With Great Doses Come Great Responsibilities

Oncologists must also protect families of cancer patients who are prescribed pain medications.

By Steve Lee, MD

To great fanfare, health services researchers at the September 2018 ASCO Quality Care Symposium announced that opioid deaths in cancer patients are ten times less likely than in the general population.  As part of a ten-year retrospective study, lead author Fumiko Chino MD of the Duke University School of Medicine reported 0.5 to 0.7 opioid deaths per 100,000 cancer patients, compared to 5 to 9 per 100,000 in the general population.  These findings, the authors argued, supported the continued carving out of cancer patients from increasingly stringent opioid prescribing laws.

These conclusions also nicely supported existing ASCO policy initiatives of reducing barriers to appropriate pain therapy and was the subject of coverage by the ASCO Post as well as an ASCO in Action podcast.

But in limiting concern of misuse of opioid misuse to cancer patients themselves, such avenues of inquiry miss the opportunity to reduce harms to caretakers and friends who gain access to harmful substances through proximity to such high doses. 

Opioid diversion has entered the public conversation, most notably with The Conners, ABC's re-reboot of the 90s classic Roseanne, in which the pilot episode portrays the opioid-related death of the fictional matriarch from a friend's supply. Real-world episodes of opioid diversion from cancer and palliative care patients have also been covered by the press including that of a daughter in Washington appropriating hundreds of opioid pills after her hospice-bound father died .

Unfortunately, rigorous study of opioid diversion is lacking, limiting policy change.  Also lacking is a clear causal narrative linking prescribed pharmaceutical opioids to the illicit substances - chiefly fentanyl - responsible for the alarming increase in American deaths reaching 72,000 in 2017. A popular hypothesis attributes the increase in fentanyl-related deaths to prescription drug control pushing users to illicit alternatives. Is caretaker prescription diversion a gateway to illicit opioids - and deaths?  Further research is needed.

Current state and federal interventions have included biologic testing, prescription drug monitoring programs (PDMPs), opioid prescribing limits, patch return, and drug takeback programs.  Few of these initiatives, however, directly address the diversion question of whether each tablet makes it to the appropriate recipient.

One solution may include directly observed therapy (DOT).  Long the domain of public health departments charged with preventing transmission of tuberculosis, innovative agencies have employed telemedicine to maintain compliance with reduced costs.   In the same way, video DOT (VDOT) is a compelling strategy for opioid tracking; in 2017, the National Institute of Drug Abuse (NIDA) funded emocha Mobile Health, a Baltimore-based VDOT start-up, to track adherence to buprenorphine.

Even if successful in trials, general rollout of interventions such as VDOT for high-dose opioid recipients such as cancer patients would surely be resource-intensive.  Important policy questions would include the party responsible for administering VDOT - physician practices are busy enough as is, pharmacy-based programs would undoubtedly add to already high drug costs, and departments of health would require new funding streams.

Ultimately, further innovation and policy are required to reduce diversion of appropriately prescribed drugs, even from legally privileged oncology and palliative care patients.