Compassion Inequities and Opioid Use Disorder: A Matched Case-Control Analysis Examining Inpatient Management of Cancer-Related Pain for Patients With Opioid Use Disorder

Creating a Palliative Care Clinic for Patients with Cancer Pain and Substance Use Disorder

BACKGROUND

Opioids are a first-line treatment for severe cancer pain. However, clinicians may be reluctant to prescribe opioids for patients with concurrent substance use disorders (SUD) or clinical concerns about non-prescribed substance use.

MEASURES

Patient volume, 60-day retention rate, and use of sublingual buprenorphine to treat opioid use disorder.

INTERVENTION

We created the Palliative Harm Reduction and Resiliency Clinic, a palliative care clinic founded on harm reduction principles and including formal collaboration with addiction psychiatry.

OUTCOMES

During the first 18 months, patient volume increased steadily; 70% of patients had at least one subsequent visit within 60 days of the initial appointment; and buprenorphine was prescribed for 55% of patients with opioid use disorder.

CONCLUSIONS/LESSONS LEARNED

The formal collaboration with addiction psychiatry and the integration of harm reduction principles and practices into ambulatory palliative care improved our ability to provide treatment to a previously underserved patient population with high symptom burden.

Why and How to Integrate Early Palliative Care Into Cutting-Edge Personalized Cancer Care

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.

Substance Use Disorders Among US Adult Cancer Survivors

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.

Methadone dose escalation in patients with opioid use disorder and cancer as a strategy for controlling cancer-related pain: A case series

OBJECTIVES

Opioid use disorder (OUD) and cancer gained attention as co-occurring diseases in the last 2 decades due to the possible relationship between opioid prescriptions for cancer pain and the risk of developing substance use disorder in cancer patients. However, little is known about patients previously diagnosed with OUD who develop cancer and how to manage both OUD symptoms and control pain.

METHODS

The present case series deals with this subpopulation and proposes a dose escalation of methadone to control both the cancer-related pain and drug addiction symptoms.

RESULTS

This approach is peculiar because methadone is not used as a first-line treatment in cancer pain management and is not often used as a second-line treatment as well. Our 4 patients experienced good clinical control of symptoms and no major adverse reactions.

SIGNIFICANCE OF RESULTS

The subgroup of patients with OUD who develop cancer could be the perfect population to reconsider the use of methadone as a first-line treatment for cancer pain. Prospective studies are needed to evaluate the efficacy and safety of increasing doses of methadone in these patients to validate our clinical approach.

Opioid use disorder in cancer patients

PURPOSE OF REVIEW

The misuse of opioids has increased significantly in recent decades. Historically, cancer patients have not been considered at risk of opioid misuse. However, cancer pain is common, and opioids are often prescribed. Guidelines addressing opioid misuse often exclude cancer patients. Given that misuse is associated with significant harm and a reduction in quality of life, it is important to understand the risk of opioid misuse in cancer patients and how we can recognise and treat it.

RECENT FINDINGS

Early cancer diagnoses and treatments have improved cancer survival rates, leading to a larger population of cancer patients and survivors. Opioid use disorder (OUD) may precede a cancer diagnosis or may develop during or after treatment. The effect of OUD extends from an individual patient to a societal level. This review examines the increasing incidence of OUD in cancer patients, ways to identify patients with OUD such as behaviour change and screening scales, prevention of OUD such as limited and targeted opioid prescriptions, and evidence-based treatment suggestions for OUD.

SUMMARY

OUD in cancer patients has only relatively recently been recognised as a growing problem. Early identification, involvement of the multidisciplinary team, and treatment can reduce the negative impact of OUD.

Endogenous opiates and behavior: 2021

This paper is the forty-fourth consecutive installment of the annual anthological review of research concerning the endogenous opioid system, summarizing articles published during 2021 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides and receptors as well as effects of opioid/opiate agonizts and antagonists. The review is subdivided into the following specific topics: molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors (1), the roles of these opioid peptides and receptors in pain and analgesia in animals (2) and humans (3), opioid-sensitive and opioid-insensitive effects of nonopioid analgesics (4), opioid peptide and receptor involvement in tolerance and dependence (5), stress and social status (6), learning and memory (7), eating and drinking (8), drug abuse and alcohol (9), sexual activity and hormones, pregnancy, development and endocrinology (10), mental illness and mood (11), seizures and neurologic disorders (12), electrical-related activity and neurophysiology (13), general activity and locomotion (14), gastrointestinal, renal and hepatic functions (15), cardiovascular responses (16), respiration and thermoregulation (17), and immunological responses (18).

Stigmatizing Language Expressed Towards Individuals With Current or Previous OUD Who Have Pain and Cancer: A Qualitative Study

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.

Artificial intelligence technologies and compassion in healthcare: A systematic scoping review

Background

Advances in artificial intelligence (AI) technologies, together with the availability of big data in society, creates uncertainties about how these developments will affect healthcare systems worldwide. Compassion is essential for high-quality healthcare and research shows how prosocial caring behaviors benefit human health and societies. However, the possible association between AI technologies and compassion is under conceptualized and underexplored.

Objectives

The aim of this scoping review is to provide a comprehensive depth and a balanced perspective of the emerging topic of AI technologies and compassion, to inform future research and practice. The review questions were: How is compassion discussed in relation to AI technologies in healthcare? How are AI technologies being used to enhance compassion in healthcare? What are the gaps in current knowledge and unexplored potential? What are the key areas where AI technologies could support compassion in healthcare?

Materials and methods

A systematic scoping review following five steps of Joanna Briggs Institute methodology. Presentation of the scoping review conforms with PRISMA-ScR (Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews). Eligibility criteria were defined according to 3 concept constructs (AI technologies, compassion, healthcare) developed from the literature and informed by medical subject headings (MeSH) and key words for the electronic searches. Sources of evidence were Web of Science and PubMed databases, articles published in English language 2011-2022. Articles were screened by title/abstract using inclusion/exclusion criteria. Data extracted (author, date of publication, type of article, aim/context of healthcare, key relevant findings, country) was charted using data tables. Thematic analysis used an inductive-deductive approach to generate code categories from the review questions and the data. A multidisciplinary team assessed themes for resonance and relevance to research and practice.

Results

Searches identified 3,124 articles. A total of 197 were included after screening. The number of articles has increased over 10 years (2011, n = 1 to 2021, n = 47 and from Jan-Aug 2022 n = 35 articles). Overarching themes related to the review questions were: (1) Developments and debates (7 themes) Concerns about AI ethics, healthcare jobs, and loss of empathy; Human-centered design of AI technologies for healthcare; Optimistic speculation AI technologies will address care gaps; Interrogation of what it means to be human and to care; Recognition of future potential for patient monitoring, virtual proximity, and access to healthcare; Calls for curricula development and healthcare professional education; Implementation of AI applications to enhance health and wellbeing of the healthcare workforce. (2) How AI technologies enhance compassion (10 themes) Empathetic awareness; Empathetic response and relational behavior; Communication skills; Health coaching; Therapeutic interventions; Moral development learning; Clinical knowledge and clinical assessment; Healthcare quality assessment; Therapeutic bond and therapeutic alliance; Providing health information and advice. (3) Gaps in knowledge (4 themes) Educational effectiveness of AI-assisted learning; Patient diversity and AI technologies; Implementation of AI technologies in education and practice settings; Safety and clinical effectiveness of AI technologies. (4) Key areas for development (3 themes) Enriching education, learning and clinical practice; Extending healing spaces; Enhancing healing relationships.

Conclusion

There is an association between AI technologies and compassion in healthcare and interest in this association has grown internationally over the last decade. In a range of healthcare contexts, AI technologies are being used to enhance empathetic awareness; empathetic response and relational behavior; communication skills; health coaching; therapeutic interventions; moral development learning; clinical knowledge and clinical assessment; healthcare quality assessment; therapeutic bond and therapeutic alliance; and to provide health information and advice. The findings inform a reconceptualization of compassion as a human-AI system of intelligent caring comprising six elements: (1) Awareness of suffering (e.g., pain, distress, risk, disadvantage); (2) Understanding the suffering (significance, context, rights, responsibilities etc.); (3) Connecting with the suffering (e.g., verbal, physical, signs and symbols); (4) Making a judgment about the suffering (the need to act); (5) Responding with an intention to alleviate the suffering; (6) Attention to the effect and outcomes of the response. These elements can operate at an individual (human or machine) and collective systems level (healthcare organizations or systems) as a cyclical system to alleviate different types of suffering. New and novel approaches to human-AI intelligent caring could enrich education, learning, and clinical practice; extend healing spaces; and enhance healing relationships.

Implications

In a complex adaptive system such as healthcare, human-AI intelligent caring will need to be implemented, not as an ideology, but through strategic choices, incentives, regulation, professional education, and training, as well as through joined up thinking about human-AI intelligent caring. Research funders can encourage research and development into the topic of AI technologies and compassion as a system of human-AI intelligent caring. Educators, technologists, and health professionals can inform themselves about the system of human-AI intelligent caring.

Consensus-Based Guidance on Opioid Management in Individuals With Advanced Cancer-Related Pain and Opioid Misuse or Use Disorder

Importance

Opioid misuse and opioid use disorder (OUD) are important comorbidities in people with advanced cancer and cancer-related pain, but there is a lack of consensus on treatment.

Objective

To develop consensus among palliative care and addiction specialists on the appropriateness of various opioid management strategies in individuals with advanced cancer-related pain and opioid misuse or OUD.

Design, Setting, and Participants

For this qualitative study, using ExpertLens, an online platform and methodology for conducting modified Delphi panels, between August and October 2020, we conducted 2 modified Delphi panels to understand the perspectives of palliative and addiction clinicians on 3 common clinical scenarios varying by prognosis (weeks to months vs months to years). Of the 129 invited palliative or addiction medicine specialists, 120 participated in at least 1 round. A total of 84 participated in all 3 rounds.

Main Outcomes and Measures

Consensus was investigated for 3 clinical scenarios: (1) a patient with a history of an untreated opioid use disorder, (2) a patient taking more opioid than prescribed, and (3) a patient using nonprescribed benzodiazepines.

Results

Participants were mostly women (47 [62%]), White (94 (78 [65%]), and held MD/DO degrees (115 [96%]). For a patient with untreated OUD, regardless of prognosis, it was deemed appropriate to begin treatment with buprenorphine/naloxone and inappropriate to refer to a methadone clinic. Beginning split-dose methadone was deemed appropriate for patients with shorter prognoses and of uncertain appropriateness for those with longer prognoses. Beginning a full opioid agonist was deemed of uncertain appropriateness for those with a short prognosis and inappropriate for those with a longer prognosis. Regardless of prognosis, for a patient with no medical history of OUD taking more opioids than prescribed, it was deemed appropriate to increase monitoring, inappropriate to taper opioids, and of uncertain appropriateness to increase the patient's opioids or transition to buprenorphine/naloxone. For a patient with a urine drug test positive for non-prescribed benzodiazepines, regardless of prognosis, it was deemed appropriate to increase monitoring, inappropriate to taper opioids and prescribe buprenorphine/naloxone.

Conclusions and Relevance

The findings of this qualitative study provide urgently needed consensus-based guidance for clinicians and highlight critical research and policy gaps.

Interprofessional Oncology Providers' Experiences and Knowledge of Opioid Use Disorders in Patients With Cancer

OBJECTIVES

To determine oncology providers' experiences and knowledge of opioid use disorders (OUDs) in patients with cancer.

SAMPLE & SETTING

The final sample of 773 participants included 42 physicians, 213 advanced practice providers (APPs), and 518 nurses at a large comprehensive cancer center.

METHODS & VARIABLES

This study used a cross-sectional descriptive survey to describe providers' experiences and knowledge of OUDs.

RESULTS

Nurses and APPs reported personal experiences with addiction and encountering issues with OUDs in patients more often compared to physicians. Knowledge deficits were identified regarding addiction, including evidence-based treatment for OUDs. Overall, OUDs are a topic of concern that the majority of oncology providers are interested in learning more about.

IMPLICATIONS FOR NURSING

The opioid epidemic presents an opportunity to improve the knowledge of interprofessional oncology providers addressing OUDs. Nurses and APPs are ideally positioned for the prevention and early recognition of patients with an OUD and cancer.