Pioneering Opioid Stewardship in Cancer Care MD Anderson’s Model for Patient Safety and Compassionate Pain Management

At The University of Texas MD Anderson Cancer Center, a dedicated opioid stewardship program is setting a new standard for managing opioid use in a complex patient population: those battling cancer. Matthew D. Clark, PharmD, a clinical pharmacy specialist in palliative care and opioid stewardship, detailed the program’s structure, the integral role of pharmacists, and the unique challenges of balancing pain relief with patient safety in cancer treatment.

A Decade in the Making: Program Structure and Evolution

While the institution-based opioid stewardship program officially launched just a year ago, its foundational framework was established nearly a decade prior. The journey began when clinicians in supportive care noticed a concerning trend: cancer patients experiencing discrepancies in their opioid use, such as early refill requests.

A pivotal moment came when a nurse practitioner suggested implementing urine drug screenings (UDS). These screenings uncovered critical safety issues:

No Opioids Present: Some patients claiming adherence had no opioids in their urine, raising concerns about potential diversion.
Illicit Substances/Unprescribed Medications: Others tested positive for illicit substances or unprescribed opioids and benzodiazepines, posing significant safety risks.

Recognizing the escalating need, MD Anderson secured funding to formalize its opioid stewardship program. The core team now consists of:

A medical director.
A full-time nurse practitioner.
A full-time clinical pharmacist (Dr. Matthew D. Clark).

Beyond this core, the program integrates other vital team members, including psychosocial counseling, social work, and case management, fostering a truly multidisciplinary approach.

The Pharmacist’s Central Role in Opioid Safety

Dr. Clark highlighted the pharmacist’s unique and central position in the program, emphasizing their expertise in opioid safety:

Urine Drug Screen Management: The pharmacist is responsible for randomizing and interpreting all urine drug screens, ensuring consistency with patients’ prescribed regimens and self-reported use. These results are then communicated to the broader care team.
Prescription Drug Monitoring Program (PDMP) Oversight: Pharmacists actively monitor the PDMP to detect potential “doctor shopping” or “pharmacy shopping,” where patients obtain prescriptions from multiple prescribers or pharmacies.
Treatment Plan Development: When discrepancies are identified, the pharmacist plays a key role in developing individualized opioid treatment plans.
Clinical Pharmacist Duties: In addition to stewardship-specific tasks, pharmacists provide essential opioid education, medication education, medication reconciliation, and other standard clinical pharmacy responsibilities within pain management and palliative care.

Navigating Unique Challenges in Cancer Care

One of the most significant challenges in cancer institutions is balancing the imperative of opioid safety with the undeniable need to manage cancer-related pain. Unlike many chronic pain clinics that might implement strict “three-strike” policies, cancer centers cannot simply dismiss patients with non-medical opioid use behaviors.

“The challenge is that even if patients misuse their opioids, use illicit substances, divert, or take more than prescribed, they still have cancer. That means they will still have pain and symptoms related to cancer… Finding the balance between safety and providing compassionate care is a major challenge for our team and institution.” — Matthew D. Clark, PharmD

The MD Anderson program addresses this by providing continuity and accountability:

Referral System: When non-medical opioid use behaviors are identified within the institution, patients are referred to the opioid stewardship team.
Close Monitoring: Patients with active misuse or illicit substance use are scheduled for weekly follow-ups to ensure adherence and abstinence. Once stable, follow-up frequency may be extended.
Compassionate Care: The program prioritizes continuous, compassionate care. While rare, extreme cases of persistent non-adherence or substance abuse may result in dismissal to community care, the primary goal is to maintain engagement and improve behavior.

Dr. Clark noted that consistent interaction with the same providers (pharmacist, physician, counselor) has a positive impact, leading to improved patient behaviors and a decrease in risky activities. This continuity is a source of pride for the program and a vital service to the institution and its vulnerable patient population.