Dr. Haffizulla: Dr. Shih, you’ve done such amazing work in the opioid addiction area. In fact, you’ve been a pioneer in the management of opioid addiction among cancer patients. What are some of the standard tools available to manage addiction in this patient population?
Dr. Shih: It’s complex, and actually, within cancer patients, there’s sort of three risk groups when you think about opioid addiction. There’s those patients who people think of immediately who actually have an opioid addiction and now suddenly they’re dealt with this diagnosis of cancer, cancer pain, maybe pain related to treatment such as surgery, how do we manage that? I would say there’s no easy answer. It’s complex. It requires a lot of time, perseverance, and the whole army, the village, so it’s not the physician alone, it’s the nurses, the nurse practitioners, the mid-level providers, the social worker, therapist, addiction medicine if you have that as a resource, otherwise psychiatry, the family as well, so it’s a lot of perseverance and working together, communication, coaxing, and a team effort. So of the three categories of cancer patients, the first are those people who are actually affected with addiction.
The second are people who are actually in recovery, so they actually have an opioid use disorder but now they’re doing great, they’re back in society. They’re either on medication replacement, or they’re completely abstinent. These patients are at high risk of relapse when they come back for cancer care and cancer treatment, and they require a lot of assistance as well,
In addition to the standard treatments as mentioned for the actual active person with an opioid use disorder, another resource where actually both categories are recovery coaches.These are people who are also with a history of substance use disorder, now in recovery and are actually trained...sort of like in between with the medical professionals can really help guide patients who are either active or in past addiction to work with the medical team best.
And then the third category are just regular people who we know have varying degrees of risk of becoming addicted to opiates when they’re exposed to opiates as part of cancer care.
And so there’s something called the Opioid Risk Tool, which can be conducted. It’s a 1-minute survey that’s very easily done that is actually recommended to be done on all patients, new cancer patients. There are questions on the family history of personal drug and alcohol use, personal alcohol and drug use, but also things like gender and age, but also a little bit more sensitive things, such as like past child abuse or sexual abuse.
So even though it’s a 1-minute survey, there are sensitive questions. It really requires a lot of respect, sensitivity, compassion in conducting these surveys, and then we can direct the patient based on whether a low risk, just give them some information, let them know about the risk of opiates, intermediate risk, or high risk and direct a little bit more directed preventive care or support for these patients.
I think one other thing that’s really important in all patients is the risk that even if a cancer patient has a low risk and they have no intention of abusing medications, those medications when you take that prescription bottle home, someone else at home can take it, either purposely or not purposely, and so that’s a diversion of medication can happen. So I think education on that scale is always important as well.
Dr. Haffizulla: Thank you very much for sharing that. That’s very important information for our viewership. And there’s also just to switch gears a minute, there’s some interesting data on using radiation to curb addiction. Can you tell us how this works and how the literature supports such an approach?
Dr. Shih: So this is an interesting idea that I’ve had and others have had as well, but there’s no real established treatment or care, but radiation increasingly is being used for something called neuromodulation. We can use radiation to actually affect the neurologic physiology of the brain, hopefully to make it more normal. For example, use radiation to help treat pain syndromes, trigeminal neuralgia, where medication is not effective and it fails surgery or the patient is not a surgical candidate, we can treat this with radiation, with really relatively high response of controlling that pain. Similarly, we can do this for tremors, seizure disorders also, that are refractory again to medications or surgery. And so, I think it’s a novel idea to consider applying it to addiction, and I think this will be an area of exciting research in the years to come.
Dr. Haffizulla: We’re looking forward to hearing more on that front.
Dr. Shih: Absolutely.
Dr. Haffizulla: And we also know deep brain stimulation has shown a lot of benefit in preliminary studies of alcoholism. Is this approach possibly…can it be translated to opioid addiction?
Dr. Shih: I think so, too. So this is another form of neuromodulation. Deep brain stimulation, or DBS, has already been used for a variety of other neurologic conditions such as Parkinson’s, essential tremors also, even depression, and now moving into more psychiatric indications such as addiction. I believe there is good preliminary data showing this, and so I think we’ll be seeing more of it. I think one of the limitations of DBS, though, it does require compliance of the individual going to surgery, implanting a stimulator, and so it can be a little bit more involved that way, but I think that’s why it’s really nice to have multiple options with regard to neuromodulation as a field.
Dr. Haffizulla: So we talked about radiation, we talked about DBS. And we know that transcranial magnetic stimulation is a possible other novel approach. Can you tell us about the science behind this therapy and if it can have a potential role in opioid addiction?
Dr. Shih: Yes. I actually think transcranial magnetic stimulation, or TMS, actually probably might have the best data so far with regard to application for…towards use in addiction. And it’s really interesting. It’s completely safe, but it’s using magnetic waves that are…these transducers are placed over the head and actually alter the electrical firing within the brain hopefully to stimulate it where it’s understimulated and normalize it.
And it’s a very standard treatment. It’s used for autism, depression, and actually it was in depression, I believe, where veterans who were coming back from active duty who were depressed and also had an alcohol problem use disorder or drug use disorder were getting TMS for their depression but then independently just stopped drinking, stopped using recreational drugs, and this has now built into a field that has become very promising.
Dr. Haffizulla: Well, we're excited to hear more about that from you, and we applaud you for the amazing work you're doing on this front.
Dr. Shih: Thank you very much.
Dr. Haffizulla: Thank you for joining us today.
Dr. Shih: Thank you.