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Islam JY, Nguyen OT, Turner K, Martinez YC, Rodriguez OG, Rodriguez DI, Rajasekhara S, Chang YD, Gonzalez BD, Jim HSL, Egan KM. Concurrent substance use among cancer patients with and without a history of cannabis use since cancer diagnosis at an NCI-Designated Cancer Center in Florida. J Natl Cancer Inst Monogr 2024; 2024:224-233. [PMID: 39108241 PMCID: PMC11303859 DOI: 10.1093/jncimonographs/lgad036] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 09/30/2023] [Accepted: 11/06/2023] [Indexed: 08/10/2024] Open
Abstract
BACKGROUND Although substance use may have adverse impacts on cancer outcomes, little is known regarding patterns of concurrent substance use with cannabis among cancer patients. Our objective was to examine predictors of concurrent substance use with cannabis among cancer patients since their cancer diagnosis and explore perceptions of cannabis among these patients. METHODS Patients treated at a National Cancer Institute-designated comprehensive cancer center were invited to participate in an electronic survey regarding medical cannabis from August to November 2021. Survey data were linked to internal data resources including electronic health records and patient intake forms to obtain history of substance use (defined as within at least 3 months of cancer diagnosis) of cigarettes, injection drugs, high levels of alcohol, or clinically unsupervised prescription drugs (total n = 1094). Concurrent substance users were defined as those with any reported substance use and cannabis use at the time of cancer diagnosis. We used descriptive statistics (χ2 or exact tests) to compare groups and estimated adjusted odds ratios (AORs) with 95% confidence intervals (CIs) to identify predictors of substance use among users and nonusers of cannabis. RESULTS Approximately 45% (n = 489) of the sample reported cannabis use since their cancer diagnosis. Of patients who reported using cannabis, 20% self-reported concurrent polysubstance use, while 8% of cannabis nonusers reported substance use (P < .001). Among patients who use cannabis, those who reported 2 or more self-reported treatment-related symptoms (eg, pain, fatigue) were more likely to have self-reported concurrent substance use (AOR = 3.15, 95% CI = 1.07 to 9.27) compared with those without any symptoms. Among nonusers, those with lower educational background were more likely to have a history of concurrent substance use (AOR = 3.74, 95% CI = 1.57 to 8.92). Patients who use cannabis with concurrent substance use were more likely to report improved sleep (P = .04), increased appetite (P = .03), and treatment of additional medical conditions (P = .04) as perceived benefits of cannabis use. CONCLUSIONS High symptom burden may be associated with concurrent substance use with cannabis among cancer patients.
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Affiliation(s)
- Jessica Y Islam
- Department of Cancer Epidemiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
- Department of Oncologic Sciences, University of South Florida, Tampa, FL, USA
| | - Oliver T Nguyen
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Kea Turner
- Department of Oncologic Sciences, University of South Florida, Tampa, FL, USA
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Yessica C Martinez
- Department of Cancer Epidemiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Omar Garcia Rodriguez
- Department of Cancer Epidemiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | | | - Sahana Rajasekhara
- Department of Oncologic Sciences, University of South Florida, Tampa, FL, USA
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Young D Chang
- Department of Supportive Care Medicine, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Brian D Gonzalez
- Department of Oncologic Sciences, University of South Florida, Tampa, FL, USA
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Heather S L Jim
- Department of Oncologic Sciences, University of South Florida, Tampa, FL, USA
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Kathleen M Egan
- Department of Cancer Epidemiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
- Department of Oncologic Sciences, University of South Florida, Tampa, FL, USA
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Check DK, Jones KF, Osazuwa-Peters OL, Blalock DV, Marais AD, Merlin JS. Misuse of Prescribed and Nonprescribed Substances Among U.S. Cancer Survivors. J Gen Intern Med 2024:10.1007/s11606-024-08940-2. [PMID: 39028406 DOI: 10.1007/s11606-024-08940-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 07/05/2024] [Indexed: 07/20/2024]
Abstract
BACKGROUND Substance misuse is common among cancer survivors and can negatively impact cancer outcomes. METHODS We conducted a cross-sectional study using National Survey on Drug Use and Health data for 2015 to 2020. We included adult respondents with a history of solid tumor cancer. We calculated the weighted prevalence and corresponding SEs (both expressed as percentages) of substance (alcohol, opioid, sedative, stimulant, other) misuse for respondents with any history of solid tumor cancer and, in secondary analyses, respondents diagnosed with cancer in the prior 12 months. RESULTS The study included 6,101 respondents with any history of cancer, 1,437 diagnosed in the prior 12 months. Alcohol was the most commonly misused substance. The average prevalence of alcohol misuse was 14.4% (SE 0.60%) across cancer types; it was markedly more common among people with a history or cervical (24.2% [3.0%]) or head and neck cancer (27.4% [7.1%]). The next most common form of substance misuse was opioid misuse (average prevalence: 2.7% [0.25%]). As with alcohol misuse, the prevalence of opioid misuse was higher among those with a lifetime history of cervical cancer (5% [1%]) or head and neck cancer (5% [3%]). Results were generally consistent among cancer survivors diagnosed in the prior 12 months. CONCLUSIONS There is a clear opportunity to address substance misuse-particularly alcohol misuse-among cancer survivors. Such efforts should focus on populations with a high prevalence of substance misuse (e.g., cervical and head and neck cancer survivors) and have strong potential to improve cancer-specific and overall health outcomes.
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Affiliation(s)
- Devon K Check
- Department of Population Health Sciences, Duke University School of Medicine, 215 Morris Street, Durham, NC, USA.
| | - Katie F Jones
- New England Geriatric Research Education and Clinical Center, VA Boston Healthcare System, Boston, USA
| | - Oyomoare L Osazuwa-Peters
- Department of Population Health Sciences, Duke University School of Medicine, 215 Morris Street, Durham, NC, USA
| | - Dan V Blalock
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, USA
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, Durham, USA
| | - Andrea Des Marais
- Department of Population Health Sciences, Duke University School of Medicine, 215 Morris Street, Durham, NC, USA
| | - Jessica S Merlin
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Jones KF, White G, Bennett A, Bulls H, Escott P, Orris S, Escott E, Fischer S, Hamm M, Krishnamurti T, Wong R, LeBlanc TW, Liebschutz J, Meghani S, Smith C, Temel J, Ritchie C, Merlin JS. Benefits, Harms, and Stakeholder Perspectives Regarding Opioid Therapy for Pain in Individuals With Metastatic Cancer: Protocol for a Descriptive Cohort Study. JMIR Res Protoc 2024; 13:e54953. [PMID: 38478905 PMCID: PMC10973954 DOI: 10.2196/54953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 01/31/2024] [Accepted: 02/01/2024] [Indexed: 04/01/2024] Open
Abstract
BACKGROUND Opioids are a key component of pain management among patients with metastatic cancer pain. However, the evidence base available to guide opioid-related decision-making in individuals with advanced cancer is limited. Patients with advanced cancer or cancer that is unlikely to be cured frequently experience pain. Opioids are a key component of pain management among patients with metastatic cancer pain. Many individuals with advanced cancer are now living long enough to experience opioid-related harm. Emerging evidence from chronic noncancer pain literature suggests that longer-term opioid therapy may have limited benefits for pain and function, and opioid-related harms are also a major concern. However, whether these benefits and harms of opioids apply to patients with cancer-related pain is unknown. OBJECTIVE This manuscript outlines the protocol for the "Opioid Therapy for Pain in Individuals With Metastatic Cancer: The Benefits, Harms, and Stakeholder Perspectives (BEST) Study." The study aims to better understand opioid decision-making in patients with advanced cancer, along with opioid benefits and harms, through prospective examination of patients' pain experiences and opioid side effects and understanding the decision-making by patients, care partners, and clinicians. METHODS This is a multicenter, prospective cohort study that aims to enroll 630 patients with advanced cancer, 20 care partners, and 20 clinicians (670 total participants). Patient participants must have an advanced solid cancer diagnosis, defined by the American Cancer Society as cancer that is unlikely to be cured. We will recruit patient participants within 12 weeks after diagnosis so that we can understand opioid benefits, harms, and perspectives on opioid decision-making throughout the course of their advanced cancer (up to 2 years). We will also specifically elicit information regarding long-term opioid use (ie, opioids for ≥90 consecutive days) and exclude patients on long-term opioid therapy before an advanced cancer diagnosis. Lived-experience perspectives related to opioid use in those with advanced cancer will be captured by qualitative interviews with a subset of patients, clinicians, and care partners. Our data collection will be grounded in a behavioral decision research approach that will allow us to develop future interventions to inform opioid-related decision-making for patients with metastatic cancer. RESULTS Data collection began in October 2022 and is anticipated to end by November 2024. CONCLUSIONS Upon successful execution of our study protocol, we anticipate the development of a comprehensive evidence base on opioid therapy in individuals with advanced cancer guided by the behavioral decision research framework. The information gained from this study will be used to guide interventions to facilitate opioid decisions among patients, clinicians, and care partners. Given the limited evidence base about opioid therapy in people with cancer, we envision this study will have significant real-world implications for cancer-related pain management and opioid-related clinical decision-making. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/54953.
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Affiliation(s)
- Katie Fitzgerald Jones
- New England Geriatrics Research, Education, and Clinical Center (GRECC), Jamaica Plain, MA, United States
| | | | - Antonia Bennett
- University of North Carolina, Chapel Hill, NC, United States
| | - Hailey Bulls
- University of Pittsburgh, Pittsburgh, PA, United States
| | - Paula Escott
- University of Pittsburgh, Pittsburgh, PA, United States
| | - Sarah Orris
- University of Pittsburgh, Pittsburgh, PA, United States
| | | | | | - Megan Hamm
- University of Pittsburgh, Pittsburgh, PA, United States
| | | | - Risa Wong
- University of Pittsburgh, Pittsburgh, PA, United States
| | | | | | | | - Cardinale Smith
- Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Jennifer Temel
- Division of Hematology/Oncology, Massachusetts General Hospital, Boston, MA, United States
| | - Christine Ritchie
- Center for Aging and Serious Illness, Massachusetts General Hospital, Boston, MA, United States
- Department of Medicine, Harvard Medical School, Boston, MA, United States
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Jones KF, Osazuwa-Peters OL, Des Marais A, Merlin JS, Check DK. Substance Use Disorders Among US Adult Cancer Survivors. JAMA Oncol 2024; 10:384-389. [PMID: 38206609 PMCID: PMC10784996 DOI: 10.1001/jamaoncol.2023.5785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 09/29/2023] [Indexed: 01/12/2024]
Abstract
Importance Some individuals are predisposed to cancer based on their substance use history, and others may use substances to manage cancer-related symptoms. Yet the intersection of substance use disorder (SUD) and cancer is understudied. Because SUD may affect and be affected by cancer care, it is important to identify cancer populations with a high prevalence of SUD, with the goal of guiding attention and resources toward groups and settings where interventions may be needed. Objective To describe the cancer type-specific prevalence of SUD among adult cancer survivors. Design, Setting, and Participants This cross-sectional study used data from the annually administered National Survey on Drug Use and Health (NSDUH) for 2015 through 2020 to identify adults with a history of solid tumor cancer. Substance use disorder was defined as meeting at least 1 of 4 Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) criteria for abuse or at least 3 of 6 criteria for dependence. Main Outcomes and Measures Per NSDUH guidelines, we made adjustments to analysis weights by dividing weights provided in the pooled NSDUH data sets by the number of years of combined data (eg, 6 for 2015-2020). The weighted prevalence and corresponding SEs (both expressed as percentages) of active SUD (ie, within the past 12 months) were calculated for respondents with any lifetime history of cancer and, in secondary analyses, respondents diagnosed with cancer within 12 months prior to taking the survey. Data were analyzed from July 2022 to June 2023. Results This study included data from 6101 adult cancer survivors (56.91% were aged 65 years or older and 61.63% were female). Among lifetime cancer survivors, the prevalence of active SUD was 3.83% (SE, 0.32%). Substance use disorder was most prevalent in survivors of head and neck cancer (including mouth, tongue, lip, throat, and pharyngeal cancers; 9.36% [SE, 2.47%]), esophageal and gastric cancer (9.42% [SE, 5.51%]), cervical cancer (6.24% [SE, 1.41%]), and melanoma (6.20% [SE, 1.34%]). Alcohol use disorder was the most common SUD (2.78% [SE, 0.26%]) overall and in survivors of head and neck cancer, cervical cancer, and melanoma. In survivors of esophageal and gastric cancers, cannabis use disorder was the most prevalent SUD (9.42% [SE, 5.51%]). Among respondents diagnosed with cancer in the past 12 months, the overall prevalence of active SUD was similar to that in the lifetime cancer survivor cohort (3.81% [SE, 0.74%]). However, active SUD prevalence was higher in head and neck (18.73% [SE, 10.56%]) and cervical cancer survivors (15.70% [SE, 5.35%]). The distribution of specific SUDs was different compared with that in the lifetime cancer survivor cohort. For example, in recently diagnosed head and neck cancer survivors, sedative use disorder was the most common SUD (9.81% [SE, 9.17%]). Conclusions and Relevance Findings of this study suggest that SUD prevalence is higher among survivors of certain types of cancer; this information could be used to identify cancer survivors who may benefit from integrated cancer and SUD care. Future efforts to understand and address the needs of adult cancer survivors with comorbid SUD should prioritize cancer populations in which SUD prevalence is high.
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Affiliation(s)
- Katie F. Jones
- New England Geriatric Research Education and Clinical Center, VA Boston Healthcare System, Boston, Massachusetts
| | | | - Andrea Des Marais
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Jessica S. Merlin
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Devon K. Check
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
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Salama V, Humbert-Vidan L, Godinich B, Wahid KA, ElHabashy DM, Naser MA, He R, Mohamed ASR, Sahli AJ, Hutcheson KA, Gunn GB, Rosenthal DI, Fuller CD, Moreno AC. Comparison of Machine Leaning Models for Prediction of Acute Pain Severity and On-Treatment Opioid Utilization in Oral Cavity and Oropharyngeal Cancer Patients Receiving Radiation Therapy: Exploratory Analysis from a Large-Scale Retrospective Cohort. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.02.06.24302341. [PMID: 38370746 PMCID: PMC10871386 DOI: 10.1101/2024.02.06.24302341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/20/2024]
Abstract
Background Acute pain is a common and debilitating symptom experienced by oral cavity and oropharyngeal cancer (OC/OPC) patients undergoing radiation therapy (RT). Uncontrolled pain can result in opioid overuse and increased risks of long-term opioid dependence. The specific aim of this exploratory analysis was the prediction of severe acute pain and opioid use in the acute on-treatment setting, to develop risk-stratification models for pragmatic clinical trials. Materials and Methods A retrospective study was conducted on 900 OC/OPC patients treated with RT during 2017 to 2023. Clinical data including demographics, tumor data, pain scores and medication data were extracted from patient records. On-treatment pain intensity scores were assessed using a numeric rating scale (0-none, 10-worst) and total opioid doses were calculated using morphine equivalent daily dose (MEDD) conversion factors. Analgesics efficacy was assessed based on the combined pain intensity and the total required MEDD. ML models, including Logistic Regression (LR), Support Vector Machine (SVM), Random Forest (RF), and Gradient Boosting Model (GBM) were developed and validated using ten-fold cross-validation. Performance of models were evaluated using discrimination and calibration metrics. Feature importance was investigated using bootstrap and permutation techniques. Results For predicting acute pain intensity, the GBM demonstrated superior area under the receiver operating curve (AUC) (0.71), recall (0.39), and F1 score (0.48). For predicting the total MEDD, LR outperformed other models in the AUC (0.67). For predicting the analgesics efficacy, SVM achieved the highest specificity (0.97), and best calibration (ECE of 0.06), while RF and GBM achieved the same highest AUC, 0.68. RF model emerged as the best calibrated model with ECE of 0.02 for pain intensity prediction and 0.05 for MEDD prediction. Baseline pain scores and vital signs demonstrated the most contributed features for the different predictive models. Conclusion These ML models are promising in predicting end-of-treatment acute pain and opioid requirements and analgesics efficacy in OC/OPC patients undergoing RT. Baseline pain score, vital sign changes were identified as crucial predictors. Implementation of these models in clinical practice could facilitate early risk stratification and personalized pain management. Prospective multicentric studies and external validation are essential for further refinement and generalizability.
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Solsky I, Patel A, Valenzuela CD, Russell G, Perry K, Duckworth K, Votanopoulos KI, Shen P, Levine EA. Quality-of-Life Outcomes for Patients Taking Opioids and Psychotropic Medications Before Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy. Ann Surg Oncol 2024; 31:577-593. [PMID: 37891454 DOI: 10.1245/s10434-023-14215-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 08/09/2023] [Indexed: 10/29/2023]
Abstract
BACKGROUND The impact of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) on quality of life (QoL) for patients taking opioids and psychotropic medications preoperatively is unclear. METHODS This study retrospectively reviewed a CRS-HIPEC single-center prospectively maintained database for 2012-2016. Demographics and clinical data on opioids/psychotropic medication use were collected via chart review. The study collected QoL outcomes at baseline, then 3, 6, and 12 months postoperatively via the Center for Epidemiologic Studies Depression Scale (CES-D), Brief Pain Inventory, Functional Assessment of Cancer Therapy, and 36-Item Short-Form Health Survey. Differences in QoL between the groups were calculated using repeated measures analysis of variance regression. Descriptive statistics and Kaplan-Meier analyses were performed. RESULTS Of 388 patients, 44.8% were taking opioids/psychotropic medications preoperatively. At baseline, those taking opioids/psychotropic medications preoperatively versus those not taking these medications had significantly worse QoL. By 1 year postoperatively, the QoL measures did not differ significantly except for emotional functioning (e.g., no medications vs. opioids/psychotropic medications: CES-D, 5.6 vs. 10.1). Median survival did not differ significantly (opioids/psychotropic medications vs. no medications: 52.3 vs. 60.6 months; p = 0.66). At 1 year after surgery, a greater percentage of patients were taking opioids, psychotropic medications, or both than at baseline (63.2% vs. 44.8%; p < 0.001). CONCLUSION Despite worse baseline QoL, patients who took opioids/psychotropic medications had QoL scores 1 year postoperatively similar to the scores of those who did not except in the emotional domains. These data point to the potential utility of a timed psychosocial intervention to enhance emotional adaptation and further support the role of CRS-HIPEC in improving QoL.
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Affiliation(s)
- Ian Solsky
- Surgical Oncology Service, Wake Forest University, Winston-Salem, NC, USA
| | - Ana Patel
- Surgical Oncology Service, Wake Forest University, Winston-Salem, NC, USA
| | | | - Gregory Russell
- Surgical Oncology Service, Wake Forest University, Winston-Salem, NC, USA
| | - Kathleen Perry
- Surgical Oncology Service, Wake Forest University, Winston-Salem, NC, USA
| | - Katie Duckworth
- Surgical Oncology Service, Wake Forest University, Winston-Salem, NC, USA
| | | | - Perry Shen
- Surgical Oncology Service, Wake Forest University, Winston-Salem, NC, USA
- Section of Surgical Oncology, Atrium Health Wake Forest Baptist, Winston-Salem, NC, USA
| | - Edward A Levine
- Surgical Oncology Service, Wake Forest University, Winston-Salem, NC, USA.
- Section of Surgical Oncology, Atrium Health Wake Forest Baptist, Winston-Salem, NC, USA.
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Mannes ZL, Livne O, Knox J, Hasin DS, Kranzler HR. Prevalence and correlates of DSM-5 opioid withdrawal syndrome in U.S. adults with non-medical use of prescription opioids: results from a national sample. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2023; 49:799-808. [PMID: 37948571 PMCID: PMC10867630 DOI: 10.1080/00952990.2023.2248646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 08/13/2023] [Indexed: 11/12/2023]
Abstract
Background: In the U.S. non-medical use of prescription opioids (NMOU) is prevalent and often accompanied by opioid withdrawal syndrome (OWS). OWS has not been studied using nationally representative data.Objectives: We examined the prevalence and clinical correlates of OWS among U.S. adults with NMOU.Methods: We used data from 36,309 U.S. adult participants in the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions-III, 1,527 of whom reported past 12-month NMOU. Adjusted linear and logistic regression models examined associations between OWS and its clinical correlates, including psychiatric disorders, opioid use disorder (OUD; excluding the withdrawal criterion), medical conditions, and healthcare utilization among people with regular (i.e. ≥3 days/week) NMOU (n = 534).Results: Over half (50.4%) of the sample was male. Approximately 9% of people with NMOU met criteria for DSM-5 OWS, with greater prevalence of OWS (∼20%) among people with regular NMOU. Individuals with bipolar disorder, dysthymia, panic disorder, and borderline personality disorder had greater odds of OWS (aOR range = 2.71-4.63). People with OWS had lower mental health-related quality of life (β=-8.32, p < .001). Individuals with OUD also had greater odds of OWS (aOR range = 26.02-27.77), an association that increased with more severe OUD. People using substance use-related healthcare services also had greater odds of OWS (aOR range = 6.93-7.69).Conclusion: OWS was prevalent among people with OUD and some psychiatric disorders. These findings support screening for OWS in people with NMOU and suggest that providing medication- assisted treatments and behavioral interventions could help to reduce the burden of withdrawal in this patient population.
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Affiliation(s)
- Zachary L. Mannes
- Department of Epidemiology, Columbia University Mailman School of Public Health, 722 West 168th St., New York, NY 10032, USA
- New York State Psychiatric Institute, 1051 Riverside Drive, New York, NY, 10032, USA
| | - Ofir Livne
- New York State Psychiatric Institute, 1051 Riverside Drive, New York, NY, 10032, USA
| | - Justin Knox
- New York State Psychiatric Institute, 1051 Riverside Drive, New York, NY, 10032, USA
- Department of Psychiatry, Columbia University Irving Medical Center, 1051 Riverside Drive, New York, NY, 10032, USA
- Department of Sociomedical Sciences, Columbia University Mailman School of Public Health, 722 West 168th St. New York, NY, 10032, USA
| | - Deborah S. Hasin
- Department of Epidemiology, Columbia University Mailman School of Public Health, 722 West 168th St., New York, NY 10032, USA
- New York State Psychiatric Institute, 1051 Riverside Drive, New York, NY, 10032, USA
- Department of Psychiatry, Columbia University Irving Medical Center, 1051 Riverside Drive, New York, NY, 10032, USA
| | - Henry R. Kranzler
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, 3535 Market Street, Philadelphia, PA, 19104, USA
- Mental Illness Research, Education, and Clinical Center, Crescenz Veterans Affairs Medical Center, 3900 Woodland Ave, Philadelphia, PA, 19104, USA
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Salama V, Geng Y, Rigert J, Fuller CD, Shete S, Moreno AC. Systematic Review of Genetic Polymorphisms Associated with Acute Pain Induced by Radiotherapy for Head and Neck Cancers. Clin Transl Radiat Oncol 2023; 43:100669. [PMID: 37954025 PMCID: PMC10634655 DOI: 10.1016/j.ctro.2023.100669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 07/10/2023] [Accepted: 08/13/2023] [Indexed: 11/14/2023] Open
Abstract
Background/objective Pain is the most common acute symptom following radiation therapy (RT) for head and neck cancer (HNC). The multifactorial origin of RT-induced pain makes it highly challenging to manage. Multiple studies were conducted to identify genetic variants associated with cancer pain, however few of them focused on RT-induced acute pain. In this review, we summarize the potential mechanisms of acute pain after RT in HNC and identify genetic variants associated with RT-induced acute pain and relevant acute toxicities. Methods A comprehensive search of Ovid Medline, EMBASE and Web of Science databases using terms including "Variants", "Polymorphisms", "Radiotherapy", "Acute pain", "Acute toxicity" published up to February 28, 2022, was performed by two reviewers. Review articles and citations were reviewed manually. The identified SNPs associated with RT-induced acute pain and toxicities were reported, and the molecular functions of the associated genes were described based on genetic annotation using The Human Gene Database; GeneCards. Results A total of 386 articles were identified electronically and 8 more articles were included after manual search. 21 articles were finally included. 32 variants in 27 genes, of which 25% in inflammatory/immune response, 20% had function in DNA damage response and repair, 20% in cell death or cell cycle, were associated with RT-inflammatory pain and acute oral mucositis or dermatitis. 4 variants in 4 genes were associated with neuropathy and neuropathic pain. 5 variants in 4 genes were associated with RT-induced mixed types of post-RT-throat/neck pain. Conclusion Different types of pain develop after RT in HNC, including inflammatory pain; neuropathic pain; nociceptive pain; and mixed oral pain. Genetic variants involved in DNA damage response and repair, cell death, inflammation and neuropathic pathways may affect pain presentation post-RT. These variants could be used for personalized pain management in HNC patients receiving RT.
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Affiliation(s)
- Vivian Salama
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Yimin Geng
- Research Medical Library, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jillian Rigert
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Clifton D. Fuller
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sanjay Shete
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Amy C. Moreno
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Patel JN, Jandrisevits E, Boselli D, Michalowski T, Parala-Metz A, Walsh D. Opioid Monitoring Using Urine Toxicology Screens in Outpatient Oncology Palliative Medicine. JCO Oncol Pract 2023; 19:990-999. [PMID: 37722086 DOI: 10.1200/op.23.00034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 07/13/2023] [Accepted: 08/18/2023] [Indexed: 09/20/2023] Open
Abstract
PURPOSE There is a paucity of real-world data on opioid screening and urine toxicology testing in outpatient oncology palliative medicine. METHODS This was a retrospective analysis of adult patients with cancer completing ≥ one outpatient palliative medicine visit and the Edmonton Symptom Assessment Scale (ESAS). Patient demographics, the Screener and Opioid Assessment for Patients with Pain-Short Form (SOAPP-SF), ESAS, medications, and urine toxicology screens (UTSs) were collected at baseline and follow-up visits. The primary end point was the frequency and type(s) of noncompliant UTSs (ie, presence of a nonprescribed substance or absence of a prescribed substance). Secondarily, risk factors for noncompliant UTSs were evaluated using univariate and multivariable logistic regression. RESULTS Of 189 evaluable patients (632 clinic visits), 113 underwent ≥one UTSs, 125 SOAPP-SF, and 75 had both. The median age was 56 (range, 26-80) years, 56% were female, 58% were White, 40% were Black, 48% had stage IV disease, the median baseline pain score was 7, and the median SOAPP-SF was 3. Oxycodone was the most prescribed drug (n = 125). Of 113 patients who underwent UTSs, 54% (n = 61) had ≥one noncompliant result. Thirty-nine percent (n = 44) had a total of 128 noncompliant results for the presence of a nonprescribed substance; 29% (n = 33) had a total of 53 noncompliant results for the absence of a prescribed substance. SOAPP-SF Q4 (use of illegal drugs) (odds ratio [OR], 3.61; 95% CI, 1.81 to 7.19; P < .001) and prescription with nonopioid adjuvant medications (OR, 2.83; 95% CI, 1.12 to 7.19; P = .029) were associated with increased odds of a noncompliant UTS. CONCLUSION More than half of the tested population had noncompliant UTS. Screening and evaluating risk factors for nonmedical opioid use is critical in oncology palliative medicine.
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Affiliation(s)
- Jai N Patel
- Department of Cancer Pharmacology & Pharmacogenomics, Levine Cancer Institute, Atrium Health, Charlotte, NC
| | - Elizabeth Jandrisevits
- Department of Cancer Pharmacology & Pharmacogenomics, Levine Cancer Institute, Atrium Health, Charlotte, NC
| | - Danielle Boselli
- Department of Biostatistics, Levine Cancer Institute, Atrium Health, Charlotte, NC
| | - Tiffany Michalowski
- Department of Pharmacy, Levine Cancer Institute, Atrium Health, Charlotte, NC
- Department of Supportive Oncology, Section of Palliative Medicine, Levine Cancer Institute, Atrium Health, Charlotte, NC
| | - Armida Parala-Metz
- Department of Supportive Oncology, Section of Palliative Medicine, Levine Cancer Institute, Atrium Health, Charlotte, NC
| | - Declan Walsh
- Department of Supportive Oncology, Section of Palliative Medicine, Levine Cancer Institute, Atrium Health, Charlotte, NC
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10
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Yusufov M, Pirl WF, Braun I, Sannes T, McHugh RK. Toward a Psychological Model of Chemical Coping with Opioids in Cancer Care. Harv Rev Psychiatry 2023; 31:259-266. [PMID: 37948154 PMCID: PMC11060627 DOI: 10.1097/hrp.0000000000000384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
LEARNING OBJECTIVES AFTER PARTICIPATING IN THIS CME ACTIVITY, THE PSYCHIATRIST SHOULD BE BETTER ABLE TO • Outline the risk factors involved with opioid accessibility in patients receiving treatment for cancer.• Identify factors to address in order to mitigate risk for opioid misuse during cancer care. ABSTRACT Most patients with advanced cancer receive treatment for related pain. Opioid accessibility, however, is a risk factor for misuse, which can present care challenges and quality-of-life concerns. There is a lack of consistent universal screening prior to initiation of opioid prescribing. One crucial issue in treating this population is adequately identifying and mitigating risk factors driving opioid misuse. Drawing on theory and research from addiction science, psychology, palliative care, and oncology, the presented conceptual framework suggests that risk factors for opioid misuse during cancer care can be stratified into historical, current, malleable, and unmalleable factors. The framework identifies necessary factors to address in order to mitigate risk for opioid misuse during cancer care, and offers key directions for future research.
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Affiliation(s)
- Miryam Yusufov
- Dana-Farber Cancer Institute, Department of Psychosocial Oncology & Palliative Care, 450 Brookline Avenue, Boston, MA 02215
- Harvard Medical School, Boston, MA 02115
| | - William F. Pirl
- Dana-Farber Cancer Institute, Department of Psychosocial Oncology & Palliative Care, 450 Brookline Avenue, Boston, MA 02215
- Harvard Medical School, Boston, MA 02115
| | - Ilana Braun
- Dana-Farber Cancer Institute, Department of Psychosocial Oncology & Palliative Care, 450 Brookline Avenue, Boston, MA 02215
- Harvard Medical School, Boston, MA 02115
| | - Timothy Sannes
- Dana-Farber Cancer Institute, Department of Psychosocial Oncology & Palliative Care, 450 Brookline Avenue, Boston, MA 02215
- Harvard Medical School, Boston, MA 02115
| | - R. Kathryn McHugh
- McLean Hospital, Center of Excellence in Alcohol, Drugs, and Addiction, 115 Mill Street, Belmont, MA 02478
- Harvard Medical School, Boston, MA 02115
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11
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Roose E, Huysmans E, Lahousse A, Mostaqim K, van Gerven L, Vissers M, Nijs J, Van Wilgen P, Beckwée D, Timmermans A, Bults R, Leysen L. Perceived Injustice in Cancer Survivors: Population-Specific Cut-Off Score and Relations with Personal Factors, Symptoms and Quality of Life-A Cross-Sectional Study. J Clin Med 2023; 12:5780. [PMID: 37762721 PMCID: PMC10531632 DOI: 10.3390/jcm12185780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 08/25/2023] [Accepted: 08/31/2023] [Indexed: 09/29/2023] Open
Abstract
Fatigue and pain are the most common side effects impacting quality of life (QoL) in cancer survivors. Recent insights have shown that perceived injustice (PI) can play a substantial role in these side effects, but research on cancer survivors is scarce. Furthermore, guidelines for recognizing clinically relevant levels of PI in cancer survivors are missing. The aims of this study are to provide a clinically relevant cut-off for PI and to explore relationships between personal characteristics, symptoms, and QoL with PI. This multicenter, cross-sectional study uses the Injustice Experience Questionnaire (IEQ), Numeric Pain Rating Scale (NPRS), Patient-Specific Complaints (PSC), Multidimensional Fatigue Index (MFI), and European Organization for Research and Treatment of Cancer QoL Questionnaire-C30 (EORTC-QLQ-C30). A clinical cut-off for PI was identified based on the 75th percentile of IEQ scores. Univariate and multivariate regressions explored the relationship between PI and personal characteristics (sex, age, cancer type, treatment type), symptoms (pain intensity, fatigue), and QoL (daily activity complaints, cancer-related QoL). Cancer survivors (n = 121) were included, and a cut-off of 20 was identified. Significant indirect associations were found between chemotherapy, NPRS, PSC, MFI, and EORTC-QLQ-C30 with PI. In the multivariate model, only MFI (B = 0.205; 95% CI: 0.125-0.018) and age (B = 0.086; 95% CI: -0.191-0.285) maintained a significant association with PI.
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Affiliation(s)
- Eva Roose
- Pain in Motion Research Group (PAIN), Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education & Physiotherapy, Vrije Universiteit Brussel, 1090 Brussels, Belgium; (E.H.); (A.L.); (K.M.); (J.N.); (P.V.W.); (R.B.); (L.L.)
- Rehabilitation Research Group, Department of Physiotherapy, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090 Brussels, Belgium;
- REVAL, Universiteit Hasselt, Agoralaan-gebouw A, 3590 Diepenbeek, Belgium;
- Department of Physical Medicine and Physiotherapy, Universitair Ziekenhuis Brussel, 1090 Brussels, Belgium
| | - Eva Huysmans
- Pain in Motion Research Group (PAIN), Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education & Physiotherapy, Vrije Universiteit Brussel, 1090 Brussels, Belgium; (E.H.); (A.L.); (K.M.); (J.N.); (P.V.W.); (R.B.); (L.L.)
- Department of Physical Medicine and Physiotherapy, Universitair Ziekenhuis Brussel, 1090 Brussels, Belgium
| | - Astrid Lahousse
- Pain in Motion Research Group (PAIN), Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education & Physiotherapy, Vrije Universiteit Brussel, 1090 Brussels, Belgium; (E.H.); (A.L.); (K.M.); (J.N.); (P.V.W.); (R.B.); (L.L.)
- Rehabilitation Research Group, Department of Physiotherapy, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090 Brussels, Belgium;
- Department of Physical Medicine and Physiotherapy, Universitair Ziekenhuis Brussel, 1090 Brussels, Belgium
- Research Foundation–Flanders (FWO), Leuvensesteenweg 38, 1000 Brussels, Belgium
| | - Kenza Mostaqim
- Pain in Motion Research Group (PAIN), Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education & Physiotherapy, Vrije Universiteit Brussel, 1090 Brussels, Belgium; (E.H.); (A.L.); (K.M.); (J.N.); (P.V.W.); (R.B.); (L.L.)
| | - Lotte van Gerven
- The Berekuyl Academy, Molenweg 4, 3849 Hierden, The Netherlands; (L.v.G.); (M.V.)
| | - Moniek Vissers
- The Berekuyl Academy, Molenweg 4, 3849 Hierden, The Netherlands; (L.v.G.); (M.V.)
| | - Jo Nijs
- Pain in Motion Research Group (PAIN), Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education & Physiotherapy, Vrije Universiteit Brussel, 1090 Brussels, Belgium; (E.H.); (A.L.); (K.M.); (J.N.); (P.V.W.); (R.B.); (L.L.)
- Department of Physical Medicine and Physiotherapy, Universitair Ziekenhuis Brussel, 1090 Brussels, Belgium
- Department of Health and Rehabilitation, Unit of Physiotherapy, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Huvudbyggnad Vasaparken, Universitetsplatsen 1, 41345 Gothenburg, Sweden
| | - Paul Van Wilgen
- Pain in Motion Research Group (PAIN), Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education & Physiotherapy, Vrije Universiteit Brussel, 1090 Brussels, Belgium; (E.H.); (A.L.); (K.M.); (J.N.); (P.V.W.); (R.B.); (L.L.)
- Transcare Pain Transdisciplinary Pain Treatment Center, 9711 Groningen, The Netherlands
| | - David Beckwée
- Rehabilitation Research Group, Department of Physiotherapy, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090 Brussels, Belgium;
- Department of Rehabilitation Sciences and Physiotherapy, Faculty of Medicine and Health Sciences, University of Antwerp, 2610 Wilrijk, Belgium
| | - Annick Timmermans
- REVAL, Universiteit Hasselt, Agoralaan-gebouw A, 3590 Diepenbeek, Belgium;
| | - Rinske Bults
- Pain in Motion Research Group (PAIN), Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education & Physiotherapy, Vrije Universiteit Brussel, 1090 Brussels, Belgium; (E.H.); (A.L.); (K.M.); (J.N.); (P.V.W.); (R.B.); (L.L.)
| | - Laurence Leysen
- Pain in Motion Research Group (PAIN), Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education & Physiotherapy, Vrije Universiteit Brussel, 1090 Brussels, Belgium; (E.H.); (A.L.); (K.M.); (J.N.); (P.V.W.); (R.B.); (L.L.)
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12
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Langford AV, Lin CC, Bero L, Blyth FM, Doctor J, Holliday S, Jeon YH, Moullin J, Murnion B, Nielsen S, Osman R, Penm J, Reeve E, Reid S, Wale J, Schneider CR, Gnjidic D. Clinical practice guideline for deprescribing opioid analgesics: summary of recommendations. Med J Aust 2023; 219:80-89. [PMID: 37356051 DOI: 10.5694/mja2.52002] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 04/14/2023] [Accepted: 04/17/2023] [Indexed: 06/27/2023]
Abstract
INTRODUCTION Long term opioids are commonly prescribed to manage pain. Dose reduction or discontinuation (deprescribing) can be challenging, even when the potential harms of continuation outweigh the perceived benefits. The Evidence-based clinical practice guideline for deprescribing opioid analgesics was developed using robust guideline development processes and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology, and contains deprescribing recommendations for adults prescribed opioids for pain. MAIN RECOMMENDATIONS Eleven recommendations provide advice about when, how and for whom opioid deprescribing should be considered, while noting the need to consider each person's goals, values and preferences. The recommendations aim to achieve: implementation of a deprescribing plan at the point of opioid initiation; initiation of opioid deprescribing for persons with chronic non-cancer or chronic cancer-survivor pain if there is a lack of overall and clinically meaningful improvement in function, quality of life or pain, a lack of progress towards meeting agreed therapeutic goals, or the person is experiencing serious or intolerable opioid-related adverse effects; gradual and individualised deprescribing, with regular monitoring and review; consideration of opioid deprescribing for individuals at high risk of opioid-related harms; avoidance of opioid deprescribing for persons nearing the end of life unless clinically indicated; avoidance of opioid deprescribing for persons with a severe opioid use disorder, with the initiation of evidence-based care, such as medication-assisted treatment of opioid use disorder; and use of evidence-based co-interventions to facilitate deprescribing, including interdisciplinary, multidisciplinary or multimodal care. CHANGES IN MANAGEMENT AS A RESULT OF THESE GUIDELINES To our knowledge, these are the first evidence-based guidelines for opioid deprescribing. The recommendations intend to facilitate safe and effective deprescribing to improve the quality of care for persons taking opioids for pain.
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Affiliation(s)
- Aili V Langford
- Centre for Medicine Use and Safety, Monash University, Melbourne, VIC
- University of Sydney, Sydney, NSW
| | - Christine Cw Lin
- Institute for Musculoskeletal Health, University of Sydney, Sydney, NSW
| | - Lisa Bero
- Center for Bioethics and Humanities, University of Colorado, Aurora (CO), USA
| | | | - Jason Doctor
- University of Southern California, Los Angeles (CA), USA
| | | | | | | | - Bridin Murnion
- University of Sydney, Sydney, NSW
- Western Sydney Local Health District, Sydney, NSW
| | - Suzanne Nielsen
- Monash Addiction Research Centre, Monash University, Melbourne, VIC
| | | | - Jonathan Penm
- University of Sydney, Sydney, NSW
- Prince of Wales Hospital and Community Health Services, Sydney, NSW
| | - Emily Reeve
- Centre for Medicine Use and Safety, Monash University, Melbourne, VIC
- University of South Australia, Adelaide, SA
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13
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Merlin JS, Black AC, Midboe AM, Troszak L, Asch SM, Bohnert A, Fenton BT, Giannitrapani KF, Glassman P, Kerns RD, Silveira M, Lorenz KA, Abel EA, Becker WC. Long-term opioid therapy trajectories and overdose in patients with and without cancer. BMJ ONCOLOGY 2023; 2:e000023. [PMID: 38259328 PMCID: PMC10802123 DOI: 10.1136/bmjonc-2022-000023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
Objective Pain is experienced by most patients with cancer and opioids are a cornerstone of management. Our objectives were (1) to identify patterns or trajectories of long-term opioid therapy (LTOT) and their correlates among patients with and without cancer and (2) to assess the association between trajectories and risk for opioid overdose, considering the potential moderating role of cancer. Methods and Analysis We conducted a retrospective cohort study among individuals in the US Veterans Health Administration (VHA) database with incident LTOT with and without cancer (N=44,351; N=285,772, respectively) between 2010-2017. We investigated the relationship between LTOT trajectory and all International Classification of Diseases-9 and 10-defined accidental and intentional opioid-related overdoses. Results Trajectories of opioid receipt observed in patients without cancer and replicated in patients with cancer were: low-dose/stable trend, low-dose/de-escalating trend, moderate-dose/stable trend, moderate-dose/escalating with quadratic downturn trend, and high-dose/escalating with quadratic downturn trend. Time to first overdose was significantly predicted by higher-dose and escalating trajectories; the two low-dose trajectories conferred similar, lower risk. Conditional hazard ratios (99% CI) for the moderate-dose, moderate-dose/escalating with quadratic downturn and high-dose/escalating with quadratic downturn trends were 1·84 (1·18, 2·85), 2·56 (1·54, 4·25), and 2·41 (1·37, 4·26), respectively. Effects of trajectories on time to overdose did not differ by presence of cancer; inferences were replicated when restricting to patients with stage 3/4 cancer. Conclusion Patients with cancer face opioid overdose risks like patients without cancer. Future studies should seek to expand and address our knowledge about opioid risk in cancer patients. Trial registration None.
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Affiliation(s)
- Jessica S Merlin
- CHAllenges on Managing and Preventing Pain (CHAMPP) Clinical Research Center, University of Pittsburgh, Pittsburgh, PA, USA
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Anne C Black
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
- Health Services Research & Development, VA Connecticut Healthcare System, West Haven, CT, USA
| | - Amanda M Midboe
- VA Palo Alto Healthcare System, Center for Innovation to Implementation, Palo Alto, CA
- Department of Medicine/Primary Care and Population Health, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Lara Troszak
- VA Palo Alto Healthcare System, Center for Innovation to Implementation, Palo Alto, CA
| | - Steven M Asch
- VA Palo Alto Healthcare System, Center for Innovation to Implementation, Palo Alto, CA
- Department of Medicine/Primary Care and Population Health, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Amy Bohnert
- VA Center for Clinical Management Research, Ann Arbor, MI, USA
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Brenda T Fenton
- Health Services Research & Development, VA Connecticut Healthcare System, West Haven, CT, USA
| | - Karleen F Giannitrapani
- VA Palo Alto Healthcare System, Center for Innovation to Implementation, Palo Alto, CA
- Department of Medicine/Primary Care and Population Health, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Peter Glassman
- VA Center for Medication Safety, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Pharmacy Benefits Management Services, Department of Veterans Affairs, Washington, DC, USA
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Robert D Kerns
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
- Health Services Research & Development, VA Connecticut Healthcare System, West Haven, CT, USA
| | - Maria Silveira
- Division of Geriatric and Palliative Medicine, University of Michigan, Ann Arbor, MI, USA
- Division of Palliative Care, Lieutenant Colonel Charles S. Kettles VA Medical Center, Ann Arbor MI, USA
| | - Karl A Lorenz
- VA Palo Alto Healthcare System, Center for Innovation to Implementation, Palo Alto, CA
- Department of Medicine/Primary Care and Population Health, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Erica A Abel
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
- Health Services Research & Development, VA Connecticut Healthcare System, West Haven, CT, USA
| | - William C Becker
- Health Services Research & Development, VA Connecticut Healthcare System, West Haven, CT, USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
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14
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Cherny NI, Ziff-Werman B. Ethical considerations in the relief of cancer pain. Support Care Cancer 2023; 31:414. [PMID: 37351702 DOI: 10.1007/s00520-023-07868-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 06/07/2023] [Indexed: 06/24/2023]
Abstract
The management of pain for patients with cancer and cancer survivors is a critical clinical task that involves a multitude of ethical issues at almost every phase of the cancer experience. This review is divided into three sections: In the first, we address rights and duties in the relief of pain from the perspective of patients, clinicians, health care institutions and organizations, and public policy. This section includes a detailed description of issues and duties in relation to opioid misuse and addiction. In the second section, we discuss the ethical consideration of therapeutic planning. The final section addresses ethical considerations in the management of pain at the end of life including a detailed discussion regarding ethical issues relating to the use of palliative sedation as a clinical intervention of last resort.
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15
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Lewis CES, Schutzer-Weissmann J, Farquhar-Smith P. Opioid use disorder in cancer patients. Curr Opin Support Palliat Care 2023; 17:98-103. [PMID: 36866646 DOI: 10.1097/spc.0000000000000640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
PURPOSE OF REVIEW The misuse of opioids has increased significantly in recent decades. Historically, cancer patients have not been considered at risk of opioid misuse. However, cancer pain is common, and opioids are often prescribed. Guidelines addressing opioid misuse often exclude cancer patients. Given that misuse is associated with significant harm and a reduction in quality of life, it is important to understand the risk of opioid misuse in cancer patients and how we can recognise and treat it. RECENT FINDINGS Early cancer diagnoses and treatments have improved cancer survival rates, leading to a larger population of cancer patients and survivors. Opioid use disorder (OUD) may precede a cancer diagnosis or may develop during or after treatment. The effect of OUD extends from an individual patient to a societal level. This review examines the increasing incidence of OUD in cancer patients, ways to identify patients with OUD such as behaviour change and screening scales, prevention of OUD such as limited and targeted opioid prescriptions, and evidence-based treatment suggestions for OUD. SUMMARY OUD in cancer patients has only relatively recently been recognised as a growing problem. Early identification, involvement of the multidisciplinary team, and treatment can reduce the negative impact of OUD.
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Affiliation(s)
- Cara E S Lewis
- Department of Anaesthesia, Perioperative Medicine, Pain and Critical Care, The Royal Marsden NHS Foundation Trust, London, England
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Wood T, Cheung W, Ruether D, Sinnarajah A, Tanguay R, Tarumi Y, Lau J, Cuthbert CA. Safe Prescribing Practices: Clinicians' Views on Prescribing Opioids to Patients With Early-Stage Cancer. JCO Oncol Pract 2023:OP2200766. [PMID: 37186890 DOI: 10.1200/op.22.00766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023] Open
Abstract
PURPOSE Opioids are often necessary for patients experiencing high-intensity pain. However, side effects exist and some patients may misuse opioids. To better understand how opioids are prescribed to patients with early-stage cancer and how to enhance opioid safety, clinicians' views of opioid prescribing were explored. METHODS This was a qualitative inquiry including any Alberta clinician prescribing opioids to patients with early-stage cancer. Semistructured interviews were conducted with nurse practitioners (NP), medical oncologists (MO), radiation oncologists (RO), surgeons (S), primary care physicians (PCP), and palliative care physicians (PC) between June 2021 and March 2022. Interpretive description was used to analyze the data using two coders (C.C. and T.W.). Debriefing sessions were used to resolve and discrepancies. RESULTS Twenty-four clinicians were interviewed (NP [n = 5], MO [n = 4], RO [n = 4], S [n = 5], PCP [n = 3], and PC [n = 3]). The majority had been in practice at least 10 years. Prescribing practices were related to disciplinary perspective, goals of care, patient condition, and resource availability. Most clinicians did not see opioid misuse as a problem but were aware that specific patient risk factors are present and that long-term use can be problematic. Most clinicians undertake safe prescribing approaches tacitly (eg, screening for past opioid misuse and reviewing number of prescribers) and not all agreed they should be universally applied. Barriers (eg, procedural and time) and facilitators (eg, education) to safe prescribing approaches were identified. CONCLUSION To enhance uptake and cross-disciplinary consistency of safe prescribing approaches, clinician education regarding opioid misuse and benefits of safe prescribing practices, and addressing procedural barriers are necessary.
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Affiliation(s)
- Timothy Wood
- Faculty of Nursing, University of Calgary, Calgary, AB, Canada
| | - Winson Cheung
- Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Dean Ruether
- Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | | | - Robert Tanguay
- Department of Psychiatry, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Yoko Tarumi
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Jenny Lau
- Department of Supportive Care, University of Toronto, Toronto, ON, Canada
| | - Colleen Ann Cuthbert
- Faculty of Nursing, University of Calgary, Calgary, AB, Canada
- Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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Jones KF, Malinowski J, Paice J, Childers J, Bulls HW, Morrison J, Ho JJ, Alsbrook K, Nugent S, Broglio K, Nickels K, Holbein M, Parajuli J, Merlin JS. Opioid-prescribing considerations in patients with cancer and substance misuse or substance use disorder: a scoping review protocol. JBI Evid Synth 2023; 21:812-825. [PMID: 36404752 PMCID: PMC10260276 DOI: 10.11124/jbies-22-00007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE This scoping review aims to describe factors in the existing literature that may inform opioid-prescribing decisions for patients with a past or present history of cancer and past or present substance misuse or substance use disorder. INTRODUCTION Opioids and opioid-related decisions are critical components of cancer care. Most individuals with cancer will experience pain during cancer care, and over half of patients will receive an opioid prescription. Opioid-prescribing decisions require weighing the benefits and harms. The presence of substance misuse or substance use disorder may elevate the risk of opioid-related harms, but there is a lack of consensus on managing patients at this intersection. INCLUSION CRITERIA This review will consider studies that include adult patients with a past or present history of cancer who also have pain and current or historical substance misuse or substance use disorder. The pain may be cancer-related or non-cancer-related. Studies of patients with all types of cancer will be eligible for inclusion, with the exception of non-melanoma skin cancers. Eligible studies will explore factors that inform opioid-prescribing decisions in this patient population. METHODS The review will be conducted according to JBI methodology for scoping reviews. Studies written in English since database inception will be included. The databases to be searched include MEDLINE (Ovid), CINAHL (EBSCO), Embase, APA PsycINFO, and Google Scholar. Eligible studies will undergo data extraction by 2 independent reviewers using a data extraction tool created by the authors. A narrative summary will describe study characteristics, population details, and strategies used to determine appropriate pain management in the patient population.
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Affiliation(s)
| | | | - Judith Paice
- Division Hematology-Oncology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Julie Childers
- Section of Palliative Care and Medical Ethics and Palliative Research Center, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Hailey W. Bulls
- Section of Palliative Care and Medical Ethics and Palliative Research Center, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jeni Morrison
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - J. Janet Ho
- University of California San Francisco, San Francisco, CA, USA
| | - Karen Alsbrook
- School of Nursing, University of Pittsburgh, Pittsburgh, PA, USA
| | - Shannon Nugent
- Division of Clinical Psychology, School of Medication at the VA Portland Healthcare System, Portland, ME, USA
| | | | - Katrina Nickels
- Department of Psychiatry, University of Kentucky, Lexington, KY, USA
| | - Monika Holbein
- Section of Hematology/Oncology, West Virginia University, Morgantown, WV, USA
| | | | - Jessica S. Merlin
- MBA Section of Palliative Care and Medical Ethics and Palliative Research Center, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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Afezolli D, Flemig D, Easton E, Austin V, Scarborough B, Smith CB. Standard Naloxone Prescribing for Palliative Care Cancer Patients on Opioid Therapy: A Single-Site Quality Improvement Pilot to Assess Attitudes and Access. J Pain Symptom Manage 2023; 65:e309-e314. [PMID: 36586519 DOI: 10.1016/j.jpainsymman.2022.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 12/16/2022] [Accepted: 12/20/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND Limited data exist on when to offer naloxone to cancer patients on opioid therapy. MEASURES We assessed patient and clinician attitudes on naloxone education (done via surveys at initial and follow up visits) and prescribing rates (via chart reviews) at a single ambulatory palliative care practice. Pharmacy records assessed naloxone dispense rates. INTERVENTION During a three-month period, all new patients receiving opioid therapy were offered naloxone. Standardized educational materials on opioid safety and naloxone use were created and shared by clinical team. OUTCOMES Naloxone prescribing rates increased from 5% to 66%. 92% (n = 23) of clinicians reported education/prescribing took ≤ five minutes, and 100% reported either a positive or neutral impact on the encounter. A total of 81% (n = 25) of patients reported no increased worry about opioid use, 68% (n = 21) felt safer with naloxone, and 97% rated the encounter as neutral or positive. 88% (n = 37) of prescriptions were dispensed and 67% of patients (n = 16) paid <$10. CONCLUSIONS/LESSONS LEARNED Opioid safety education and naloxone prescribing can be done quickly and is well-received by clinicians and patients.
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Affiliation(s)
- Debora Afezolli
- Brookdale Department of Geriatrics and Palliative Medicine (D.A.), Icahn School of Medicine, New York, New York, USA.
| | - David Flemig
- Hennepin Healthcare (D.F.), Minneapolis, Minnesota, USA
| | - Eve Easton
- Brookdale Department of Geriatrics and Palliative Medicine (E.E., V.A.), Mount Sinai Hospital, New York, New York, USA
| | - Vanessa Austin
- Brookdale Department of Geriatrics and Palliative Medicine (E.E., V.A.), Mount Sinai Hospital, New York, New York, USA
| | | | - Cardinale B Smith
- Division of Hematology/Medical Oncology and Brookdale Department of Geriatrics and Palliative Medicine (C.B.S.), Icahn School of Medicine at Mount Sinai, New York, New York, USA
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19
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Smith DM, Figg WD. Evidence Regarding Pharmacogenetics in Pain Management and Cancer. Oncologist 2023; 28:189-192. [PMID: 36718020 PMCID: PMC10020807 DOI: 10.1093/oncolo/oyac277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 12/15/2022] [Indexed: 02/01/2023] Open
Abstract
Patients experience interindividual variation in response to analgesics, which may be partially explained by genetics. This commentary discusses a recently published trial on COMT genotype and opioid dose requirements and describes the potential role for COMT and other genes (eg, CYP2D6) on opioid therapy and the current evidence for germline pharmacogenetics and resources for opioid pharmacogenetics.
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Affiliation(s)
- D Max Smith
- Corresponding author: D. Max Smith, PharmD, MedStar Health, 3007 Tilden Street NW, Suite 7L, Washington, DC 20008, USA.
| | - William D Figg
- Molecular Pharmacology Section, Genitourinary Malignancies Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
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20
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Canick JE, Bhardwaj A, Patel A, Kuziez D, Larsen R, Misra S, Pearson B, Smith BD, Rohde RL, Adjei Boakye E, Kahmke RR, Osazuwa-Peters N. Sociodemographic Differences in Patient-Reported Pain and Pain Management of Patients With Head and Neck Cancer in a Community Oncology Setting. JCO Oncol Pract 2023; 19:e397-e406. [PMID: 36480772 PMCID: PMC10022872 DOI: 10.1200/op.22.00132] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Revised: 09/20/2022] [Accepted: 10/12/2022] [Indexed: 12/14/2022] Open
Abstract
PURPOSE While pain is prevalent among survivors of head and neck cancer (HNC), there is a lack of data on pain management in the community oncology setting. We described sociodemographic correlates and disparities associated with patient-reported pain among patients with HNC. METHODS We used the 2017-2021 nationwide community oncology data set from Navigating Cancer, which included electronic patient-reported outcomes. We identified a retrospective cohort of patients diagnosed with HNC (N = 25,572), with ≥ 1 patient-reported pain event. We adjusted for demographic (sex, age, smoking history, marital status) and clinical (cancer site) factors associated with pain reporting and pain resolution by new pain prescription on the basis of race (White v non-White patients), using multivariate logistic regression models. RESULTS Our analytic cohort included 2,331 patients, 90.58% White, 58.62% married, with an average age of 66.47 years. Of these, 857 patients (36.76%) reported ≥ 1 pain event during study period. Mean resolution time (in minutes) for pain incidents was significantly longer for White patients than non-White patients (99.6 ± 3.2 v 74.9 ± 7.2, P < .05). After adjusting for covariates, smoking was associated with a 25% increased odds of reporting pain incidents (adjusted odds ratio [aOR], 1.25; 95% CI, 1.03 to 1.52). There was no statistically significant difference in odds of pain reporting between White versus non-White patients (aOR, 0.97; 95% CI, 0.73 to 1.30). However, White patients were significantly more likely to receive new prescription for pain than non-White patients (aOR, 2.52; 95% CI, 1.09 to 5.86). CONCLUSION We found racial differences in patient-reported pain management, with White patients significantly more likely to receive new pain prescriptions. As pain management is a mainstay in cancer care, equity in pain management is critical to optimize quality of life for patients with HNC.
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Affiliation(s)
- Julia E. Canick
- Duke University School of Medicine, Department of Head and Neck Surgery & Communication Sciences, Durham, NC
| | | | | | - Duaa Kuziez
- Wake Forest School of Medicine, Department of Surgery, Winston-Salem, NC
| | | | | | | | - Blaine D. Smith
- Duke University School of Medicine, Department of Head and Neck Surgery & Communication Sciences, Durham, NC
| | - Rebecca L. Rohde
- Medical College of Wisconsin, Department of Otolaryngology & Communication Sciences, Milwaukee, WI
| | - Eric Adjei Boakye
- Henry Ford Health System, Department of Otolaryngology-Head & Neck Surgery, Detroit, MI
- Henry Ford Health System, Department of Population Health Sciences, Detroit, MI
| | - Russel R. Kahmke
- Duke University School of Medicine, Department of Head and Neck Surgery & Communication Sciences, Durham, NC
- Duke Cancer Institute, Durham, NC
| | - Nosayaba Osazuwa-Peters
- Duke University School of Medicine, Department of Head and Neck Surgery & Communication Sciences, Durham, NC
- Duke Cancer Institute, Durham, NC
- Duke University School of Medicine, Department of Population Health Sciences, Durham, NC
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21
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Lee YH, Chang YC, Nabil AK, Barry AE. Self-reported reasons for opioid and analgesic misuse among participants without cancer in the United States. JOURNAL OF SUBSTANCE USE 2023. [DOI: 10.1080/14659891.2023.2173096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Yen-Han Lee
- Department of Health Sciences, University of Central Florida, Orlando, Florida, USA
| | - Yen-Chang Chang
- Center for General Education, National Tsing Hua University, Hsinchu, Taiwan
| | - Anas Khurshid Nabil
- Department of Health Behavior, Texas A&M University, College Station, Texas, USA
| | - Adam E. Barry
- Department of Health Behavior, Texas A&M University, College Station, Texas, USA
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22
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Chavez MN, Marshall VK, Martinez Tyson D, Mason TM, Rechenberg K. Psychological Impact of COVID-19 on Oncology Patients: Perceptions of Oncology Health Care Providers. West J Nurs Res 2023; 45:152-160. [PMID: 35897163 PMCID: PMC10079896 DOI: 10.1177/01939459221114634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The COVID-19 pandemic profoundly impacted psychological well-being worldwide. Oncology health care professionals' (OHCPs') perceptions of psychological effects of COVID-19 among people in active cancer treatment were explored. Semi-structured interviews with a purposive sample of OHCPs actively providing care were conducted. Interviews were audio-recorded, transcribed, and coded using Atlas.ti v8 and thematic analysis. In total, 30 OHCPs participated. Most were registered nurses (70%), worked in outpatient setting (56.7%) and were in their current position 1-5 years (53.3%). Overarching themes are as follows: (a) cancer treatment disrupted due to patients' fear of exposure to COVID-19; (b) social distancing restrictions caused discontinued social support and supportive services that exacerbated psychological distress; (c) pandemic-related stressors led to overwhelmed coping skills; and (d) OHCPs played a vital role in providing emotional support and connecting patients with family/friends through technology. Behavioral health interventions should focus within the "new world of COVID-19" of reduced face-to-face support and increased online support for patients.
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Affiliation(s)
- Melody N. Chavez
- College of Public Health, University of
South Florida, Tampa, FL, USA
| | | | | | - Tina M. Mason
- H. Lee Moffitt Cancer Center &
Research Institute, Tampa, FL, USA
- Tina M. Mason, Department of Nursing
Research, H. Lee Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL 33612,
USA.
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23
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Kwon MY, Lee MY, Han YJ, Lee SH, Kim EJ, Park S, Lee Y, Koo DH. Predicting tolerability of high-dose fentanyl buccal tablets in cancer patients. PLoS One 2023; 18:e0280212. [PMID: 36608031 PMCID: PMC9821425 DOI: 10.1371/journal.pone.0280212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 12/22/2022] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND & AIMS Fentanyl buccal tablets (FBTs) are a rapid-onset opioid indicated for breakthrough cancer pain (BTcP) and FBT titration is needed to optimize BTcP management. We aimed to predict which patients could tolerate a high dose of FBT (400 μg or more at a time). METHODS A retrospective analysis was performed to assess the final FBT dose. The final FBT doses were compared according to the clinical features. The prediction accuracy of patients tolerant of 400 μg or higher FBT was compared using the area under the receiver operating characteristic (ROC) curves. A risk scoring model based on the odds ratio (OR) was developed from the final multivariable model, and patients were assigned into two groups: low tolerance (0-1 point) and high tolerance (2-3 points). RESULTS Among 131 patients, the most frequently effective dose of FBT was 200 μg (54%), followed by 100 μg (30%). The median value of morphine equivalent daily doses (MEDD) was 60 mg/day, and the most common daily use was 3-4 times/day. In multivariable analysis, male sex, younger age, and use of FBTs three or more times per day were independently associated with high-dose FBT. According to the risk scoring model, the patients with a final FBT of 400 μg or higher were significantly more in the high tolerance group (17%) compared to the low tolerance group (3%; p = 0.023). CONCLUSIONS According to the dose relationship between the final FBT dose and the clinical features, three factors (sex, age, daily use of FBT) were independently associated with the final dose of FBT. Our risk score model could help predict tolerance to high-dose FBT and guide the titration plan for BTcP.
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Affiliation(s)
- Mi-Young Kwon
- Department of Anesthesiology and Pain Medicine, National Medical Center, Seoul, Korea
| | - Mi-Yeon Lee
- Division of Biostatistics, Department of R&D Management, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yun Jae Han
- Department of Anesthesiology and Pain Medicine, National Medical Center, Seoul, Korea
| | - Sung Hyun Lee
- Department of Anesthesiology and Pain Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Eo Jin Kim
- Division of Hematology/Oncology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Songyi Park
- Division of Hematology/Oncology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yun‑Gyoo Lee
- Division of Hematology/Oncology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dong-Hoe Koo
- Division of Hematology/Oncology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
- * E-mail:
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24
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Opioid Use Behaviors Among People With Disability in the United States: An Analysis of the National Survey on Drug Use and Health. J Addict Med 2023; 17:e27-e35. [PMID: 35861360 DOI: 10.1097/adm.0000000000001031] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE People with disability (PWD) often experience chronic pain, and opioid is widely used prescription medication. However, population-based evidence of opioid use behaviors among PWD is lacking. This study examined the prevalence of opioid use behaviors by sociodemographic and health-related characteristics among PWD compared with people without disability (PWoD). METHODS This cross-sectional study used data from 2015-2019 National Survey on Drug Use and Health. Three types of opioid use behaviors (any use, misuse, and use disorder) were defined and compared by disability status. Five self-reported disability types were measured, including hearing, vision, cognitive, mobility, and complex activity limitations. Complex survey design-adjusted descriptive and logistic regression models were used for statistical analysis. RESULTS Of 201,376 respondents aged 18 years or older, 34.6% reported any opioid use, 4.2% opioid misuse, and 0.8% opioid use disorder. Compared with PWoD, PWD had higher prevalence of any opioid use (49.7% vs 30.7%), misuse (6.2% vs 3.7%), and use disorder (1.7% vs 0.8%). In adjusted analysis, PWD with mobility limitation (odds ratio [OR], 1.95; 95% confidence interval, 1.81-2.11) or multiple limitations (OR, 1.92; 95% CI, 1.83-2.02) were almost 2 times more likely to report any opioid use than PWoD. The likelihood of reporting any opioid use (ORs, 1.42-2.50), misuse (ORs, 1.24-2.41), and disorder (ORs, 1.38-2.54) increased as the number of limitations increased. CONCLUSIONS People with vision, cognitive, or multiple limitations had higher rates of opioid misuse and disorder than PWoD. Development of more inclusive opioid abuse prevention strategies for PWD is warranted.
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25
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Hamlish T, Pasquinelli M, Gastala N, Huber M, Manst D, Andersen K, Jarrett JB, Neeb C, Tuite J, Maes P, Sung C, Fleurimont J, Feldman L. A team-based approach to effective management of pain and opioid use disorder in patients with cancer: Case report. CURRENT PROBLEMS IN CANCER: CASE REPORTS 2022. [DOI: 10.1016/j.cpccr.2022.100196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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26
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Binswanger IA, Shetterly SM, Xu S, Narwaney KJ, McClure DL, Rinehart DJ, Nguyen AP, Glanz JM. Opioid Dose Trajectories and Associations With Mortality, Opioid Use Disorder, Continued Opioid Therapy, and Health Plan Disenrollment. JAMA Netw Open 2022; 5:e2234671. [PMID: 36197665 PMCID: PMC9535531 DOI: 10.1001/jamanetworkopen.2022.34671] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
IMPORTANCE Uncertainty remains about the longer-term benefits and harms of different opioid management strategies, such as tapering and dose escalation. For instance, opioid tapering could help patients reduce opioid exposure to prevent opioid use disorder, but patients may also seek care elsewhere and engage in nonprescribed opioid use. OBJECTIVE To evaluate the association between opioid dose trajectories observed in practice and patient outcomes. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study was conducted in 3 health systems in Colorado and Wisconsin. The study population included patients receiving long-term opioid therapy between 50 and 200 morphine milligram equivalents between August 1, 2014, and July 31, 2017. Follow-up ended on December 31, 2019. Data were analyzed from January 2020 to August 2022. EXPOSURES Group-based trajectory modeling identified 5 dosing trajectories over 1 year: 1 decreasing, 1 high-dose increasing, and 3 stable. MAIN OUTCOMES AND MEASURES Primary outcomes assessed after the trajectory period were 1-year all-cause mortality, incident opioid use disorder, continued opioid therapy at 1 year, and health plan disenrollment. Associations were tested using Cox proportional hazards regression and log-binomial models, adjusting for baseline covariates. RESULTS A total of 3913 patients (mean [SD] age, 59.2 [14.4] years; 2767 White non-Hispanic [70.7%]; 2237 female patients [57.2%]) were included in the study. Compared with stable trajectories, the decreasing dose trajectory was negatively associated with opioid use disorder (adjusted hazard ratio [aHR], 0.40; 95% CI, 0.29-0.55) and continued opioid therapy (site 1: adjusted relative risk [aRR], 0.39; 95% CI, 0.34-0.44), but was positively associated with health plan disenrollment (aHR, 1.66; 95% CI, 1.24-2.22). The decreasing trajectory was not associated with mortality (aHR, 1.28; 95% CI, 0.87-1.86). In contrast, the high-dose increasing trajectory was positively associated with mortality (aHR, 2.19; 95% CI, 1.44-3.32) and opioid use disorder (aHR, 1.81; 95% CI, 1.39-2.37) but was not associated with disenrollment (aHR, 0.90; 95% CI, 0.56-1.42) or continued opioid therapy (site 1: aRR, 0.98; 95% CI, 0.94-1.03). CONCLUSIONS AND RELEVANCE In this cohort study, decreasing opioid dose was associated with reduced risk of opioid use disorder and continued opioid therapy but increased risk of disenrollment compared with stable dosing, whereas the high-dose increasing trajectory was associated with an increased risk of mortality and opioid use disorder. These findings can inform opioid management decision-making.
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Affiliation(s)
- Ingrid A. Binswanger
- Institute for Health Research, Kaiser Permanente Colorado, Aurora
- Chemical Dependency Treatment Services, Colorado Permanente Medical Group, Aurora
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
| | | | - Stanley Xu
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | | | - David L. McClure
- Center for Clinical Epidemiology and Population Health, Marshfield Clinic Research Institute, Marshfield, Wisconsin
| | - Deborah J. Rinehart
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora
- Center for Health Systems Research, Office of Research, Denver Health and Hospital Authority, Denver, Colorado
| | - Anh P. Nguyen
- Institute for Health Research, Kaiser Permanente Colorado, Aurora
| | - Jason M. Glanz
- Institute for Health Research, Kaiser Permanente Colorado, Aurora
- Department of Epidemiology, Colorado School of Public Health, Aurora
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27
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Akui C, Kimura T, Hirose M. Associations between insomnia and central sensitization in cancer survivors undergoing opioid therapy for chronic cancer pain: A STROBE-compliant prospective cohort study. Medicine (Baltimore) 2022; 101:e30845. [PMID: 36197271 PMCID: PMC9509184 DOI: 10.1097/md.0000000000030845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Several risk factors for insomnia in cancer patients have been recognized, including chronic pain and treatment with opioid. Although associations between insomnia and central sensitization were previously reported in patients with chronic non-cancer pain, those have not been elucidated among cancer survivors undergoing opioid therapy for chronic cancer pain. To investigate the associations between insomnia and central sensitization among cancer survivors undergoing opioid therapy for chronic cancer pain, consecutive patients undergoing chemotherapy with chronic cancer pain under opioid therapy on an outpatient basis were enrolled from September 2019 to August 2020 and answered questions from the Athens Insomnia Scale (AIS) for assessing insomnia. Pain characteristics, including pain intensity, neuropathic pain, central sensitization assessed using the central sensitization inventory (CSI), opioid use disorder, and pain-related psychological symptoms were also examined. Uni- and multivariate regression analyses were performed to elucidate correlations between the AIS score and these pain characteristics. Of 44 enrolled patients, 20 patients completed to answer all questions. Insomnia was identified in 9 patients (45%). Although AIS scores showed no significant associations with pain intensity, neuropathic pain, opioid use disorder, or psychological symptoms, multivariate regression analysis revealed that CSI scores showed a positive relationship with AIS scores (P = .004). Discrimination was assessed using linear regression analysis which confirmed a significant association between the AIS and CSI scores (P = .002). Insomnia appears to be associated with central sensitization in cancer survivors with chronic cancer pain under opioid therapy.
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Affiliation(s)
- Chiaki Akui
- Department of Anesthesiology and Pain Medicine, Hyogo Medical University (Formerly Hyogo College of Medicine), School of Medicine, Nishinomiya, Hyogo, Japan
- Department of Pharmacy, Hyogo Medical University Hospital, Hyogo, Japan
| | - Takeshi Kimura
- Department of Pharmacy, Hyogo Medical University Hospital, Hyogo, Japan
| | - Munetaka Hirose
- Department of Anesthesiology and Pain Medicine, Hyogo Medical University (Formerly Hyogo College of Medicine), School of Medicine, Nishinomiya, Hyogo, Japan
- *Correspondence: Munetaka Hirose, Department of Anesthesiology and Pain Medicine, Hyogo Medical University (Formerly Hyogo College of Medicine), School of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Hyogo 663-8501, Japan (e-mail: )
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28
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Treatment with opioids in patients with locally advanced or metastatic urothelial carcinoma and matched non-cancer controls. Urol Oncol 2022; 40:411.e9-411.e18. [DOI: 10.1016/j.urolonc.2022.06.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 04/19/2022] [Accepted: 06/16/2022] [Indexed: 11/24/2022]
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Beauchemin MP, Raghunathan RR, Accordino MK, Cogan JC, Kahn JM, Wright JD, Hershman DL. New persistent opioid use among adolescents and young adults with sarcoma. Cancer 2022; 128:2777-2785. [PMID: 35599575 PMCID: PMC10664461 DOI: 10.1002/cncr.34238] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 03/16/2022] [Accepted: 03/24/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Adolescents and young adults (AYA) with sarcoma experience both acute and chronic pain related to their disease and treatment. Studies in older adults have reported a high risk of persistent opioid use after cancer therapy among previously opioid-naive patients; however, few studies have evaluated posttreatment opioid use among AYAs. This article describes patterns of new persistent opioid use among AYAs in the year after treatment for sarcoma. METHODS Opioid-naive patients who were 10 to 26 years old and diagnosed with sarcoma (2008-2016) were identified with the IBM Marketscan Database. Included subjects had an International Classification of Diseases code for sarcoma (ninth or tenth revision), received anticancer therapy (chemotherapy, surgery, and/or radiation) within 30 days of the first diagnosis code, and had continuous insurance coverage (commercial or Medicaid) for more than 12 months both before the diagnosis and after the last therapy. The primary outcome was new persistent opioid use, which was defined as at least 2 opioid prescriptions in the 12 months following treatment completion. Covariates included age, sex, insurance, tumor type, surgical procedure, mental health (MH) or substance use diagnoses before or during therapy, and concomitant lorazepam use. RESULTS In total, 938 patients met the inclusion criteria; 521 (56%) were male, and 578 (62%) were younger than 18 years. In total, 727 (78%) had commercial insurance, and 273 (29%) had an MH diagnosis either before or during the treatment period. Of the total group, 464 (49%) used opioids during treatment only. Of those who used opioids during treatment, 135 (23%) received at least 2 prescriptions in the year after therapy. In a multivariable analysis, Medicaid versus commercial insurance (odds ratio [OR], 1.74; 95% confidence interval [CI], 1.15-2.64) and non-soft tissue sarcoma (OR for Ewing sarcoma, 3.23; 95% CI, 1.81-5.78; OR for osteosarcoma, 2.05; 95% CI, 1.36-3.09) conferred a higher likelihood of new persistent use. CONCLUSIONS In this cohort of AYAs treated for sarcoma, 64% of the patients received opioid prescriptions during treatment, and 23% of these patients became new persistent users. Because of the risks associated with persistent opioid use, studies of novel pain management strategies along with age-appropriate education and anticipatory guidance are urgently needed. LAY SUMMARY Using an insurance claims database, we conducted a study to determine the rate of new persistent opioid use among adolescents and young adults treated for sarcoma. We found that 64% of adolescents and young adults treated for sarcoma received opioid prescriptions during treatment, and 23% of these patients met the criteria for new persistent opioid use. These findings support the need for age-appropriate education and novel pain management strategies in this vulnerable population.
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Affiliation(s)
- Melissa P. Beauchemin
- School of Nursing, Columbia University Irving Medical Center, New York, New York
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, New York
- Division of Pediatric Hematology/Oncology/Stem Cell Transplantation, Department of Pediatrics, Columbia University Irving Medical Center, New York, New York
| | - Rohit R. Raghunathan
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, New York
| | - Melissa K. Accordino
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, New York
- Division of Hematology/Oncology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Jacob C. Cogan
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, New York
- Division of Hematology/Oncology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Justine M. Kahn
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, New York
- Division of Pediatric Hematology/Oncology/Stem Cell Transplantation, Department of Pediatrics, Columbia University Irving Medical Center, New York, New York
| | - Jason D. Wright
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, New York
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, New York
| | - Dawn L. Hershman
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, New York
- Division of Hematology/Oncology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
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Fitzgerald Jones K, Khodyakov D, Arnold R, Bulls H, Dao E, Kapo J, Meier D, Paice J, Liebschutz J, Ritchie C, Merlin J. Consensus-Based Guidance on Opioid Management in Individuals With Advanced Cancer-Related Pain and Opioid Misuse or Use Disorder. JAMA Oncol 2022; 8:1107-1114. [PMID: 35771550 DOI: 10.1001/jamaoncol.2022.2191] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Importance Opioid misuse and opioid use disorder (OUD) are important comorbidities in people with advanced cancer and cancer-related pain, but there is a lack of consensus on treatment. Objective To develop consensus among palliative care and addiction specialists on the appropriateness of various opioid management strategies in individuals with advanced cancer-related pain and opioid misuse or OUD. Design, Setting, and Participants For this qualitative study, using ExpertLens, an online platform and methodology for conducting modified Delphi panels, between August and October 2020, we conducted 2 modified Delphi panels to understand the perspectives of palliative and addiction clinicians on 3 common clinical scenarios varying by prognosis (weeks to months vs months to years). Of the 129 invited palliative or addiction medicine specialists, 120 participated in at least 1 round. A total of 84 participated in all 3 rounds. Main Outcomes and Measures Consensus was investigated for 3 clinical scenarios: (1) a patient with a history of an untreated opioid use disorder, (2) a patient taking more opioid than prescribed, and (3) a patient using nonprescribed benzodiazepines. Results Participants were mostly women (47 [62%]), White (94 (78 [65%]), and held MD/DO degrees (115 [96%]). For a patient with untreated OUD, regardless of prognosis, it was deemed appropriate to begin treatment with buprenorphine/naloxone and inappropriate to refer to a methadone clinic. Beginning split-dose methadone was deemed appropriate for patients with shorter prognoses and of uncertain appropriateness for those with longer prognoses. Beginning a full opioid agonist was deemed of uncertain appropriateness for those with a short prognosis and inappropriate for those with a longer prognosis. Regardless of prognosis, for a patient with no medical history of OUD taking more opioids than prescribed, it was deemed appropriate to increase monitoring, inappropriate to taper opioids, and of uncertain appropriateness to increase the patient's opioids or transition to buprenorphine/naloxone. For a patient with a urine drug test positive for non-prescribed benzodiazepines, regardless of prognosis, it was deemed appropriate to increase monitoring, inappropriate to taper opioids and prescribe buprenorphine/naloxone. Conclusions and Relevance The findings of this qualitative study provide urgently needed consensus-based guidance for clinicians and highlight critical research and policy gaps.
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Affiliation(s)
- Katie Fitzgerald Jones
- William F. Connell School of Nursing, Boston College, Chestnut Hill, Massachusetts.,VA Boston Healthcare System, Boston, Massachusetts
| | | | - Robert Arnold
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Hailey Bulls
- CHAllenges in Managing and Preventing Pain (CHAMPP) Clinical Research Center, Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Emily Dao
- RAND Corporation, Santa Monica, California
| | - Jennifer Kapo
- MSCE Palliative Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Diane Meier
- Department of Geriatrics and Palliative Medicine, Center to Advance Palliative Care, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Judith Paice
- RN Feinberg School of Medicine, Division of Hematology-Oncology, Northwestern University, Chicago, Illinois
| | - Jane Liebschutz
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Christine Ritchie
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston
| | - Jessica Merlin
- CHAllenges in Managing and Preventing Pain (CHAMPP) Clinical Research Center, Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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Zylberberg HM, Woodrell C, Rustgi SD, Aronson A, Kessel E, Amin S, Lucas AL. Opioid Prescription Is Associated With Increased Survival in Older Adult Patients With Pancreatic Cancer in the United States: A Propensity Score Analysis. JCO Oncol Pract 2022; 18:e659-e668. [PMID: 34990289 DOI: 10.1200/op.21.00488] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 10/12/2021] [Accepted: 11/12/2021] [Indexed: 12/14/2022] Open
Abstract
PURPOSE Few studies have assessed the interaction between pain treatment and mortality in pancreatic cancer. The aim of this study was to investigate the association between receipt of opioid prescriptions and survival in adults with pancreatic cancer. METHODS The SEER-Medicare linked database was used to identify patients diagnosed with late-stage pancreatic cancer between 2007 and 2015. Kaplan-Meier models were used to assess the association between opioid prescriptions in the year after cancer diagnosis and survival. Cox proportional hazard models were used to determine the association between opioid receipt and survival, adjusting for propensity score and other relevant confounders including cancer-directed therapies and palliative care referral. RESULTS A total of 5,770 older adults with pancreatic cancer were identified; 1,678 (29.1%) were prescribed opioids for at least 60 days. Median survival was increased in those with opioid prescriptions (6.0 months) compared with those without (4.0 months, P < .0001). After adjustment for confounders, opioid prescriptions were still associated with improved survival (hazard ratio 0.80; 95% CI, 0.75 to 0.86). On multivariable analysis, opioid prescriptions were associated with older age, female sex, residing in nonmetro areas, and treatment with celiac plexus neurolysis, chemotherapy, and radiation. CONCLUSION Receipt of opioid prescriptions is associated with longer survival in patients with pancreatic cancer. This may be due to the impact of cancer-related pain, although further studies are needed to better understand the interaction between pain management, cancer-directed therapies, and systemic factors, such as palliative care, availability of opioids, and clinical practice culture.
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Affiliation(s)
- Haley M Zylberberg
- Division of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Christopher Woodrell
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
- Geriatric Research, Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY
| | - Sheila D Rustgi
- Division of Digestive and Liver Disease, Department of Medicine, Columbia University Medical Center, New York, NY
| | - Anne Aronson
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Elizabeth Kessel
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Sunil Amin
- Division of Gastroenterology, University of Miami Leonard Miller School of Medicine, Miami, FL
| | - Aimee L Lucas
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY
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Lowry S. When Management of Cancer-Related Pain Is Complicated by Coexisting Opioid Use Disorder: A Case Review. J Hosp Palliat Nurs 2022; 24:112-118. [PMID: 35045051 DOI: 10.1097/njh.0000000000000828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Patients with cancer are living longer, and many experience pain secondary to tumor invasion or as a consequence of cancer-directed therapies. Opioid use disorders and associated morbidity and mortality have increased with dramatic rise during the SARS-CoV-2 pandemic. National and international stakeholders have developed clinical practice guidelines in an effort to curb opioid misuse and overdose-related death. However, to ensure that patients with cancer do not experience barriers to adequate pain management, most of these guidelines are not intended for patients with cancer-related pain or for those receiving palliative or hospice care. Oncology, palliative, and hospice care providers are increasingly tasked with the management of severe disease-related pain in the setting of coexisting opioid use disorder without research on the most effective risk and harm reduction strategies to guide care. Clinicians should be familiar with addiction medicine and chronic pain literature and be able to incorporate some of these best practices. This case study reviews the management of severe cancer-related pain in a patient with co-occurring opioid use disorder, utilizing many of the best practices in available clinical practice guidelines for the management of chronic non-cancer-related pain.
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Affiliation(s)
- Sarah Lowry
- Sarah Lowry, DNP, ACPN-BC, AOCNP, ACHPN, is nurse practitioner, Knight Cancer Institute Community Hematology Oncology, and assistant professor, School of Medicine, Oregon Health & Science University, Portland
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Check DK, Avecilla RAV, Mills C, Dinan MA, Kamal AH, Murphy B, Rezk S, Winn A, Oeffinger KC. Opioid Prescribing and Use Among Cancer Survivors: A Mapping Review of Observational and Intervention Studies. J Pain Symptom Manage 2022; 63:e397-e417. [PMID: 34748896 DOI: 10.1016/j.jpainsymman.2021.10.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 10/22/2021] [Accepted: 10/23/2021] [Indexed: 12/12/2022]
Abstract
CONTEXT Recent years show a sharp increase in research on opioid use among cancer survivors, but evidence syntheses are lacking, leaving knowledge gaps. Corresponding research needs are unclear. OBJECTIVES To provide an evidence synthesis. METHODS We searched PubMed and Embase, identifying articles related to cancer, and opioid prescribing/use published through September 2020. We screened resulting titles/abstracts. Relevant studies underwent full-text review. Inclusion criteria were quantitative examination of and primary focus on opioid prescribing or use, and explicit inclusion of cancer survivors. Exclusion criteria included end-of-life opioid use and opioid use as a secondary or downstream outcome (for intervention studies). We extracted information on the opioid-related outcome(s) examined (including definitions and terminology used), study design, and methods. RESULTS Research returned 16,591 articles; 296 were included. Only 22 of 296 studies evaluated an intervention. There were 105 studies evaluating outcomes indicative of potentially high-risk, nonrecommended, or avoidable opioid use, e.g., continuous use-described as chronic use, prolonged use, and persistent use (n = 17); use after completion of curative-intent treatment-described as chronic opioid use, long-term opioid use, persistent opioid use, prolonged opioid use, continued opioid use, late opioid use, post-treatment opioid use (n = 27); use of opioids concurrent with other potentially high-risk medications (n = 13), and opioid misuse (n = 14). CONCLUSIONS We found lack of consistency in the measurement of and terms used to describe similar opioid use outcomes, and a lack of interventional research targeting well-documented patterns of potentially nonrecommended, potentially avoidable, or potentially high-risk opioid prescribing or use.
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Affiliation(s)
- Devon K Check
- Department of Population Health Sciences, Duke University School of Medicine (D.K.C.), Durham, North Carolina; Duke Cancer Institute, Duke University Medical Cente (D.K.C., R.A.A., C.M., A.H.K., K.C.O.), Durham, North Carolina.
| | - Renee A V Avecilla
- Duke Cancer Institute, Duke University Medical Cente (D.K.C., R.A.A., C.M., A.H.K., K.C.O.), Durham, North Carolina
| | - Coleman Mills
- Duke Cancer Institute, Duke University Medical Cente (D.K.C., R.A.A., C.M., A.H.K., K.C.O.), Durham, North Carolina
| | - Michaela A Dinan
- Department of Chronic Disease Epidemiology, Yale School of Public Health (M.A.D.), New Haven, Connecticut; Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale Cancer Center (M.A.D.), New Haven, Connecticut
| | - Arif H Kamal
- Duke Cancer Institute, Duke University Medical Cente (D.K.C., R.A.A., C.M., A.H.K., K.C.O.), Durham, North Carolina; Department of Medicine, Duke University Medical Center (A.H.K.), Durham, North Carolina
| | - Beverly Murphy
- Duke University Medical Center Library & Archives, Duke University School of Medicine (B.M.), Durham, North Carolina
| | - Salma Rezk
- Division of Pharmaceutical Outcomes and Policy, UNC Eshelman School of Pharmacy (S.R.), Chapel Hill, North Carolina
| | - Aaron Winn
- School of Pharmacy, Medical College of Wisconsin (A.W.), Milwaukee, Wisconsin
| | - Kevin C Oeffinger
- Duke Cancer Institute, Duke University Medical Cente (D.K.C., R.A.A., C.M., A.H.K., K.C.O.), Durham, North Carolina; Department of Medicine, Duke University School of Medicine (K.C.O.), Durham, North Carolina
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Pergolizzi JV, Magnusson P, Christo PJ, LeQuang JA, Breve F, Mitchell K, Varrassi G. Opioid Therapy in Cancer Patients and Survivors at Risk of Addiction, Misuse or Complex Dependency. FRONTIERS IN PAIN RESEARCH (LAUSANNE, SWITZERLAND) 2022; 2:691720. [PMID: 35295520 PMCID: PMC8915703 DOI: 10.3389/fpain.2021.691720] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 10/13/2021] [Indexed: 12/21/2022]
Abstract
A clinical conundrum can occur when a patient with active opioid use disorder (OUD) or at elevated risk for the condition presents with cancer and related painful symptoms. Despite earlier beliefs that cancer patients were relatively unaffected by opioid misuse, it appears that cancer patients have similar risks as the general population for OUD but are more likely to need and take opioids. Treating such patients requires an individualized approach, informed consent, and a shared decision-making model. Tools exist to help stratify patients for risk of OUD. While improved clinician education in pain control is needed, patients too need to be better informed about the risks and benefits of opioids. Patients may fear pain more than OUD, but opioids are not always the most effective pain reliever for a given patient and some patients do not tolerate or want to take opioids. The association of OUD with mental health disorders (dual diagnosis) can also complicate delivery of care as patients with mental health issues may be less adherent to treatment and may use opioids for “chemical coping” as much as for pain control.
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Affiliation(s)
| | - Peter Magnusson
- Centre for Research & Development, Uppsala University, Uppsala, Sweden.,Department of Medicine, Cardiology Research Unit, Karolinska Institutet, Stockholm, Sweden
| | - Paul J Christo
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | | | - Frank Breve
- Department of Pharmacy Practice, Temple University School of Pharmacy, Philadelphia, PA, United States
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Gibson DC, Raji MA, Holmes HM, Baillargeon JG, Kuo YF. Risk of an Opioid-Related Emergency Department Visit or Hospitalization Among Older Breast, Colorectal, Lung, and Prostate Cancer Survivors. Mayo Clin Proc 2022; 97:560-570. [PMID: 35135691 PMCID: PMC8898260 DOI: 10.1016/j.mayocp.2021.08.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 05/20/2021] [Accepted: 08/26/2021] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To assess whether long-term cancer survivors (≥5 years after diagnosis) are at an increased risk of experiencing an opioid-related emergency department (ED) visit or hospitalization compared with persons without cancer. METHODS A 1:1 matched retrospective cohort study was performed using the Surveillance, Epidemiology, and End Results-Medicare linked data sets. The analysis was conducted from October 2020 to December 2020 in persons who lived 5 years or more after a breast, colorectal, lung, or prostate cancer diagnosis matched to noncancer controls on the basis of age, sex, race, pain conditions, and previous opioid use. Fine-Gray regression models were used to assess the relationship between cancer survivorship status and opioid-related ED visit or hospitalization. RESULTS The incidence of opioid-related ED visits and hospitalizations was 51.2 (95% CI, 43.5 to 59.8) and 62.2 (95% CI, 53.4 to 72.1) per 100,000 person-years among cancer survivors and matched noncancer controls, respectively. No significant association was observed between survivorship and opioid-related adverse event among opioid naive (hazard ratio, 0.79; 95% CI, 0.61 to 1.02) and non-naive (hazard ratio, 1.26; 95% CI, 0.84 to 1.89) cohorts. CONCLUSION Cancer survivors and noncancer controls had a similar risk of an ED visit or inpatient admission. Guidelines and policies should promote nonopioid pain management approaches especially to opioid non-naive older adults, a population at high risk for an opioid-related ED visit or hospitalization.
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Affiliation(s)
- Derrick C Gibson
- Department of Preventive Medicine and Population Health, University of Texas Medical Branch, Galveston.
| | - Mukaila A Raji
- Division of Geriatrics and Palliative Medicine, Department of Internal Medicine, University of Texas Medical Branch, Galveston
| | - Holly M Holmes
- Division of Geriatrics and Palliative Medicine, Department of Internal Medicine, University of Texas Health Science Center, Houston
| | - Jacques G Baillargeon
- Department of Preventive Medicine and Population Health, Office of Biostatistics, University of Texas Medical Branch, Galveston
| | - Yong-Fang Kuo
- Department of Preventive Medicine and Population Health, Office of Biostatistics, University of Texas Medical Branch, Galveston
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Arya R, Hong D, Schultz O, Jutzy JM, Cotangco K, Peters P, Daily EW, McCall AR, Howard AR, Hasan Y, Kothari R, Son CH. Opioid Use in Patients With Cervical Cancer at Two Urban Medical Centers. Adv Radiat Oncol 2022; 7:100833. [PMID: 35387422 PMCID: PMC8977857 DOI: 10.1016/j.adro.2021.100833] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 10/06/2021] [Indexed: 12/15/2022] Open
Abstract
Purpose Patients with cervical cancer are at high risk for opioid use. This study aimed to characterize opioid prescribing patterns at 2 urban hospitals. Methods and Materials Data from patients with cervical cancer treated with curative intent from 2011 to 2018 were retrospectively collected. Women with unrelated chronic opioid use before diagnosis, persistent/recurrent disease at 3 months after initiation of treatment, or initiation of opioids >6 months after treatment were excluded. Demographics, disease characteristics, treatment, and outpatient prescription practices were collected. Endpoints included duration of opioid use ≥6 and ≥12 months. Results There were 106 women included, of whom 83% received definitive radiation. Most patients (n = 91, 85.8%) received outpatient opioids. Most common timing of prescriptions were before cancer therapy (35.9%), postprocedure (26.4%), and during radiation therapy (17.0%). Median duration was 3 (interquartile range, 1-11) months; 35.2% of these patients received opioids ≥6 months and 22% received opioids ≥12 months. Greater International Federation of Gynaecology and Obstetrics (FIGO) stage, recurrent/residual disease, initiation of opioids before treatment, history of depression or anxiety, and use of gabapentin or steroids were associated with long-term opioid use. Conclusions Most patients were prescribed outpatient opioids, many of whom used opioids for 12 months. Improvement in provider communication and education, increased posttreatment monitoring, and further evaluation of nonopioid therapies are needed in this patient population to reduce long-term opioid use.
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Glare P, Aubrey K, Gulati A, Lee YC, Moryl N, Overton S. Pharmacologic Management of Persistent Pain in Cancer Survivors. Drugs 2022; 82:275-291. [PMID: 35175587 PMCID: PMC8888381 DOI: 10.1007/s40265-022-01675-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/10/2022] [Indexed: 12/14/2022]
Abstract
Improvements in screening, diagnosis and treatment of cancer has seen cancer mortality substantially diminish in the past three decades. It is estimated there are almost 20 million cancer survivors in the USA alone, but some 40% live with chronic pain after completing treatment. While a broad definition of survivorship that includes all people living with, through and beyond a cancer diagnosis—including those with active cancer—is often used, this narrative review primarily focuses on the management of pain in people who are disease-free after completing primary cancer treatment as adults. Chronic pain in this population needs a different approach to that used for people with a limited prognosis. After describing the common chronic pain syndromes caused by cancer treatment, and the pathophysiologic mechanisms involved, the pharmacologic management of entities such as post-surgical pain, chemotherapy-induced neuropathy, aromatase inhibitor musculoskeletal syndrome and checkpoint inhibitor-related pain are described. The challenges associated with opioid prescribing in this population are given special attention. Expert guidelines on pain management in cancer survivors now recommend a combination of pharmacologic and non-pharmacologic modalities, and these are also briefly covered.
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Affiliation(s)
- Paul Glare
- Pain Management Research Institute, Kolling Institute, University of Sydney and Northern Sydney Local Health District, Sydney, NSW, Australia.
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia.
| | - Karin Aubrey
- Pain Management Research Institute, Kolling Institute, University of Sydney and Northern Sydney Local Health District, Sydney, NSW, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Amitabh Gulati
- Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Yi Ching Lee
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Chris O'Brien Lifehouse, Sydney, NSW, Australia
- Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Natalie Moryl
- Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Sarah Overton
- Pain Management Research Centre, Royal North Shore Hospital, Sydney, NSW, Australia
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de Albuquerque LZ, da Silva JL, Dos Santos ALS, Rodrigues IP, de Melo AC. Prevalence of long-term opioid use after radiotherapy for cervical cancer in a Brazilian cancer center. J Cancer Surviv 2022; 17:686-693. [PMID: 35146613 DOI: 10.1007/s11764-022-01183-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 02/04/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE This study aimed to describe the clinical and demographic profile of cervical cancer patients exploring risk factors for prolonged use of opioids. METHODS The database of the Brazilian National Cancer Institute was queried out and 214 women with cervical cancer diagnosed between January 2014 and December 2015 who underwent isolated external beam radiation therapy (EBRT) or chemoradiotherapy (CRT) with complete response were included. Patients who no longer used opioids 6 months after completion of radiation therapy were classified as stoppers; patients who continued using opioids were non-stoppers. Variables were comparatively evaluated as risk factors for prolonged use of opioids. RESULTS The median age was 49.4 years. Most women were non-white (64.5%) and had ECOG Performance Status (PS) ≥ 1 (76.6%), International Federation of Gynecology and Obstetrics (FIGO) stage II-III (84.1%), and squamous cell carcinoma (82.7%). Smoking and alcohol consumption rates were, respectively, 44.9% and 39.7%. The median time from diagnosis to the onset of EBRT was 111 days (interquartile range 66.2). Most patients underwent CRT (88.8%). The rate of non-stoppers was 65.0%. By multivariate analysis, prescription of strong opioids (p = 0.005) and disease recurrence (p < 0.001) were suggested as independent factors for prolonged use of opioids. CONCLUSION The rate of prolonged use of opioids after radiotherapy is alarming. Prescription of strong opioids and disease recurrence might be independent risk factors for its persistent use. IMPLICATIONS FOR CANCER SURVIVORS These results reveal an unmet and urgent need to implement public multiprofessional support programs with well-established protocols for dependence withdrawal, as well as stricter national measures of control in opioid prescription.
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Affiliation(s)
- Lucas Zanetti de Albuquerque
- Division of Clinical Research and Technological Development, Brazilian National Cancer Institute (INCA), 37 André Cavalcanti Street, 5th floor, Annex Building, Downtown, Rio de Janeiro, RJ, ZIP Code 20231-050, Brazil.
| | - Jesse Lopes da Silva
- Division of Clinical Research and Technological Development, Brazilian National Cancer Institute (INCA), 37 André Cavalcanti Street, 5th floor, Annex Building, Downtown, Rio de Janeiro, RJ, ZIP Code 20231-050, Brazil
| | - Alexssandra Lima Siqueira Dos Santos
- Division of Clinical Research and Technological Development, Brazilian National Cancer Institute (INCA), 37 André Cavalcanti Street, 5th floor, Annex Building, Downtown, Rio de Janeiro, RJ, ZIP Code 20231-050, Brazil
| | - Isabella Pereira Rodrigues
- Division of Clinical Research and Technological Development, Brazilian National Cancer Institute (INCA), 37 André Cavalcanti Street, 5th floor, Annex Building, Downtown, Rio de Janeiro, RJ, ZIP Code 20231-050, Brazil
| | - Andreia Cristina de Melo
- Division of Clinical Research and Technological Development, Brazilian National Cancer Institute (INCA), 37 André Cavalcanti Street, 5th floor, Annex Building, Downtown, Rio de Janeiro, RJ, ZIP Code 20231-050, Brazil
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Chahin M, Matosz S, Khalel I, Day S, Keruakous A. Pain Management in Oncology Patients Amidst the Opioid Epidemic: How To Minimize Non-Medical Opioid Use. Cureus 2021; 13:e19500. [PMID: 34912639 PMCID: PMC8666098 DOI: 10.7759/cureus.19500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2021] [Indexed: 11/05/2022] Open
Abstract
The opioid epidemic continues to be a significant public health concern. On the surface, it appears difficult to understate the profound consequences and unnecessary loss of life at the hands of the opioid crisis throughout the 2010s. This reality should not dissuade rigorous attention toward those who have suffered unnecessarily due to an overreaching backlash toward the opioid crisis. Oncology patients have been significantly impacted on both ends of the opioid crisis. Like other populations, cancer patients were first affected during the initial surge of opioid availability, prescription, and use at the beginning of the crisis, where opioid abuse and overdose negatively impacted cancer patient populations at similar rates as the general population. Yet, cancer patients were perhaps even more heavily affected during secondary events after the initial crisis, as opioid restrictions and the stigmatization, undoubtedly beneficial in many spaces, of opioid use became prevalent across the American society. During this second period of the opioid crisis (loosely from 2013 to the present day after the Veterans Health Administration Opioid Safety Initiative started), restrictions on opioids have significantly decreased the use and access of opioids for cancer patients. Management of pain, in general, is a complex topic, and cancer pain is no exception. Cancer patients may experience pain related to the disease itself, its treatment, or other comorbidities. This review aims to clarify the impact of reducing opioid use on cancer patients over the past eight years. We summarize the challenges facing providers as they attempt to manage cancer-related pain. Additionally, we propose tools for best practices to reduce the unnecessary suffering of cancer patients and protect against the overuse and abuse of opioids.
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Affiliation(s)
- Michael Chahin
- Department of Hematology and Oncology, Georgia Cancer Center at Augusta University, Augusta, USA
| | - Sabrina Matosz
- Department of Hematology and Oncology, Georgia Cancer Center at Augusta University, Augusta, USA
| | - Irene Khalel
- Internal Medicine, University of Alexandria, Faculty of Medicine, Alexandria, EGY
| | - Silas Day
- Hematology and Medical Oncology, University of Oklahoma Health Sciences Center, Oklahoma City, USA
| | - Amany Keruakous
- Department of Hematology and Oncology, Georgia Cancer Center at Augusta University, Augusta, USA
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Schatman ME, Shapiro H. Chronic Pain Patient "Advocates" and Their Focus on Opiophilia: Barking Up the Wrong Tree? J Pain Res 2021; 14:3627-3630. [PMID: 34880670 PMCID: PMC8646865 DOI: 10.2147/jpr.s349631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 11/21/2021] [Indexed: 11/23/2022] Open
Affiliation(s)
- Michael E Schatman
- Division of Medical Ethics, NYU School of Medicine, New York, NY, USA.,Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU School of Medicine, New York, NY, USA.,School of Social Work, North Carolina State University, Raleigh, NC, USA
| | - Hannah Shapiro
- School of Social Work, North Carolina State University, Raleigh, NC, USA.,McLean Hospital, Division of Alcohol, Drugs, and Addiction, Harvard Medical School, Boston, MA, USA
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41
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Merlin JS, Khodyakov D, Arnold R, Bulls HW, Dao E, Kapo J, King C, Meier D, Paice J, Ritchie C, Liebschutz JM. Expert Panel Consensus on Management of Advanced Cancer-Related Pain in Individuals With Opioid Use Disorder. JAMA Netw Open 2021; 4:e2139968. [PMID: 34962565 DOI: 10.1001/jamanetworkopen.2021.39968] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
IMPORTANCE Opioid use disorder (OUD) is an important comorbidity in individuals with advanced cancer, in whom pain is common. Full-agonist opioid medications are the cornerstone of cancer pain management, but the existing literature does not address how to manage cancer pain in patients with OUD. OBJECTIVE To conduct an expert panel to develop consensus on the appropriateness of management of cancer pain in individuals with co-occurring advanced cancer and OUD. EVIDENCE REVIEW A 3-round modified Delphi process was completed from August to October 2020 with 2 cases: patient with advanced cancer, pain, and OUD treated with buprenorphine-naloxone or methadone. Participants rated management strategies in round 1, discussed results in round 2, and provided final responses in round 3. ExpertLens, an online approach to conducting modified Delphi panels, was used. Participants were experts in palliative care, addiction, or both, recruited by email from palliative care and addiction-focused professional groups, lists from prior studies, and snowball sampling. Data analysis was performed from November 2020 to July 2021. FINDINGS Of 120 experts (median age, 40-49 years), most were White (78 participants [94%]), female (74 participants [62%]), and held MD or DO degrees (115 participants [96%]); 84 (70%) participated in all rounds. For a patient with OUD taking buprenorphine-naloxone, it was deemed appropriate to continue buprenorphine-naloxone with thrice-daily dosing. Continuing buprenorphine-naloxone and adding a full-agonist opioid was deemed to be appropriate for patients with a prognosis of weeks to months and of uncertain appropriateness for patients with a prognosis of months to years. For a patient with OUD taking methadone dispensed at a methadone clinic, it was deemed appropriate to take over prescribing and dose twice or thrice daily. Continuing methadone daily while adding another full-agonist opioid was deemed appropriate for patients with a prognosis of weeks to months and of uncertain appropriateness for those with a prognosis of months to years. CONCLUSIONS AND RELEVANCE The findings of this qualitative study provide urgently needed, consensus-based guidance for clinicians and highlight critical research and policy gaps needed to facilitate implementation.
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Affiliation(s)
- Jessica S Merlin
- CHAllenges in Managing and Preventing Pain Clinical Research Center, University of Pittsburgh, Pittsburgh, Pennsylvania
- Division of General Internal Medicine, Center for Research on Health Care, University of Pittsburgh, Pittsburgh, Pennsylvania
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Robert Arnold
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Hailey W Bulls
- CHAllenges in Managing and Preventing Pain Clinical Research Center, University of Pittsburgh, Pittsburgh, Pennsylvania
- Division of General Internal Medicine, Center for Research on Health Care, University of Pittsburgh, Pittsburgh, Pennsylvania
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Emily Dao
- RAND Corporation, Santa Monica, California
| | - Jennifer Kapo
- Palliative Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Caroline King
- Department of Biomedical Engineering, School of Medicine, Oregon Health & Science University, Portland
| | - Diane Meier
- Department of Geriatrics and Palliative Medicine, Center to Advance Palliative Care, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Judith Paice
- Feinberg School of Medicine, Division Hematology-Oncology, Northwestern University, Chicago, Illinois
| | - Christine Ritchie
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston
| | - Jane M Liebschutz
- Division of General Internal Medicine, Center for Research on Health Care, University of Pittsburgh, Pittsburgh, Pennsylvania
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42
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Burns K, McNally GA. Implicit Bias Training: Improving Outcomes for Patients With Cancer Who Have Substance Use Disorders. Clin J Oncol Nurs 2021; 25:595-599. [PMID: 34533523 DOI: 10.1188/21.cjon.595-599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Being mindful of one's implicit bias in the treatment of patients with cancer who have substance use disorders is fundamental to quality of care and good patient outcomes. Implicit bias held by healthcare professionals could negatively affect patient assessment, diagnosis and treatment decisions, and follow-ups at discharge.
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Affiliation(s)
- Kathy Burns
- Arthur G. James Cancer Hospital and Richard J. Solove Research Institute
| | - Gretchen A McNally
- Arthur G. James Cancer Hospital and Richard J. Solove Research Institute
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Yuen KCJ, Mortensen MJ, Azadi A, Fonkem E, Findling JW. Rethinking the management of immune checkpoint inhibitor-related adrenal insufficiency in cancer patients during the COVID-19 pandemic. Endocrinol Diabetes Metab 2021; 4:e00246. [PMID: 34268454 PMCID: PMC8250331 DOI: 10.1002/edm2.246] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 02/15/2021] [Accepted: 02/20/2021] [Indexed: 12/12/2022] Open
Abstract
Introduction The coronavirus disease 2019 (COVID-19) is currently a major pandemic challenge, and cancer patients are at a heightened risk of severity and mortality from this infection. In recent years, immune checkpoint inhibitor (ICI) use to treat multiple cancers has increased in oncology, but equally has raised the question of whether ICI therapy and its side-effects is harmful or beneficial during this pandemic. Methods A combination of published literature in PubMed between January 2010 and December 2020, recommended guidelines in non-cancer patients, and clinical experience was utilized to outline recommendations on glucocorticoid timing and dosing regimens in ICI-treated patients presenting with AI during this COVID-19 pandemic. Results The potential immune interaction between ICIs and COVID-19 require major consideration because these agents act at the intersection between effective cancer immunotherapy and increasing patient susceptibility, severity and complications from the SARS-CoV-2 sepsis. Furthermore, ICI use can induce autoimmune adrenal insufficiency (AI) that further increases infection susceptibility. Thus, ICI-treated cancer patients with AI may be at greater risk of COVID-19 infection. Glucocorticoids are the cornerstone for replacement therapy, and for treatment and mitigation of adrenal crisis and relief of mass effects in ICI-related hypophysitis. High-dose glucocorticoids have also been used with cytotoxic chemotherapy as part of cancer treatment, and iatrogenic AI may arise after glucocorticoid discontinuation that increases the risk of adrenal crisis. Furthermore, in patients who develop the "long COVID-19" syndrome, when to discontinue glucocorticoid therapy becomes crucial to avoid unnecessary prolongation of therapy and the development of iatrogenic hypercortisolemia. Conclusion During the COVID-19 pandemic, much of cancer care have been impacted and an important clinical question is how to optimally manage ICI-related AI during these unprecedented times. Herein, we suggest practical recommendations on the timing and dosing regimens of glucocorticoids in different clinical scenarios of ICI-treated cancer patients presenting with AI during this COVID-19 pandemic.
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Affiliation(s)
- Kevin C. J. Yuen
- Departments of Neuroendocrinology and NeurosurgeryBarrow Neurological InstituteUniversity of Arizona College of Medicine and Creighton School of MedicinePhoenixArizonaUSA
| | | | - Amir Azadi
- Departments of Neurology and Neuro‐OncologyBarrow Neurological Institute/Ivy Brain Center at PhoenixSt. Joseph’s Hospital and Medical CenterPhoenixArizonaUSA
| | - Ekokobe Fonkem
- Departments of Neurology and Neuro‐OncologyBarrow Neurological Institute/Ivy Brain Center at PhoenixSt. Joseph’s Hospital and Medical CenterPhoenixArizonaUSA
| | - James W. Findling
- Division of Endocrinology and Molecular MedicineMedical College of WisconsinMilwaukeeWisconsinUSA
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44
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Schatman ME, Shapiro H, Wegrzyn EL. Questionable Conceptualizations of Nonmedical Use Can Contribute to Needless Distress. JAMA Oncol 2021; 7:941-942. [PMID: 33856407 DOI: 10.1001/jamaoncol.2021.0569] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Michael E Schatman
- Department of Diagnostic Sciences, Tufts University School of Dental Medicine, Boston, Massachusetts.,Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, Massachusetts
| | - Hannah Shapiro
- McLean Hospital, Division of Alcohol, Drugs, and Addiction, Harvard Medical School, Boston, Massachusetts
| | - Erica L Wegrzyn
- Department of Pharmacy, Stratton VA Medical Center, Albany, New York
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