Beyond the Three-Strike Rule: How Opioid Stewardship is Evolving Cancer Care
Nearly 1 in 4 cancer patients experience significant pain, making effective pain management a cornerstone of their care. But a growing awareness of the opioid crisis has forced a critical re-evaluation of prescribing practices. While many chronic pain clinics operate under a “three-strike” dismissal policy for non-adherence, cancer care demands a different approach. A new model, exemplified by the opioid stewardship program at MD Anderson Cancer Center, is prioritizing continuity and compassionate care – and it’s poised to reshape how we think about responsible opioid use in vulnerable populations.
The Rise of Institutional Opioid Stewardship
For years, healthcare institutions have grappled with balancing the need for effective pain relief with the risks of opioid misuse, diversion, and addiction. The framework for proactive management began to emerge almost a decade ago, as institutions like MD Anderson noticed discrepancies in patient opioid usage – early refills, lost prescriptions, and inconsistencies revealed through urine drug screenings. These early warning signs prompted the implementation of monitoring systems, but it wasn’t until recently that dedicated, funded opioid stewardship programs became widespread.
Matthew D. Clark, PharmD, clinical pharmacy specialist in palliative care and opioid stewardship at MD Anderson, explains that their program now centers around a core team: a medical director, a nurse practitioner, and a pharmacist. This team, bolstered by psychosocial counseling, social work, and case management, focuses on identifying patients at risk and providing individualized care plans. The pharmacist’s role is particularly crucial, acting as the central point for monitoring prescriptions, interpreting urine drug screen results, and coordinating with the broader care team.
Pharmacists: The Linchpin of Opioid Safety
The opioid stewardship pharmacist isn’t simply a gatekeeper; they’re a critical care coordinator. Randomized urine drug screenings, coupled with prescription drug monitoring program (PDMP) checks, allow pharmacists to identify potential issues like diversion (opioids being used by someone other than the patient), the presence of illicit substances, or “doctor shopping” (seeking prescriptions from multiple providers). But the response isn’t punitive. Instead, pharmacists work with the team to develop tailored treatment plans, offering education, medication reconciliation, and close monitoring.
This proactive approach is a departure from reactive measures. As Clark emphasizes, dismissing patients isn’t an option when they’re battling cancer. The goal is to provide continuity of care, building trust and addressing underlying issues that contribute to risky opioid behaviors. This continuity, seeing the same providers consistently, has demonstrably improved patient adherence and reduced risky behaviors at MD Anderson.
Unique Challenges in Cancer Care: Balancing Safety and Compassion
Cancer patients present unique challenges compared to those with chronic non-cancer pain. Their pain is often complex, fluctuating, and directly related to the disease itself and its treatment. Simply reducing or eliminating opioids isn’t a viable solution. The focus, therefore, shifts to mitigating risk while ensuring adequate pain control. This requires a nuanced understanding of each patient’s individual circumstances, including their psychological and social needs.
The MD Anderson model prioritizes identifying patients *at risk* for misuse, rather than solely focusing on those actively engaged in it. This allows for preventative interventions and a more compassionate approach. Weekly follow-ups are implemented for patients exhibiting concerning behaviors, gradually transitioning to monthly visits as stability is achieved. Dismissal to community care remains rare, reserved for cases of persistent non-adherence or continued substance abuse.
Looking Ahead: The Future of Opioid Stewardship
The success of programs like MD Anderson’s points to several key trends in opioid stewardship. First, we’ll likely see increased integration of technology, including predictive analytics to identify high-risk patients *before* problems arise. Artificial intelligence could play a role in analyzing PDMP data and identifying patterns of concerning behavior. Second, a greater emphasis on non-pharmacological pain management techniques – such as physical therapy, acupuncture, and mindfulness – will become essential. The National Cancer Institute offers comprehensive resources on cancer pain management.
Finally, and perhaps most importantly, the role of the pharmacist will continue to expand. Pharmacists are uniquely positioned to bridge the gap between prescribing, dispensing, and patient education, ensuring that opioids are used safely and effectively. The future of opioid stewardship isn’t about restricting access; it’s about optimizing care, fostering trust, and providing compassionate support to patients who need it most. What innovative strategies are *you* seeing implemented in your institution to address the complexities of opioid management in cancer care? Share your experiences in the comments below!
