline. J Clin Oncol. 2016;34(27):3325-3345.
PDQ Supportive and Palliative Care Editorial Board. PDQ Cancer Pain. Bethesda, MD: National Cancer Institute. Updated August 30, 2017. www.ncbi.nlm.nih.gov/books/NBK65949. Accessed January 22, 2018.
Weinstein SM, Portenoy R, Harrington S. UNIPAC 3: Assessment and Treatment of Physical Pain Associated with Life-Limiting Illness. 4th ed. American Academy of Hospice and Palliative Medicine. Glenview, Illinois:2012.
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