Staying Proficient in Managing Chronic Cancer-Related Pain With Tanya Uritsky, PharmD

Oncology Data Advisor: To start off, would you like to introduce yourself and share what your work focuses on?

Tanya Uritsky, PharmD: Yes, I'm Tanya Uritsky. I'm a pharmacist, and I work at the Hospital of the University of Pennsylvania—it's Penn Medicine in Philadelphia. My title is the Opioid Stewardship Coordinator, but I'm specialty-trained in pain management and palliative care. I helped start the Palliative Care Service and practiced in palliative care for 10 years before going into stewardship. Now I do a lot of work around safe opiate prescribing, thinking about how to keep people safe from risky medication.

Oncology Data Advisor: So, I believe you're also President of the Society of Pain and Palliative Care Pharmacists?

Dr. Uritsky: That's correct.

Oncology Data Advisor: Great. I'm interested to learn more about it. Would you like to share more about what the organization does?

Dr. Uritsky: Yes, absolutely. We are a small organization of pharmacists. We are Pain Management and Palliative Care Specialists. There are about 300 of us. We are experts in our field, and we work to promote education. We do a lot of continuing education (CE). We have a virtual conference coming up in June. So, we do a lot of education advocacy for pain management and palliative care, promoting the profession to move the profession forward. We're working on metrics to help people justify additional positions and thinking about partnering and networking with other professionals and other societies to really grow and advance our field.

Oncology Data Advisor: That's great. So, you just presented a session called When Pain Holds a Grudge, Give It a Nudge. On this theme, have there been any recent developments in approaches for managing cancer-related pain?

Dr. Uritsky: So, it's interesting, because most of what we do is around expert guidance, and evidence is not always robust. It's not all that different from practicing specifically in palliative care as well, where a lot of what we're doing is harder to study or understudied, or just lacking a lot of momentum in evidence. So, newer advances have not come around all that often. I do think that by treating the underlying pains—so, treating the disease—we've had advanced therapies to treat the disease that can help with pain management in general. Although, sometimes the people are living longer with more chronic pain syndrome, so that does change the landscape. The people still having pain, just different.

So, we really do still rely on a lot of our traditional modalities. I think Linda, my co-presenter, talked a lot about our interventions and our blocks and our pumps and things like that. Those things, they've been around forever, but I think are underutilized and are probably a tool that we could use more for our chronic pain patients. She cited a study from 2002, so we need more recent evidence, because we don't have it. So, I would argue that our pain strategies and evidence for that are lagging behind significantly from the cancer-related studies, and that that's just an unfortunate reality. I think there are a lot of things in our toolbox, though, that we still can use. So, we're not limited in resources, but we could use some advances.

Oncology Data Advisor: Are there any directions where advances are going, or is it still a need?

Dr. Uritsky: Yes, people are studying novel mechanisms and targets for sure. I think people are using more buprenorphine now, getting a better handle on how to use that for any type of chronic pain really. They're studying more how that works, the basis of using that more commonly, and there are other receptors that are being studied to be targeted. People are using things like ketamine. People are studying things like hallucinogens or psychostimulants to do more focused pain treatment. So, that's good. I think it's on the horizon—I do think we have a lot of opportunity on the horizon hopefully. They have been touted as less subject to abuse medications or misuse medications. I'm not sure how that will pan out, because there are things like abuse deterrent formulations. With an abuse deterrent formulation, you can still take more of them. So, even though they might not be able to crush it and inject it, patient can still take 30. So, it's not necessarily foolproof. I don't know that anything is.

I think there's hope, and we do look forward to advances in the field. In the meantime, I also think advances in the field do involve safer management and thinking about how to keep people safe overall, because there's this, "Just prescribe because you can," kind of thing, which is not really a thing at the present anymore. So, that is in a way, and for some people, a setback if you can't get the meds you need, but there are advance in how we think about thinking to keep a holistic approach to pain management.

Oncology Data Advisor: So, along those lines, if anyone is interested in learning more about how to improve pain management, are there any resources they can look to?

Dr. Uritsky: Absolutely. Linda had quoted the ASPMN, or American Society of Pain Management Nursing; they have guidelines and resources. The American Society of Clinical Oncology (ASCO) has some really great guidelines and resources as well. They have survivorship guidelines. They just put out a pain management guideline for chronic pain. The National Comprehensive Cancer Network (NCCN) has guidelines for supportive care, pain management, and survivorship. So, there are tons of resources out there. They're all very much expert opinion with evidence sprinkled in. Those are really, really good tools to help think about what to do specifically in our patients with cancer.

Oncology Data Advisor: Great. Lastly, for nurses who couldn't attend, who are listening to this later, are there any take-home messages from your presentation you'd like to share?

Dr. Uritsky: I think so. I think what's important to think about is that when you're managing cancer pain with opioids, when you're in an active state in transitioning into survivorship, before you even start the opioids, is to talk about expectations. I think expectations are very important right now. Then in the long term, are we continuing these, or how are we managing these? Thinking very much not just this minute, but these medications may be continued for a while.

Another key take-home would be thinking about the medication as the risky things. The opioid has risks that, in and of itself, are inherent to the medication rather than the patient. The patient's going to have risk factors, but no matter who you are, if you have an opioid in the home, they have risks. Thinking about it from that perspective, to help destigmatize the risks of opioids and using opioids and taking them for pain can really help, because patients are fearful. We have to address it from the underlying root of why they're fearful and give them tools to feel that they are safe. If they're worried about having them in the home, they should have Narcan^® there. This way if—God forbid—something were to happen, they know they have something. Then hopefully if it's explained the right way, they won't feel as scared.

I think, also, the key thing to think about from Linda's perspective is really thinking about intervention sooner. Interventions, of course, are good, and they're helpful. There are always positives and negatives, always risks and benefits to anything you're doing in medication intervention. I think having that on the radar before it gets to the point where the patient's disease is advancing to use that is also a very good thing. As a nurse or a nurse practitioner, you may not be the one doing that, but you can surely mention it, bring it up, and talk to the patient about it. Think about this, is this an option? Mention it to the oncologist. Have it on the radar, so that the pain doesn't need to get so bad. They don't have to be in such severe suffering. Then if they get to end of life, it's too late. It's just too late to put things like that in. So, I think those are really good tips to think about.

Oncology Data Advisor: Awesome. Well, this has been great. Thanks so much for talking to me about this.

Dr. Uritsky: Thank you. Yes, absolutely. Thank you.

About Dr. Uritsky

Tanya Uritsky, PharmD, is the Opioid Stewardship Coordinator and Co-Chair of the Opioid Task Force at the Hospital of the University of Pennsylvania. As well, she serves as the President for the Society of Pain and Palliative Care Pharmacists. Dr. Uritsky specializes in pain management and palliative care and has contributed a plethora of research and knowledge to the subject. So much so that she has been recognized as Palliative Care Practitioner of the Year by the American Society of Pain Educators in 2015 and received the 2020 Pennsylvania Society of Health-System Pharmacists Joe E. Smith Award.

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Transcript edited for clarity. Any views expressed above are the speaker's own and do not necessarily reflect those of Oncology Data Advisor.