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Yusufov M, Melanson SEF, Kang P, Kematick B, Schiff GD, Chua IS. Clinician Ordering and Management Patterns of Urine Toxicology Results at a Cancer Center. J Pain Symptom Manage 2024; 68:e36-e45. [PMID: 38599533 DOI: 10.1016/j.jpainsymman.2024.04.006] [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] [Received: 01/08/2024] [Revised: 04/01/2024] [Accepted: 04/03/2024] [Indexed: 04/12/2024]
Abstract
CONTEXT Opioid therapy is a cornerstone for treatment of cancer-related pain, but standardized management practices for patients with cancer and aberrant urine drug test (UDT) results are lacking. OBJECTIVES To identify the prevalence of UDT ordering (both screening and definitive testing) in the oncology setting and to examine clinician management practices for patients with cancer on opioid therapy with aberrant definitive UDT results. METHODS We conducted a retrospective chart review of patients with cancer on opioid therapy at an academic cancer center in the United States. Outcomes included UDT ordering patterns and clinician management practices in response to aberrant definitive UDT results. RESULTS Our study revealed an overall UDT ordering rate of 3.7% among 10,371 patients with cancer on opioid therapy. Among 143 patients for whom definitive UDTs were ordered, oncologists only ordered 14 (9.8%) UDTs, while palliative care ordered the majority (n = 129; 90.2%). Fifty-five (38.5%) patients had aberrant results, and the most common aberrancy was presence of illicit drugs 22 [15.4%]. Clinicians rarely made medication changes (20 [36.4%]) when UDT results were aberrant, and in the setting of possible fentanyl use (n = 8), only 3 (37.5%) patients were started/switched to methadone, and none were started/switched to buprenorphine. CONCLUSION Overall UDT ordering was infrequent for patients with cancer on opioid therapy, especially by oncologists, and clinicians rarely made prescribing changes when definitive UDT results were aberrant. More definitive guidance related to UDT ordering and opioid management are needed for patients with cancer and aberrant UDT results.
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Affiliation(s)
- Miryam Yusufov
- Department of Psychosocial Oncology and Palliative Care (M.Y., B.K., I.S.C.), Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Harvard Medical School (M.Y., S.E.F.M., G.D.S., I.S.C.), Boston, Massachusetts, USA
| | - Stacy E F Melanson
- Department of Pathology (S.E.F.M., P.K.), Brigham and Women's Hospital, Boston, Massachusetts, USA; Harvard Medical School (M.Y., S.E.F.M., G.D.S., I.S.C.), Boston, Massachusetts, USA
| | - Phillip Kang
- Department of Pathology (S.E.F.M., P.K.), Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Benjamin Kematick
- Department of Psychosocial Oncology and Palliative Care (M.Y., B.K., I.S.C.), Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Gordon D Schiff
- Center for Patient Safety Research and Practice (G.D.S.), Brigham and Women's Hospital, Boston, Massachusetts, USA; Department of Medicine (G.D.S., I.S.C.), Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA; Harvard Medical School (M.Y., S.E.F.M., G.D.S., I.S.C.), Boston, Massachusetts, USA; Harvard Medical School Center for Primary Care (G.D.S.), Boston, Massachusetts, USA
| | - Isaac S Chua
- Department of Psychosocial Oncology and Palliative Care (M.Y., B.K., I.S.C.), Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Department of Medicine (G.D.S., I.S.C.), Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA; Harvard Medical School (M.Y., S.E.F.M., G.D.S., I.S.C.), Boston, Massachusetts, USA.
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Arthur J, Childers J, Del Fabbro E. Should Urine Drug Screen be Done Universally or Selectively in Palliative Care Patients on Opioids? J Pain Symptom Manage 2023; 66:e687-e692. [PMID: 37429531 DOI: 10.1016/j.jpainsymman.2023.06.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 06/30/2023] [Indexed: 07/12/2023]
Abstract
Urine drug screen (UDS) is a useful test conducted in patients receiving opioids for chronic pain to aid in validating patient adherence to opioid treatment and to detect any nonmedical opioid use (NMOU). One controversial topic regarding its use in palliative care is whether to conduct the test universally and randomly in all patients who are receiving opioids for chronic pain irrespective of their level of risk for NMOU, or to conduct the test selectively in only those with a high risk for engaging in NMOU behaviors. In this "Controversies in Palliative Care" article, 3 expert clinicians independently answer this question. Specifically, each expert provides a synopsis of the key studies that inform their thought processes, share practical advice on their clinical approach, and highlight the opportunities for future research. They all agreed that UDS has some utility in routine palliative care practice but acknowledged the insufficient existing evidence supporting its efficacy. They also underscored the need to improve clinician proficiency in UDS interpretation to enhance its utility. Two experts endorsed random UDS in all patients receiving opioids regardless of their risk profile while the other expert recommended targeted UDS until there is more clinical evidence to support universal, random testing. Use of more methodologically robust study designs in UDS research, examination of the cost-effectiveness of UDS tests, development of innovative programs to manage NMOU behaviors, and investigation of the impact of improved clinician proficiency in UDS interpretation on clinical outcomes, were important areas of future research that the experts identified.
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Affiliation(s)
- Joseph Arthur
- Department of Palliative Care (J.A.), Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.
| | - Julie Childers
- Section of Palliative Care and Medical Ethics (J.C.), Section of Treatment, Research, and Education in Addiction Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Egidio Del Fabbro
- Division of Palliative Medicine (E.D.F.), Medical College of Georgia, Augusta University, Augusta, Georgia
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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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Amaram-Davila J, Reddy A, Clark MD, Nancherla A, Arthur J, Bruera E. Reliability of urine drug testing among patients on buprenorphine transdermal patch. Palliat Support Care 2023:1-3. [PMID: 37525588 PMCID: PMC10830884 DOI: 10.1017/s147895152300086x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2023]
Abstract
BACKGROUND Urine drug testing (UDT) plays a significant role in monitoring patients on chronic opioid therapy (COT) for non-medical opioid use (NMOU). UDT, at times, can be inconsistent and misleading. We present a case where a patient on a buprenorphine patch had false negative results. CASE DESCRIPTION A female in her 70s with metastatic breast cancer presented with uncontrolled pain from a T6 compression fracture. She had no relief with tramadol 50 mg every 6 hours as needed. Due to an allergic reaction to hydromorphone, our team prescribed a buprenorphine patch of 5 μg/h. Subsequently, she expressed excellent pain control, and the clinician confirmed the patch placement on examination. She underwent a UDT during the visit. The UDT was negative for both buprenorphine and its metabolites. The literature review showed that false negative UDT results are relatively common among patients with low-dose buprenorphine patches. The combination of a thorough physical examination, a review of the Prescription Drug Monitoring Program, and reassuring scores on screening tools placed her at low risk for NMOU. DISCUSSION Buprenorphine has a ceiling effect on respiratory depression and a lower risk for addiction. However, when used in low doses, the drug might not have enough metabolites in the urine, leading to a false negative UDT. Such results might affect patient-physician relationships. CONCLUSION In addition to the UDT, a thorough history, screening for NMOU, physical exam, a review of PDMP, and a good understanding of opioid metabolism are necessary to help guide pain management.
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Affiliation(s)
- Jaya Amaram-Davila
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Akhila Reddy
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Matthew D. Clark
- Pharmacy Clinical Programs, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Anita Nancherla
- University of the incarnate word, Feik school of Pharmacy, San Antonio, Tx, USA
| | - Joseph Arthur
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Eduardo Bruera
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Amaram-Davila J, Kim MJ, Reddy A, Edwards T, Dai J, Urbauer D, Shelal Z, Ross Y, Hosain M, Bruera E, Arthur J. Health Care Provider Attitudes and Beliefs Toward Nonmedical Opioid Use in Patients with Cancer Pain. J Palliat Med 2023; 26:248-252. [PMID: 36476019 PMCID: PMC9894589 DOI: 10.1089/jpm.2022.0293] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2022] [Indexed: 12/12/2022] Open
Abstract
Background: Data on health care providers' (HCPs') perceptions about patients with cancer pain and nonmedical opioid use (NMOU) are lacking. We examined the perceptions and attitudes of HCPs and assessed the usefulness of an interdisciplinary opioid stewardship program (OSP) while caring for these patients. Methods: An anonymous cross-sectional survey was conducted among the supportive care HCPs between September and November 2021. Results: Of 85 HCPs, 64 responded (75%) to the survey. Participants perceived that NMOU is underdiagnosed (42/64; 67%), and caring for such patients is difficult (58/64, 91%) and time consuming (54/64, 87%). A majority (50/51, 98%) were aware of the OSP, and (48/51; 94%) found it helpful. Conclusion: HCPs reported that NMOU is underdiagnosed and is challenging to manage. They endorsed the utility of an OSP in managing patients with concurrent cancer pain and NMOU. Future research should identify ways to standardize care and integrate OSP in routine supportive oncology practice.
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Affiliation(s)
- Jaya Amaram-Davila
- Department of Palliative, Rehabilitation, and Integrative Medicine and The University of Texas MD Anderson Cancer, Houston, Texas, USA
| | - Min Ji Kim
- Department of Supportive and Palliative Care, Baylor University Medical Center, Dallas, Texas, USA
| | - Akhila Reddy
- Department of Palliative, Rehabilitation, and Integrative Medicine and The University of Texas MD Anderson Cancer, Houston, Texas, USA
| | - Tonya Edwards
- Department of Palliative, Rehabilitation, and Integrative Medicine and The University of Texas MD Anderson Cancer, Houston, Texas, USA
| | - Jianliang Dai
- Department of Biostatistics, The University of Texas MD Anderson Cancer, Houston, Texas, USA
| | - Diana Urbauer
- Department of Biostatistics, The University of Texas MD Anderson Cancer, Houston, Texas, USA
| | - Zeena Shelal
- Department of Palliative, Rehabilitation, and Integrative Medicine and The University of Texas MD Anderson Cancer, Houston, Texas, USA
| | - Yvette Ross
- Department of Palliative, Rehabilitation, and Integrative Medicine and The University of Texas MD Anderson Cancer, Houston, Texas, USA
| | - Monawar Hosain
- Department of Palliative, Rehabilitation, and Integrative Medicine and The University of Texas MD Anderson Cancer, Houston, Texas, USA
| | - Eduardo Bruera
- Department of Palliative, Rehabilitation, and Integrative Medicine and The University of Texas MD Anderson Cancer, Houston, Texas, USA
| | - Joseph Arthur
- Department of Palliative, Rehabilitation, and Integrative Medicine and The University of Texas MD Anderson Cancer, Houston, Texas, USA
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6
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Arthur JA, Edwards T, Lu Z, Tang M, Amaram-Davila J, Reddy A, Hui D, Yennurajalingam S, Anderson AE, Jennings K, Reddy S, Bruera E. Interdisciplinary intervention for the management of nonmedical opioid use among patients with cancer pain. Cancer 2022; 128:3718-3726. [PMID: 35997289 PMCID: PMC10304363 DOI: 10.1002/cncr.34392] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 06/06/2022] [Accepted: 06/15/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Few studies have assessed interventions aimed at managing nonmedical opioid use (NMOU) behavior among patients with cancer. The authors developed the Compassionate High-Alert Team (CHAT) intervention to manage patients receiving opioids for cancer pain who demonstrate NMOU behavior. The objective of this study was to determine the change in frequency of NMOU behaviors, pain intensity, and opioid requirements among those who received the intervention. METHODS A total of 130 patients receiving opioids for cancer pain that had documented evidence of NMOU and received the CHAT intervention were reviewed. Demographic and clinical information such as NMOU behaviors, pain scores, and morphine equivalent daily dose at baseline, 3, and 6 months post-intervention was obtained. RESULTS NMOU behaviors significantly decreased from a median (interquartile range) of 2 (1-3) at baseline to 0 (0-1) at both 3 and 6 months post-intervention (p < .001). A total of 45 of 75 (60%) and 31 of 50 (62%) of CHAT recipients achieved complete response to the intervention at 3 and 6 months, respectively. Higher baseline number of NMOU behaviors was independently associated with patient response to the intervention (odds ratio [OR], 1.97; 95% confidence interval [CI],1.09-4.28, p = .049 at 3 months; OR, 2.5; 95% CI, 1.20-6.47, p = .03 at 6 months). The median pain score decreased from 7 at baseline to 6 at both 3 and 6 months (p = .01). Morphine equivalent daily dose did not significantly change during that same period (143 mg/day vs. 139 mg/day, p = .13). CONCLUSIONS Most patients who received the CHAT intervention improved in their NMOU behaviors and pain intensity scores 3 and 6 months post-intervention. These preliminary findings support the efficacy of CHAT in managing patients receiving opioids for cancer pain who demonstrate NMOU behavior.
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Affiliation(s)
- Joseph A. Arthur
- Department of Palliative, Rehabilitation, and Integrative
Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas,
USA
| | - Tonya Edwards
- Department of Palliative, Rehabilitation, and Integrative
Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas,
USA
| | - Zhanni Lu
- Department of Palliative, Rehabilitation, and Integrative
Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas,
USA
| | - Michael Tang
- Department of Palliative, Rehabilitation, and Integrative
Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas,
USA
| | - Jaya Amaram-Davila
- Department of Palliative, Rehabilitation, and Integrative
Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas,
USA
| | - Akhila Reddy
- Department of Palliative, Rehabilitation, and Integrative
Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas,
USA
| | - David Hui
- Department of Palliative, Rehabilitation, and Integrative
Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas,
USA
| | - Sriram Yennurajalingam
- Department of Palliative, Rehabilitation, and Integrative
Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas,
USA
| | - Aimee E. Anderson
- Department of Palliative, Rehabilitation, and Integrative
Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas,
USA
| | - Kristofer Jennings
- Department of Biostatistics, The University of Texas MD
Anderson Cancer Center, Houston, Texas, USA
| | - Suresh Reddy
- Department of Palliative, Rehabilitation, and Integrative
Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas,
USA
| | - Eduardo Bruera
- Department of Palliative, Rehabilitation, and Integrative
Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas,
USA
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Bramati PS, Cadavid A, Bansal A, Fellman B, Tanco K, Bruera E. Letter to the Editor: Prevalence of Self-Reported Cannabis Use among Patients at a Supportive Care Clinic in a Tertiary Cancer Center. J Palliat Med 2022; 25:1176-1178. [PMID: 35913476 DOI: 10.1089/jpm.2022.0199] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Patricia S Bramati
- Department of Palliative Care, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Adriana Cadavid
- Department of Palliative Care, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Anjuly Bansal
- Department of Palliative Care, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Bryan Fellman
- Department of Palliative Care, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Kimberson Tanco
- Department of Palliative Care, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Eduardo Bruera
- Department of Palliative Care, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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A systematic review of assessment approaches to predict opioid misuse in people with cancer. Support Care Cancer 2022; 30:5645-5658. [PMID: 35166898 PMCID: PMC9135805 DOI: 10.1007/s00520-022-06895-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 02/02/2022] [Indexed: 11/11/2022]
Abstract
Context Cancer prevalence is increasing, with many patients requiring opioid analgesia. Clinicians need to ensure patients receive adequate pain relief. However, opioid misuse is widespread, and cancer patients are at risk. Objectives This study aims (1) to identify screening approaches that have been used to assess and monitor risk of opioid misuse in patients with cancer; (2) to compare the prevalence of risk estimated by each of these screening approaches; and (3) to compare risk factors among demographic and clinical variables associated with a positive screen on each of the approaches. Methods Medline, Cochrane Controlled Trial Register, PubMed, PsycINFO, and Embase databases were searched for articles reporting opioid misuse screening in cancer patients, along with handsearching the reference list of included articles. Bias was assessed using tools from the Joanna Briggs Suite. Results Eighteen studies met the eligibility criteria, evaluating seven approaches: Urine Drug Test (UDT) (n = 8); the Screener and Opioid Assessment for Patients with Pain (SOAPP) and two variants, Revised and Short Form (n = 6); the Cut-down, Annoyed, Guilty, Eye-opener (CAGE) tool and one variant, Adapted to Include Drugs (n = 6); the Opioid Risk Tool (ORT) (n = 4); Prescription Monitoring Program (PMP) (n = 3); the Screen for Opioid-Associated Aberrant Behavior Risk (SOABR) (n = 1); and structured/specialist interviews (n = 1). Eight studies compared two or more approaches. The rates of risk of opioid misuse in the studied populations ranged from 6 to 65%, acknowledging that estimates are likely to have varied partly because of how specific to opioids the screening approaches were and whether a single or multi-step approach was used. UDT prompted by an intervention or observation of aberrant opioid behaviors (AOB) were conclusive of actual opioid misuse found to be 6.5–24%. Younger age, found in 8/10 studies; personal or family history of anxiety or other mental ill health, found in 6/8 studies; and history of illicit drug use, found in 4/6 studies, showed an increased risk of misuse. Conclusions Younger age, personal or familial mental health history, and history of illicit drug use consistently showed an increased risk of opioid misuse. Clinical suspicion of opioid misuse may be raised by data from PMP or any of the standardized list of AOBs. Clinicians may use SOAPP-R, CAGE-AID, or ORT to screen for increased risk and may use UDT to confirm suspicion of opioid misuse or monitor adherence. More research into this important area is required. Significance of results This systematic review summarized the literature on the use of opioid misuse risk approaches in people with cancer. The rates of reported risk range from 6 to 65%; however, true rate may be closer to 6.5–24%. Younger age, personal or familial mental health history, and history of illicit drug use consistently showed an increased risk of opioid misuse. Clinicians may choose from several approaches. Limited data are available on feasibility and patient experience. PROSPERO registration number. CRD42020163385.
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Delaney SR, Tacker DH, Snozek CLH. The North American opioid epidemic: opportunities and challenges for clinical laboratories. Crit Rev Clin Lab Sci 2022; 59:309-331. [PMID: 35166639 DOI: 10.1080/10408363.2022.2037122] [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: 11/03/2022]
Abstract
Since 1999, the opioid epidemic in North America has resulted in over 1 million deaths, and it continues to escalate despite numerous efforts in various arenas to combat the upward trend. Clinical laboratories provide drug testing to support practices such as emergency medicine, substance use disorder treatment, and pain management; increasingly, these laboratories are collaborating in novel partnerships including drug-checking services (DCS) and multidisciplinary treatment teams. This review examines drug testing related to management of licit and illicit opioid use, new technologies and test strategies employed by clinical laboratories, barriers hindering laboratory response to the opioid epidemic, and areas for improvement and standardization within drug testing. Literature search terms included combinations of "opioid," "opiate," "fentanyl," "laboratory," "epidemic," "crisis," "mass spectrometry," "immunoassay," "drug screen," "drug test," "guidelines," plus review of PubMed "similar articles" and references within publications. While immunoassay (IA) and point-of-care (POC) test options for synthetic opioids are increasingly available, mass spectrometry (MS) platforms offer the greatest flexibility and sensitivity for detecting novel, potent opioids. Previously reserved as a second-tier application in most drug test algorithms, MS assays are gaining a larger role in initial screening for specific patients and DCS. However, there are substantial differences among laboratories in terms of updating test menus, algorithms, and technologies to meet changing clinical needs. While some clinical laboratories lack the resources and expertise to implement MS, many are also slow to adopt available IA and POC tests for newer opioids such as fentanyl. MS-based testing also presents challenges, including gaps in available guidance for assay validation and ongoing performance assessment that contribute to a dramatic lack of standardization among laboratories. We identify opportunities for improvement in laboratory operations, reporting, and interpretation of drug test results, including laboratorian and provider education and laboratory-focused guidelines. We also highlight the need for collaboration with providers, assay and instrument manufacturers, and national organizations to increase the effectiveness of clinical laboratory and provider efforts in preventing morbidity and mortality associated with opioid use and misuse.
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Affiliation(s)
- Sarah R Delaney
- Department of Laboratory Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.,Department of Laboratory Medicine & Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Danyel H Tacker
- Department of Pathology, Anatomy, and Laboratory Medicine, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Christine L H Snozek
- Department of Laboratory Medicine and Pathology, Mayo Clinic Arizona, Phoenix, AZ, USA
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Amaram-Davila JS, Arthur J, Reddy A, Bruera E. Managing Nonmedical Opioid Use Among Patients With Cancer Pain During the COVID-19 Pandemic Using the CHAT Model and Telehealth. J Pain Symptom Manage 2021; 62:192-196. [PMID: 33515659 PMCID: PMC8274019 DOI: 10.1016/j.jpainsymman.2021.01.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 12/16/2020] [Accepted: 01/10/2021] [Indexed: 12/22/2022]
Affiliation(s)
- Jaya Sheela Amaram-Davila
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer, Houston, Texas, USA
| | - Joseph Arthur
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer, Houston, Texas, USA.
| | - Akhila Reddy
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer, Houston, Texas, USA
| | - Eduardo Bruera
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer, Houston, Texas, USA
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11
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Arthur JA, Tang M, Lu Z, Hui D, Nguyen K, Rodriguez EM, Edwards T, Yennurajalingam S, Dalal S, Dev R, Reddy A, Tanco K, Haider A, Liu DD, Bruera E. Random urine drug testing among patients receiving opioid therapy for cancer pain. Cancer 2021; 127:968-975. [PMID: 33231885 PMCID: PMC10015495 DOI: 10.1002/cncr.33326] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 08/24/2020] [Accepted: 10/06/2020] [Indexed: 11/06/2022]
Abstract
BACKGROUND There is limited information regarding the true frequency of nonmedical opioid use (NMOU) among patients receiving opioid therapy for cancer pain. Data to guide patient selection for urine drug testing (UDT) as well as the timing and frequency of ordering UDT are insufficient. This study examined the frequency of abnormal UDT among patients with cancer who underwent random UDT and their characteristics. METHODS Demographic and clinical information for patients with cancer who underwent random UDT were retrospectively reviewed and compared with a historical cohort that underwent targeted UDT. Random UDT was ordered regardless of a patient's risk potential for NMOU. Targeted UDT was ordered on the basis of a physician's estimation of a patient's risk for NMOU. RESULTS In all, 552 of 573 eligible patients (96%) underwent random UDT. Among these patients, 130 (24%) had 1 or more abnormal results; 38 of the 88 patients (43%) who underwent targeted UDT had 1 or more abnormal results. When marijuana was excluded, 15% of the random group and 37% of the targeted group had abnormal UDT findings (P < .001). It took a shorter time from the initial consultation to detect 1 or more abnormalities with the random test than the targeted test (median, 130 vs 274 days; P = .02). Abnormal random UDT was independently associated with younger age (P < .0001), male sex (P = .03), Cut Down, Annoyed, Guilty, and Eye Opener-Adapted to Include Drugs positivity (P = .001), and higher Edmonton Symptom Assessment System anxiety (P = .01). CONCLUSIONS Approximately 1 in 4 patients receiving opioids for cancer pain at a supportive care clinic who underwent random UDT had 1 or more abnormalities. Random UDT detected abnormalities earlier than the targeted test. These findings suggest that random UDT is justified among patients with cancer pain.
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Affiliation(s)
- Joseph A Arthur
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Michael Tang
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Zhanni Lu
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - David Hui
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Kristy Nguyen
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Eden Mae Rodriguez
- Pharmacy Services, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Tonya Edwards
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sriram Yennurajalingam
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Shalini Dalal
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Rony Dev
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Akhila Reddy
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Kimberson Tanco
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ali Haider
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Diane D Liu
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Eduardo Bruera
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
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12
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Arthur J, Edwards T, Lu Z, Hui D, Fellman B, Bruera E. Health Care Provider Attitudes, Beliefs, and Perceived Confidence in Managing Patients With Cancer Pain and Nonmedical Opioid Use. J Pain Symptom Manage 2021; 61:128-135.e6. [PMID: 32645456 PMCID: PMC9990526 DOI: 10.1016/j.jpainsymman.2020.06.040] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 06/23/2020] [Accepted: 06/30/2020] [Indexed: 10/23/2022]
Abstract
CONTEXT Health care provider education is an effective strategy to improve knowledge and competencies in opioid-prescribing practices. However, there are very few studies regarding this among providers of patients with cancer pain and nonmedical opioid use (NMOU). The aim of our study was to assess participants' attitudes, beliefs, and self-perceived confidence in caring for patients with cancer pain and NMOU before and after attending an opioid educational seminar on the use and nonmedical use of opioids in patients with cancer. METHODS An anonymous cross-sectional survey was conducted among health care providers who attended an opioid educational event in April 2018 and May 2019. RESULTS The overall response rate was 63% (129 of 206). Approximately 72% of participants had concerns about NMOU in patients with cancer, 69% felt that such patients are frequently underdetected, and 63% felt that cancer pain is frequently undertreated. At baseline, only 23% reported adequate knowledge and 35% reported confidence in caring for patients with cancer with NMOU-related issues. Among those who completed both the preseminar and postseminar surveys, these numbers improved significantly at the end of the seminar (26% vs. 71% and 43% vs. 84%, respectively; all P < 0.001). CONCLUSION Most health care providers expressed concerns about underdetection of NMOU and undertreatment of pain among patients with cancer. Many self-reported knowledge and confidence deficits in caring for patients with cancer with NMOU. Seminar participation was associated with an increase in the number of participants with self-perceived knowledge and confidence. Future studies are needed to ascertain the impact of such opioid educational events on patient care practices.
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Affiliation(s)
- Joseph Arthur
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer, Houston, Texas, USA.
| | - Tonya Edwards
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer, Houston, Texas, USA
| | - Zhanni Lu
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer, Houston, Texas, USA
| | - David Hui
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer, Houston, Texas, USA
| | - Bryan Fellman
- Department of Biostatistics, The University of Texas MD Anderson Cancer, Houston, Texas, USA
| | - Eduardo Bruera
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer, Houston, Texas, USA
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