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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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Hadler RA, Klinedinst R, Jones CA, Bao Y, Pathak R, Zarrabi AJ, Rosa WE. Dangerous Variation or Patient-Centered Care? Palliative Care and Pain Providers' Comfort, Experiences, and Approaches when Treating Cancer Pain With Coexisting Aberrant Behaviors. Am J Hosp Palliat Care 2024:10499091241259034. [PMID: 38830349 DOI: 10.1177/10499091241259034] [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: 06/05/2024] Open
Abstract
BACKGROUND Patients with cancer-related pain are at high risk for aberrant drug use behaviors (ADB), including self-escalation, diversion and concurrent illicit substance or opioid misuse; however, limited evidence is available to guide opioid prescribing for patients with life-limiting illness and concurrent or suspected ADB. We sought to characterize how specialists evaluate for and manage these high-risk behaviors in patients with cancer-related pain. METHODS We conducted telephonic semi-structured interviews with palliative care and pain medicine providers. Participants discussed their own comfort and experience level with identifying and managing ADB in patients with life-limiting illness. They were subsequently presented with a series of standardized scenarios and asked to describe their concerns and management strategies. RESULTS 95 interdisciplinary pain and palliative care specialists were contacted; 37 agreed to participate (38.9%). Analysis of interview contents revealed several central themes: (1) widespread discomfort and anxiety regarding safe and compassionate opioid prescribing for high-risk patients, (2) belief that widely used risk-mitigation tools such as opioid contracts and urine drug screens provided inadequate support for decision-making, and (3) lack of institutional and organizational support and guidance for safe prescribing strategies. Most clinicians reported self-education regarding addiction and alternative prescribing/pain management strategies. Providers varied widely in their willingness to discontinue opioid prescribing in a patient with aberrant behavior and pain associated with life-limiting illness. CONCLUSION Providers caring for patients demonstrating ADB and cancer-related pain struggle to balance safe prescribing with symptom management. Increased guidance is needed regarding opioid prescribing, monitoring, and discontinuation in high-risk patients.
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Affiliation(s)
- Rachel A Hadler
- Department of Anesthesiology, Emory University, Atlanta, GA, USA
- Emory Critical Care Center, Emory University, Atlanta, GA, USA
| | - Rachel Klinedinst
- Palliative Care Alliance, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Christopher A Jones
- Palliative Care Program, Department of Medicine, Duke University, Durham, NC, USA
| | - Yuhua Bao
- Department of Population Health Sciences, Weill-Cornell Medicine, New York, NY, USA
| | - Ravi Pathak
- Department of Anesthesiology, Emory University, Atlanta, GA, USA
- Division of Palliative Medicine, Department of Family and Preventive Medicine, Emory University, Atlanta, GA, USA
| | - Ali J Zarrabi
- Division of Palliative Medicine, Department of Family and Preventive Medicine, Emory University, Atlanta, GA, USA
| | - William E Rosa
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
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Petrillo LA, Jones KF, El-Jawahri A, Sanders J, Greer JA, Temel JS. Why and How to Integrate Early Palliative Care Into Cutting-Edge Personalized Cancer Care. Am Soc Clin Oncol Educ Book 2024; 44:e100038. [PMID: 38815187 DOI: 10.1200/edbk_100038] [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: 06/01/2024]
Abstract
Early palliative care, palliative care integrated with oncology care early in the course of illness, has myriad benefits for patients and their caregivers, including improved quality of life, reduced physical and psychological symptom burden, enhanced prognostic awareness, and reduced health care utilization at the end of life. Although ASCO and others recommend early palliative care for all patients with advanced cancer, widespread implementation of early palliative care has not been realized because of barriers such as insufficient reimbursement and a palliative care workforce shortage. Investigators have recently tested several implementation strategies to overcome these barriers, including triggers for palliative care consultations, telehealth delivery, navigator-delivered interventions, and primary palliative care interventions. More research is needed to identify mechanisms to distribute palliative care optimally and equitably. Simultaneously, the transformation of the oncology treatment landscape has led to shifts in the supportive care needs of patients and caregivers, who may experience longer, uncertain trajectories of cancer. Now, palliative care also plays a clear role in the care of patients with hematologic malignancies and may be beneficial for patients undergoing phase I clinical trials and their caregivers. Further research and clinical guidance regarding how to balance the risks and benefits of opioid therapy and safely manage cancer-related pain across this wide range of settings are urgently needed. The strengths of early palliative care in supporting patients' and caregivers' coping and centering decisions on their goals and values remain valuable in the care of patients receiving cutting-edge personalized cancer care.
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Affiliation(s)
- Laura A Petrillo
- Division of Palliative Care and Geriatrics, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Katie Fitzgerald Jones
- Harvard Medical School, Boston, MA
- New England Geriatrics Research, Education, and Clinical Center (GRECC), Jamaica Plain, MA
| | - Areej El-Jawahri
- Harvard Medical School, Boston, MA
- Division of Hematology/Oncology, Massachusetts General Hospital, Boston, MA
| | - Justin Sanders
- Division of Supportive and Palliative Care, McGill University Health Centre, Montreal, CA
- Department of Family Medicine, McGill University, Montreal, CA
| | - Joseph A Greer
- Harvard Medical School, Boston, MA
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA
| | - Jennifer S Temel
- Harvard Medical School, Boston, MA
- Division of Hematology/Oncology, Massachusetts General Hospital, Boston, MA
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Coyne P, Lowry S, Mulvenon C, Paice JA. American Society for Pain Management Nursing and Hospice and Palliative Nurses Association Position Statement: Pain Management at the End of Life. Pain Manag Nurs 2024:S1524-9042(24)00141-3. [PMID: 38697888 DOI: 10.1016/j.pmn.2024.03.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 03/31/2024] [Indexed: 05/05/2024]
Abstract
Fundamental to the quality of life is assisting patients in relieving pain including at the end of life. Compassionate, effective, evidence-based pain care for the dying improves the quality of life for patients and may reduce distress and complicated bereavement in the loved ones witnessing this death. However, efforts designed to mitigate the consequences of the opioid epidemic have seriously compromised pain care at the end of life. This has created an urgent need to focus on the barriers to relief, and solutions necessary to provide safe and effective pain and symptom management in this population. To that end, a committee of experts was convened by the American Society for Pain Management Nursing and the Hospice and Palliative Nursing Association. These experts reviewed the current literature, developed a draft position statement which underwent consecutive revisions. This statement was then endorsed by the respective organizations. Elucidation of barriers to effective pain control in advanced disease allows targeted interventions; including those related to clinical care, education, accessibility, and research. As nurses, we must continuously advocate for humane and dignified care, promoting ethical, effective pain and symptom management at the end of life for all.
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Affiliation(s)
- Patrick Coyne
- Consultant, Assistant Professor, Medical University of South Carolina, Charleston, South Carolina
| | - Sarah Lowry
- Assistant Professor, Division of Hematology/Medical Oncology, School of Medicine, Oregon Health & Science University, Portland, Oregon; Knight Cancer Institute, Beaverton, Oregon
| | - Carol Mulvenon
- Clinical Nurse Specialist, Palliative Care, The University of Kansas Health System, Kansas City, Kansas.
| | - Judith A Paice
- Director, Cancer Pain Program, Division of Hematology/Oncology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois
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Noreika D, Konecny M. The Pendulum: The Need to Develop a Safe, Effective, and Equitable Management Strategy for Opioids in Cancer Patients. Risk Manag Healthc Policy 2024; 17:1079-1082. [PMID: 38686131 PMCID: PMC11057629 DOI: 10.2147/rmhp.s455252] [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] [Received: 12/16/2023] [Accepted: 04/11/2024] [Indexed: 05/02/2024] Open
Abstract
The opioid epidemic has caused major morbidity and mortality to Americans. Although there are multiple sources of this staggering issue, one inciting factor has been the use of opioids to manage pain. Although recent efforts have changed care pathways for patients with chronic pain, the first-line management of cancer pain remains opioids. Despite this, there is very little evidence and no guidelines/regulations to assist in the management of these patients. Although the literature suggests a number of current barriers to identifying and managing the challenges (such as the preferred management of patients with opioid use disorder (OUD), the optimal approach to taperering, or approaches to disparities), there are no concrete strategies for providers to manage these circumstances. Investing in further research utilizing the national opioid settlement funding, exploring the equity gaps using community based participatory research and community health worker models, and increasing provider education pathways are all potential approaches to improving this issue. These solutions could help identify and address some of the gaps that affect cancer patients taking opioids for pain.
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Yoo SH, Kang J, Kim HJ, Lee SW, Hong M, Jung EH, Kim YJ, Yon DK, Kang B. Opioid use and subsequent delirium risk in patients with advanced cancer in palliative care: a multicenter registry study. Sci Rep 2024; 14:6004. [PMID: 38472471 PMCID: PMC10933309 DOI: 10.1038/s41598-024-56675-1] [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] [Received: 12/15/2023] [Accepted: 03/08/2024] [Indexed: 03/14/2024] Open
Abstract
The prevalent use of opioids for pain management in patients with advanced cancer underscores the need for research on their neuropsychiatric impacts, particularly delirium. Therefore, we aimed to investigate the potential association between opioid use and the risk of delirium in patients with advanced cancer admitted to the acute palliative care unit. We conducted a retrospective observational study utilizing a multicenter, patient-based registry cohort by collecting the data from January 1, 2019, to December 31, 2020, in South Korea. All data regarding exposures, outcomes, and covariates were obtained through retrospective chart reviews by a team of specialized medical professionals with expertise in oncology. Full unmatched and 1:1 propensity-score matched cohorts were formed, and stratification analysis was conducted. The primary outcome, delirium, was defined and diagnosed by the DSM-IV. Of the 2,066 patients with advanced cancer, we identified 42.8% (mean [SD] age, 64.4 [13.3] years; 60.8% male) non-opioid users and 57.2% (62.8 [12.5] years; 55.9% male) opioid users, respectively. Opioid use was significantly associated with an increased occurrence of delirium in patients with advanced cancer (OR, 2.02 [95% CI 1.22-3.35]). The risk of delirium in patients with advanced cancer showed increasing trends in a dose-dependent manner. High-dose opioid users showed an increased risk of delirium in patients with advanced cancer compared to non-opioid users (low-dose user: OR, 2.21 [95% CI 1.27-3.84]; high-dose user: OR, 5.75 [95% CI 2.81-11.77]; ratio of OR, 2.60 [95% CI 1.05-6.44]). Patients with old age, male sex, absence of chemotherapy during hospitalization, and non-obese status were more susceptible to increased risk of delirium in patients with cancer. In this multicenter patient-based registry cohort study, we found a significant, dose-dependent association between opioid use and increased risk of delirium in patients with advanced cancer. We also identified specific patient groups more susceptible to delirium. These findings highlight the importance of opioid prescription in these patients with advanced cancer, balancing effective doses for pain management and adverse dose-inducing delirium.
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Affiliation(s)
- Shin Hye Yoo
- Center for Palliative Care and Clinical Ethics, Seoul National University Hospital, Seoul, South Korea
| | - Jiseung Kang
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
- Division of Sleep Medicine, Harvard Medical School, Boston, MA, USA
| | - Hyeon Jin Kim
- Center for Digital Health, Medical Science Research Institute, Kyung Hee University College of Medicine, Seoul, South Korea
- Department of Regulatory Science, Kyung Hee University, Seoul, South Korea
| | - Si Won Lee
- Division of Medical Oncology, Department of Internal Medicine, Yonsei Cancer Center, Yonsei University Health System, Seoul, South Korea
- Palliative Cancer Center, Yonsei Cancer Center, Yonsei University Health System, Seoul, South Korea
| | - Moonki Hong
- Division of Medical Oncology, Department of Internal Medicine, Yonsei Cancer Center, Yonsei University Health System, Seoul, South Korea
- Palliative Cancer Center, Yonsei Cancer Center, Yonsei University Health System, Seoul, South Korea
| | - Eun Hee Jung
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea
| | - Yu Jung Kim
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea
| | - Dong Keon Yon
- Division of Sleep Medicine, Harvard Medical School, Boston, MA, USA.
- Center for Digital Health, Medical Science Research Institute, Kyung Hee University College of Medicine, Seoul, South Korea.
- Department of Pediatrics, Kyung Hee University Medical Center, Kyung Hee University College of Medicine, 23 Kyungheedae-Ro, Dongdaemun-Gu, Seoul, 02447, South Korea.
| | - Beodeul Kang
- Division of Medical Oncology, Department of Internal Medicine, CHA Bundang Medical Center, CHA University School of Medicine, 59 Yatap-Ro, Bundang-Gu, Seongnam, 13496, South Korea.
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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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Jones KF, Khodyakov D, Han BH, Arnold RM, Dao E, Morrison J, Kapo J, Meier DE, Paice JA, Liebschutz JM, Ritchie CS, Merlin JS, Bulls HW. Expert consensus-based guidance on approaches to opioid management in individuals with advanced cancer-related pain and nonmedical stimulant use. Cancer 2023; 129:3978-3986. [PMID: 37691479 PMCID: PMC10910244 DOI: 10.1002/cncr.34921] [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] [Received: 02/13/2023] [Revised: 03/19/2023] [Accepted: 04/17/2023] [Indexed: 09/12/2023]
Abstract
BACKGROUND Clinicians treating cancer-related pain with opioids regularly encounter nonmedical stimulant use (i.e., methamphetamine, cocaine), yet there is little evidence-based management guidance. The aim of the study is to identify expert consensus on opioid management strategies for an individual with advanced cancer and cancer-related pain with nonmedical stimulant use according to prognosis. METHODS The authors conducted two modified Delphi panels with palliative care and addiction experts. In Panel A, the patient's prognosis was weeks to months and in Panel B the prognosis was months to years. Experts reviewed, rated, and commented on the case using a 9-point Likert scale from 1 (very inappropriate) to 9 (very appropriate) and explained their responses. The authors applied the three-step analytical approach outlined in the RAND/UCLA to determine consensus and level of clinical appropriateness of management strategies. To better conceptualize the quantitative results, they thematically analyzed and coded participant comments. RESULTS Consensus was achieved for all management strategies. The 120 Experts were mostly women (47 [62%]), White (94 [78%]), and physicians (115 [96%]). For a patient with cancer-related and nonmedical stimulant use, regardless of prognosis, it was deemed appropriate to continue opioids, increase monitoring, and avoid opioid tapering. Buprenorphine/naloxone transition was inappropriate for a patient with a short prognosis and of uncertain appropriateness for a patient with a longer prognosis. CONCLUSION Study findings provide urgently needed consensus-based guidance for clinicians managing cancer-related pain in the context of stimulant use and highlight a critical need to develop management strategies to address stimulant use disorder in people with cancer. PLAIN LANGUAGE SUMMARY Among palliative care and addiction experts, regardless of prognosis, it was deemed appropriate to continue opioids, increase monitoring, and avoid opioid tapering in the context of cancer-related pain and nonmedical stimulant use. Buprenorphine/naloxone transition as a harm reduction measure was inappropriate for a patient with a short prognosis and of uncertain appropriateness for a patient with a longer prognosis.
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Affiliation(s)
- Katie Fitzgerald Jones
- New England Geriatric Research, Education and Clinical Center and Division of Palliative Care, VA Boston Healthcare System, Boston, Massachusetts, USA
| | | | - Benjamin H. Han
- Division of Geriatrics, Gerontology, and Palliative Care, University of California, San Diego, California, USA
| | - Robert M. Arnold
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Emily Dao
- RAND Corporation, Santa Monica, California, USA
| | - Jeni Morrison
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jennifer Kapo
- Palliative Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Diane E. Meier
- Department of Geriatrics and Palliative Medicine, Center to Advance Palliative Care, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Judith A. Paice
- Division Hematology-Oncology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
| | - Jane M. Liebschutz
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Christine S. Ritchie
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jessica S. Merlin
- Challenges in Managing and Preventing Pain Clinical Research Center, Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Hailey W. Bulls
- Challenges in Managing and Preventing Pain Clinical Research Center, Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Jones KF, Joudrey P, Meier D, Meghani S, Merlin J. Juggling Two Full-Time Jobs - Methadone Clinic Engagement and Cancer Care. N Engl J Med 2023; 389:2024-2026. [PMID: 38009604 PMCID: PMC10875342 DOI: 10.1056/nejmp2310123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Affiliation(s)
- Katie F Jones
- From the New England Geriatric Research, Education, and Clinical Center, VA Boston Healthcare System, Boston (K.F.J.); the Division of General Internal Medicine (P.J.) and the Section of Palliative Care and Medical Ethics (J.M.), University of Pittsburgh School of Medicine, Pittsburgh; the Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York (D.M.); and the New Courtland Center for Transitions and Health, University of Pennsylvania, Philadelphia (S.M.)
| | - Paul Joudrey
- From the New England Geriatric Research, Education, and Clinical Center, VA Boston Healthcare System, Boston (K.F.J.); the Division of General Internal Medicine (P.J.) and the Section of Palliative Care and Medical Ethics (J.M.), University of Pittsburgh School of Medicine, Pittsburgh; the Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York (D.M.); and the New Courtland Center for Transitions and Health, University of Pennsylvania, Philadelphia (S.M.)
| | - Diane Meier
- From the New England Geriatric Research, Education, and Clinical Center, VA Boston Healthcare System, Boston (K.F.J.); the Division of General Internal Medicine (P.J.) and the Section of Palliative Care and Medical Ethics (J.M.), University of Pittsburgh School of Medicine, Pittsburgh; the Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York (D.M.); and the New Courtland Center for Transitions and Health, University of Pennsylvania, Philadelphia (S.M.)
| | - Salimah Meghani
- From the New England Geriatric Research, Education, and Clinical Center, VA Boston Healthcare System, Boston (K.F.J.); the Division of General Internal Medicine (P.J.) and the Section of Palliative Care and Medical Ethics (J.M.), University of Pittsburgh School of Medicine, Pittsburgh; the Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York (D.M.); and the New Courtland Center for Transitions and Health, University of Pennsylvania, Philadelphia (S.M.)
| | - Jessica Merlin
- From the New England Geriatric Research, Education, and Clinical Center, VA Boston Healthcare System, Boston (K.F.J.); the Division of General Internal Medicine (P.J.) and the Section of Palliative Care and Medical Ethics (J.M.), University of Pittsburgh School of Medicine, Pittsburgh; the Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York (D.M.); and the New Courtland Center for Transitions and Health, University of Pennsylvania, Philadelphia (S.M.)
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Chwistek M, Sherry D, Kinczewski L, Silveira MJ, Davis M. Should Buprenorphine Be Considered a First-Line Opioid for the Treatment of Moderate to Severe Cancer Pain? J Pain Symptom Manage 2023; 66:e638-e643. [PMID: 37343903 DOI: 10.1016/j.jpainsymman.2023.06.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 06/02/2023] [Accepted: 06/09/2023] [Indexed: 06/23/2023]
Abstract
Cancer pain remains a significant problem worldwide, affecting more than half of patients receiving anti-cancer treatment and most patients with advanced disease. Opioids remain the cornerstone of therapy, and morphine, given its availability, multiple formulations, price, and evidence base, is typically considered the first-line treatment for moderate to severe cancer pain. Buprenorphine has emerged in recent decades as an alternative opioid for treating chronic pain and substance use disorder (SUD). However, it remains controversial whether buprenorphine should be considered a first-line opioid for moderate to severe cancer pain. In this "Controversies in Palliative Care" article, three expert clinicians independently answer this question. Specifically, each group provides a synopsis of the key studies that inform their thought process, share practical advice on their clinical approach, and highlight the opportunities for future research. All three groups agree that there is a place for the use of buprenorphine as a first-line opioid in cancer pain. Specifically, they mention populations of elderly patients, patients with renal failure, and those with (SUD). They also underscore many unique and favorable characteristics of buprenorphine, such as the low risk for respiratory depression, lack of adverse effects on testosterone levels in men, no risk of serotonin syndrome when combined with antidepressants, and ease of use given its transdermal, transmucosal, and sublingual formulations. However, further studies are needed to guide the use of buprenorphine for cancer pain-primarily randomized clinical trials (RCTs) comparing buprenorphine with other opioids in various pain syndromes.
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Affiliation(s)
- Marcin Chwistek
- Department of Hematology and Oncology (M.C., D.S., L.K.), Fox Chase Cancer Center/Temple University Health System, Philadelphia, PA, USA.
| | - Dylan Sherry
- Department of Hematology and Oncology (M.C., D.S., L.K.), Fox Chase Cancer Center/Temple University Health System, Philadelphia, PA, USA
| | - Leigh Kinczewski
- Department of Hematology and Oncology (M.C., D.S., L.K.), Fox Chase Cancer Center/Temple University Health System, Philadelphia, PA, USA
| | - Maria J Silveira
- Division of Geriatric and Palliative Medicine (M.J.S.), University of Michigan & Geriatric Research Education and Clinical Center, Ann Arbor Veteran Administration Medical Center, Ann Arbor, MI, USA
| | - Mellar Davis
- Department of Palliative Care, Geisinger Medical Center, Geisinger Health Geisinger Commonwealth School of Medicine (M.D.), Danville, PA, USA
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11
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Taylor EP, Vellozzi-Averhoff C, Vettese T. Care Throughout the Journey-The Interaction Between Primary Care and Palliative Care. Clin Geriatr Med 2023; 39:379-393. [PMID: 37385690 DOI: 10.1016/j.cger.2023.04.002] [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] [Indexed: 07/01/2023]
Abstract
Palliative care is no longer synonymous with end-of-life care, and because supply has been well outstripped by demand, much of the practice of palliative care early in a patient's illness journey will take place in the primary care clinic-referred to as primary palliative care. Referral to specialty palliative care for complex symptom management or clarification on decision-making is appropriate, and can facilitate hospice referral, if indicated and in line with patient/family goals.
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Affiliation(s)
- Emily Pinto Taylor
- Division of Hospice and Palliative Medicine, Department of Family and Preventative Medicine, Emory University School of Medicine, Atlanta, GA, USA; Division of General Internal Medicine, Department of Internal Medicine, Emory University School of Medicine, Atlanta, GA, USA.
| | - Cristina Vellozzi-Averhoff
- Division of Hospice and Palliative Medicine, Department of Family and Preventative Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Theresa Vettese
- Division of General Internal Medicine, Department of Internal Medicine, Emory University School of Medicine, Atlanta, GA, USA
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12
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Jones KF, Broglio K, Ho JJ, Rosa WE. Compassionate Care for People with Cancer and Opioid Use Disorder. Am J Nurs 2023; 123:56-61. [PMID: 37498041 PMCID: PMC10619200 DOI: 10.1097/01.naj.0000947480.74410.06] [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: 07/28/2023]
Abstract
ABSTRACT Opioid use disorder (OUD) is an important comorbidity to assess and manage in people with cancer. In this article, the authors discuss strategies for safe opioid management in individuals with OUD and cancer-related pain using a composite case example. They highlight core approaches to pain management, including motivational interviewing, harm reduction, and evidence-based treatments, as well as advocacy for person-centered end-of-life care.
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Affiliation(s)
- Katie Fitzgerald Jones
- Katie Fitzgerald Jones is a palliative and addiction NP and researcher in the VA Boston Healthcare System. Kathleen Broglio is associate professor of medicine in the Geisel School of Medicine at Dartmouth, Hanover, NH. J. Janet Ho is a palliative and addiction medicine physician at the University of California, San Francisco. William E. Rosa is assistant attending behavioral scientist, Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York City. Contact author: Katie Fitzgerald Jones, . The authors have disclosed no potential conflicts of interest, financial or otherwise
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13
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Rosa WE, Pandey S, Epstein AS, Connor SR, Andersen LJ, Blackler L, Desai AV, Koranteng LA, Breitbart WS, Nelson JE. The Third Annual US Celebration of World Hospice and Palliative Care Day: A virtual coming together to unify the global palliative care community. Palliat Support Care 2023; 21:378-384. [PMID: 37016910 PMCID: PMC10272993 DOI: 10.1017/s1478951523000391] [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: 04/06/2023]
Abstract
OBJECTIVES On 3-4 October 2022, the Memorial Sloan Kettering Cancer Center Supportive Care Service and Department of Psychiatry and Behavioral Sciences hosted the Third Annual United States (US) Celebration of World Hospice and Palliative Care Day (WHPCD). The purpose of this article is to reflect on the event within the broader context of the international WHPCD theme: "healing hearts and communities." We describe lessons learned in anticipation of the fourth annual conference to be held on 3-4 October 2023. METHODS Description of the third annual event, conference planning team reflection, and attendee evaluation responses. RESULTS The Worldwide Hospice Palliative Care Alliance launched WHPCD in 2005 as an annual unified day of action to celebrate and support hospice and palliative care globally. Since 2020, the conference has attracted an increasing number of attendees from around the world. Two primary aims continue to guide the event: community building and wisdom sharing. Fifty-two interprofessional palliative care experts, advocates, patients, and caregivers provided 13 unique interactive sessions. Four hundred and fifty-eight multidisciplinary registrants from at least 17 countries joined the program. Free registration for colleagues in low- and middle-income countries, students and trainees, and individuals experiencing financial hardship remains a cornerstone of inclusion and equitable access to the event. SIGNIFICANCE OF RESULTS The US WHPCD celebration provides a virtual platform that offers opportunities for scientific dissemination and collective reflection on hospice and palliative care delivery amid significant local and global changes in clinical practice, research, policy and advocacy, and population health. We remain committed to ensuring an internationally relevant, culturally diverse, and multidisciplinary agenda that will continue to draw increased participation worldwide during future annual events.
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Affiliation(s)
- William E Rosa
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Shila Pandey
- Supportive Care Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Andrew S Epstein
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Laurie J Andersen
- Supportive Care Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Liz Blackler
- Ethics Committee, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Anjali V Desai
- Supportive Care Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - William S Breitbart
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Judith E Nelson
- Supportive Care Service, Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, NY, USA
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14
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Chang VT, Sandifer C, Zhong F. GI Symptoms in Pancreatic Cancer. Clin Colorectal Cancer 2023; 22:24-33. [PMID: 36623952 DOI: 10.1016/j.clcc.2022.12.002] [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: 08/30/2022] [Accepted: 12/21/2022] [Indexed: 12/31/2022]
Abstract
This review will apply a multidisciplinary approach to GI symptoms with attention to symptom assessment (instruments and qualitative aspects), differential diagnosis, and recent findings relevant to management of symptoms and underlying diseases. We conclude that further development of supportive interventions for GI symptoms for both patient and caregivers has the potential to reduce distress from GI symptoms, and anticipate better symptom control with advances in scientific knowledge and improvement of the evidence base.
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Affiliation(s)
- Victor T Chang
- Section Hematology Oncology (111), VA New Jersey Health Care System, East Orange, NJ; Department of Medicine, Rutgers - New Jersey Medical School, Newark, NJ.
| | | | - Fengming Zhong
- Section Hematology Oncology (111), VA New Jersey Health Care System, East Orange, NJ; Department of Medicine, Rutgers - New Jersey Medical School, Newark, NJ
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15
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DiScala S, Uritsky TJ, Brown ME, Abel SM, Humbert NT, Naidu D. Society of Pain and Palliative Care Pharmacists White Paper on the Role of Opioid Stewardship Pharmacists. J Pain Palliat Care Pharmacother 2023; 37:3-15. [PMID: 36519288 DOI: 10.1080/15360288.2022.2149670] [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: 12/23/2022]
Abstract
Opioid stewardship is one essential function of pain and palliative care pharmacists and a critical need in the United States. In recent years, this country has been plagued by two public health emergencies: an opioid crisis and the COVID-19 pandemic, which has exacerbated the opioid epidemic through its economic and psychosocial toll. To develop an opioid stewardship program, a systematic approach is needed. This will be detailed in part here by the Opioid Stewardship Taskforce of the Society of Pain and Palliative Care Pharmacists (SPPCP), focusing on the role of the pharmacist. Many pain and palliative care pharmacists have made significant contributions to the development and daily operation of such programs while also completing other competing clinical tasks, including direct patient care. To ensure dedicated time and attention to critical opioid stewardship efforts, SPPCP recommends and endorses opioid stewardship models employing a full time, opioid stewardship pharmacist in both the inpatient and outpatient setting. Early research suggests that opioid stewardship pharmacists are pivotal to improving opioid metrics and pain care outcomes. However, further research and development in this area of practice is needed and encouraged.
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16
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Sedney CL, Dekeseredy P, Singh SA, Holbein M. Stigmatizing Language Expressed Towards Individuals With Current or Previous OUD Who Have Pain and Cancer: A Qualitative Study. J Pain Symptom Manage 2023; 65:553-561. [PMID: 36804424 DOI: 10.1016/j.jpainsymman.2023.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 02/01/2023] [Accepted: 02/05/2023] [Indexed: 02/17/2023]
Abstract
CONTEXT Stigma is known to impact the care of patients with opioid use disorder (OUD). OBJECTIVES This qualitative study seeks to understand how stigma is expressed in the medical chart by healthcare workers towards patients with cancer pain and OUD treated at an academic medical center. METHODS This descriptive qualitative study utilized a thematic analysis approach to analyze the medical charts of 25 hospitalized patients with current or previous opioid use disorder and cancer with respect to their pain care in forty pain-related hospital admissions to a tertiary academic center from 2015 to 2020. The codebook utilized a well-characterized stigma framework and emerging themes were identified through an iterative, comparative method. COREQ guidelines were followed. RESULTS Evidence of stigma marking was present in the medical chart aligning with several intersecting stigmas. Drivers such as blame and stereotypes impeded pain care, while facilitators such as legal or policy influences and non-care advocates could be either positive or negative determinants to pain care. Care by known providers within the healthcare environment was largely a facilitator of improved pain care. CONCLUSIONS Healthcare provider stigma must be addressed as its effects are both quantitatively and qualitatively affecting patient care; in particular access to pain treatment. Continuity of care by known care providers may improve pain care for patients with cancer and OUD who are acutely hospitalized.
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Affiliation(s)
- Cara L Sedney
- Department of Neurosurgery (C.L.S., P.D.), Rockefeller Neuroscience Institute, West Virginia University, Morgantown, West Virginia, USA.
| | - Patricia Dekeseredy
- Department of Neurosurgery (C.L.S., P.D.), Rockefeller Neuroscience Institute, West Virginia University, Morgantown, West Virginia, USA
| | - Sarah A Singh
- Department of Radiation Oncology (S.A.S.), West Virginia University, Morgantown, West Virginia, USA
| | - Monika Holbein
- Department of Medicine (M.H.), Pennsylvania State College of Medicine, Hershey, Pennsylvania, USA
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17
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Smart R, Grant S, Gordon AJ, Pacula RL, Stein BD. Expert Panel Consensus on State-Level Policies to Improve Engagement and Retention in Treatment for Opioid Use Disorder. JAMA HEALTH FORUM 2022; 3:e223285. [PMID: 36218944 PMCID: PMC10041351 DOI: 10.1001/jamahealthforum.2022.3285] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Importance In the US, recent legislation and regulations have been considered, proposed, and implemented to improve the quality of treatment for opioid use disorder (OUD). However, insufficient empirical evidence exists to identify which policies are feasible to implement and successfully improve patient and population-level outcomes. Objective To examine expert consensus on the effectiveness and the ability to implement state-level OUD treatment policies. Evidence Review This qualitative study used the ExpertLens online platform to conduct a 3-round modified Delphi process to convene 66 stakeholders (health care clinicians, social service practitioners, addiction researchers, health policy decision-makers, policy advocates, and persons with lived experience). Stakeholders participated in 1 of 2 expert panels on 14 hypothetical state-level policies targeting treatment engagement and linkage, evidence-based and integrated care, treatment flexibility, and monitoring or support services. Participants rated policies in round 1, discussed results in round 2, and provided final ratings in round 3. Participants used 4 criteria associated with either the effectiveness or implementability to rate and discuss each policy. The effectiveness panel (n = 29) considered policy effects on treatment engagement, treatment retention, OUD remission, and opioid overdose mortality. The implementation panel (n = 34) considered the acceptability, feasibility, affordability, and equitability of each policy. We measured consensus using the interpercentile range adjusted for symmetry analysis technique from the RAND/UCLA appropriateness method. Findings Both panels reached consensus on all items. Experts viewed 2 policies (facilitated access to medications for OUD and automatic Medicaid enrollment for citizens returning from correctional settings) as highly implementable and highly effective in improving patient and population-level outcomes. Participants rated hub-and-spoke-type policies and provision of financial incentives to emergency departments for treatment linkage as effective; however, they also rated these policies as facing implementation barriers associated with feasibility and affordability. Coercive policies and policies levying additional requirements on individuals with OUD receiving treatment (eg, drug toxicology testing, counseling requirements) were viewed as low-value policies (ie, decreasing treatment engagement and retention, increasing overdose mortality, and increasing health inequities). Conclusions and Relevance The findings of this study may provide urgently needed consensus on policies for states to consider either adopting or deimplementing in their efforts to address the opioid overdose crisis.
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Affiliation(s)
- Rosanna Smart
- Economics, Sociology, and Statistics Department, RAND Corporation, Santa Monica, California.,Drug Policy Research Center, RAND Corporation, Santa Monica, California
| | - Sean Grant
- Department of Social & Behavioral Sciences, Indiana University Richard M. Fairbanks School of Public Health, Indianapolis
| | - Adam J Gordon
- Program for Addiction Research, Clinical Care, Knowledge and Advocacy, Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City.,Informatics, Decision-Enhancement, and Analytic Sciences Center, VA Salt Lake City Health Care System, Salt Lake City, Utah
| | - Rosalie Liccardo Pacula
- Sol Price School of Public Policy and Leonard D. Schaeffer Center for Health Policy & Economics, University of Southern California, Los Angeles
| | - Bradley D Stein
- Behavioral and Policy Sciences Department, RAND Corporation, Pittsburgh, Pennsylvania
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18
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Arthur J, Bruera E. Managing Cancer Pain in Patients With Opioid Use Disorder or Nonmedical Opioid Use. JAMA Oncol 2022; 8:1104-1105. [PMID: 35771548 PMCID: PMC10015490 DOI: 10.1001/jamaoncol.2022.2150] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Joseph Arthur
- Department of Palliative, Rehabilitation and Integrative Medicine, 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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