1
|
Kay AH, Othieno A, Boscardin J, Chen LL, Alvarez EA, Swanson M, Ueda S, Chen LM, Chapman JS. The past, present, and future of opioid prescribing: perioperative opioid use in gynecologic oncology patients after laparotomy at a single institution from 2012 to 2021. Gynecol Oncol Rep 2023; 46:101172. [PMID: 37065538 PMCID: PMC10090236 DOI: 10.1016/j.gore.2023.101172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 03/21/2023] [Accepted: 03/22/2023] [Indexed: 03/30/2023] Open
Abstract
Objective To describe the evolution of perioperative opioid management in gynecologic oncology patients after open surgeries and determine current opioid over-prescription rates. Methods Part one of this two-part study was a retrospective chart review of adult patients who underwent laparotomy by a gynecologic oncologist from July 1, 2012 to June 30, 2021, comparing changes in clinical characteristics, pain management and discharge opioid prescription sizes between fiscal year 2012 (FY2012) and 2020 (FY2020). In part two, we prospectively surveyed patients after laparotomy in 2021 to determine opioid use after hospital discharge. Results 1187 patients were included in the chart review. Demographic and surgical characteristics remained stable from FY2012 to FY2020 with differences notable for increased rates of interval cytoreductive surgeries for advanced ovarian cancer and decreased rates of full lymph node dissection. Median inpatient opioid use decreased by 62 % from FY2012 to FY2020. Median discharge opioid prescription size was 675 oral morphine equivalents (OME) per patient in FY2012 and decreased by 77.7 % to 150 OME in FY2020. Of 95 surveyed patients in 2021, median self-reported opioid use after discharge was 22.5 OME. Patients had an excess of opioids equivalent to 1331 doses of 5-milligram oxycodone tablets per 100 patients. Conclusion Inpatient opioid use in our gynecologic oncology open surgical patients and post-discharge opioid prescription size significantly decreased over the last decade. Despite this progress, our current prescribing patterns continue to significantly overestimate patients' actual opioid use after hospital discharge. Individualized point of care tools are needed to determine an appropriate opioid prescription size.
Collapse
|
2
|
Arya R, Hong D, Schultz O, Jutzy JM, Cotangco K, Peters P, Daily EW, McCall AR, Howard AR, Hasan Y, Kothari R, Son CH. Opioid Use in Patients With Cervical Cancer at Two Urban Medical Centers. Adv Radiat Oncol 2022; 7:100833. [PMID: 35387422 PMCID: PMC8977857 DOI: 10.1016/j.adro.2021.100833] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 10/06/2021] [Indexed: 12/15/2022] Open
Abstract
Purpose Patients with cervical cancer are at high risk for opioid use. This study aimed to characterize opioid prescribing patterns at 2 urban hospitals. Methods and Materials Data from patients with cervical cancer treated with curative intent from 2011 to 2018 were retrospectively collected. Women with unrelated chronic opioid use before diagnosis, persistent/recurrent disease at 3 months after initiation of treatment, or initiation of opioids >6 months after treatment were excluded. Demographics, disease characteristics, treatment, and outpatient prescription practices were collected. Endpoints included duration of opioid use ≥6 and ≥12 months. Results There were 106 women included, of whom 83% received definitive radiation. Most patients (n = 91, 85.8%) received outpatient opioids. Most common timing of prescriptions were before cancer therapy (35.9%), postprocedure (26.4%), and during radiation therapy (17.0%). Median duration was 3 (interquartile range, 1-11) months; 35.2% of these patients received opioids ≥6 months and 22% received opioids ≥12 months. Greater International Federation of Gynaecology and Obstetrics (FIGO) stage, recurrent/residual disease, initiation of opioids before treatment, history of depression or anxiety, and use of gabapentin or steroids were associated with long-term opioid use. Conclusions Most patients were prescribed outpatient opioids, many of whom used opioids for 12 months. Improvement in provider communication and education, increased posttreatment monitoring, and further evaluation of nonopioid therapies are needed in this patient population to reduce long-term opioid use.
Collapse
|
3
|
Kim SR, Laframboise S, Nelson G, McCluskey SA, Avery L, Kujbid N, Zia A, Bernardini MQ, Ferguson SE, May T, Hogen L, Cybulska P, Bouchard-Fortier G. Implementation of a restrictive opioid prescription protocol after minimally invasive gynecologic oncology surgery. Int J Gynecol Cancer 2021; 31:1584-1588. [PMID: 34750198 DOI: 10.1136/ijgc-2021-002968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Accepted: 10/19/2021] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES Opioids are routinely prescribed after minimally invasive gynecologic oncology surgery, with minimal data to inform the ideal dose. The aim of this study was to evaluate the impact of a restrictive opioid prescription protocol on the median morphine milligram equivalents prescribed and pain control in patients undergoing minimally invasive surgery. METHODS A restrictive opioid prescription protocol was implemented from January through December 2020 at a single tertiary cancer center in Ontario, Canada. Consecutive patients undergoing minimally invasive hysterectomy for suspected malignancy were included. Simultaneously, we implemented use of multimodal analgesia, patient and provider education, pre-printed standardized prescriptions, and tracking of opioid prescriptions. Total median morphine milligram equivalents prescribed were compared between pre- and post-intervention cohorts. Patients were surveyed regarding opioid use and pain control at 30 days post-surgery. RESULTS A total of 101 women in the post-intervention cohort were compared with 92 consecutive pre-intervention controls. Following protocol implementation, median morphine milligram equivalents prescribed decreased from 50 (range 9-100) to 25 (range 8-75) (p<0.001). In the post-intervention cohort, 75% (76/101) used 10 median morphine milligram equivalents or less and 55 patients (54%) used 0 median morphine milligram equivalent. There was no additional increase in opioid refill requests after implementation of our strategy. Overall, patients reported a median pain score of 3/10 at 30 days post-surgery; the highest pain scores and most of the pain occurred in the first week after surgery. CONCLUSIONS Implementation of a restrictive opioid prescription protocol led to a significant reduction in opioid use after minimally invasive gynecologic oncology surgery, with over 50% of patients requiring no opioids postoperatively.
Collapse
Affiliation(s)
- Soyoun Rachel Kim
- Gynecologic Oncology, University of Toronto, Toronto, Ontario, Canada.,Gynecologic Oncology, Princess Margaret Hospital Cancer Centre, Toronto, Ontario, Canada
| | - Stephane Laframboise
- Gynecologic Oncology, Princess Margaret Hospital Cancer Centre, Toronto, Ontario, Canada
| | - Gregg Nelson
- Department of Obstetrics & Gynecology, University of Calgary, Calgary, Alberta, Canada
| | - Stuart A McCluskey
- Department of Anesthesia and Pain Management, University Health Network, Toronto, Ontario, Canada
| | - Lisa Avery
- Department of Biostatistics, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Nastasia Kujbid
- Gynecologic Oncology, Princess Margaret Hospital Cancer Centre, Toronto, Ontario, Canada
| | - Aysha Zia
- Gynecologic Oncology, Princess Margaret Hospital Cancer Centre, Toronto, Ontario, Canada
| | - Marcus Q Bernardini
- Gynecologic Oncology, Princess Margaret Hospital Cancer Centre, Toronto, Ontario, Canada
| | | | - Taymaa May
- Gynecologic Oncology, Princess Margaret Hospital Cancer Centre, Toronto, Ontario, Canada
| | - Liat Hogen
- Gynecologic Oncology, Princess Margaret Hospital Cancer Centre, Toronto, Ontario, Canada
| | - Paulina Cybulska
- Gynecologic Oncology, Princess Margaret Hospital Cancer Centre, Toronto, Ontario, Canada
| | - Geneviève Bouchard-Fortier
- Gynecologic Oncology, Princess Margaret Hospital Cancer Centre, Toronto, Ontario, Canada .,Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
4
|
Chu TH, Rueter M, Palmaro A, Lapeyre-Mestre M. Potential inappropriate use of strong opioid analgesics in cancer outpatients during the last year of life in France and associated factors. Br J Clin Pharmacol 2021; 88:1691-1703. [PMID: 34327727 DOI: 10.1111/bcp.15011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 07/15/2021] [Accepted: 07/20/2021] [Indexed: 12/01/2022] Open
Abstract
AIMS A better knowledge of opioid prescribing patterns would help to identify areas of potential improvement in cancer pain management. This study aimed to identify potential inappropriate use (PIU) of strong opioid analgesics in cancer outpatients in their last year of life. METHODS A retrospective cohort of cancer patients who died between 2011 and 2014 and were exposed as outpatient to a strong opioid analgesic in the last year of life was identified in the Echantillon Généraliste de Bénéficiaires (a 1/97th random sample of the French general population). Prescribing patterns of strong opioids were analysed and PIU was defined by at least 1 of these criteria: overlapping prescriptions; contraindicated prescriptions; lack of laxatives; potential drug interactions; prescription in patients hospitalized for opioid-related disorders. Factors associated with PIU were investigated through a multiple logistic regression model. RESULTS One third of the 2236 patients (median age 72 years [interquartile range: 61-82], 44.1% women) presented a PIU (insufficient laxative prescription [19.6% of patients], insufficient background treatment with transmucosal fentanyl [14.8%], overlapping prescriptions [2.6%]). The rate of PIU significantly decreased from 37.6% (2011) to 29.8% (2014). For patients with a duration of opioid use ≥3 months, factors associated with PIU were fentanyl prescription (adjusted odds ratio = 2.36; 95% confidence interval [1.86-3.00]) and previous use of strong opioid (adjusted odds ratio = 1.88; [1.50-2.36]). CONCLUSION In France, 1/3 of cancer patients exposed to strong opioids experienced PIU and this proportion tended to decrease over time. There is still room for progress in cancer pain management at the end of life.
Collapse
Affiliation(s)
- Thanh Hang Chu
- Faculté de Médecine-Universite Paul Sabatier - Toulouse 3 Service de Pharmacologie Médicale et Clinique, CHU de Toulouse, Toulouse, France
| | - Manuela Rueter
- Faculté de Médecine-Universite Paul Sabatier - Toulouse 3 Service de Pharmacologie Médicale et Clinique, CHU de Toulouse, Toulouse, France.,Centre d'Investigation Clinique, CIC 1436, INSERM, CHU de Toulouse, Toulouse, France.,Equipe Pharmacologie En Population, cohorteS, biobanqueS, PEPSS, Université de Toulouse, Toulouse, France
| | - Aurore Palmaro
- Faculté de Médecine-Universite Paul Sabatier - Toulouse 3 Service de Pharmacologie Médicale et Clinique, CHU de Toulouse, Toulouse, France
| | - Maryse Lapeyre-Mestre
- Faculté de Médecine-Universite Paul Sabatier - Toulouse 3 Service de Pharmacologie Médicale et Clinique, CHU de Toulouse, Toulouse, France.,Centre d'Investigation Clinique, CIC 1436, INSERM, CHU de Toulouse, Toulouse, France.,Equipe Pharmacologie En Population, cohorteS, biobanqueS, PEPSS, Université de Toulouse, Toulouse, France
| |
Collapse
|
5
|
Sakamoto MR, Eguchi M, Azelby CM, Diamond JR, Fisher CM, Borges VF, Bradley CJ, Kabos P. New Persistent Opioid and Benzodiazepine Use After Curative-Intent Treatment in Patients With Breast Cancer. J Natl Compr Canc Netw 2021; 19:29-38. [PMID: 33406490 DOI: 10.6004/jnccn.2020.7612] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 06/26/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Opioid and benzodiazepine use and abuse is a national healthcare crisis to which patients with cancer are particularly vulnerable. Long-term use and risk factors for opioid and benzodiazepine use in patients with breast cancer is poorly characterized. METHODS We conducted a retrospective population-based study of patients with breast cancer diagnosed between 2008 and 2015 undergoing curative-intent treatment identified through the SEER-Medicare linked database. Primary outcomes were new persistent opioid use and new persistent benzodiazepine use. Factors associated with new opioid and benzodiazepine use were investigated by univariate and multivariable logistic regression. RESULTS Among opioid-naïve patients, new opioid use was observed in 22,418 (67.4%). Of this group, 611 (2.7%) developed persistent opioid use at 3 months and 157 (0.7%) at 6 months after treatment. Risk factors for persistent use at 3 and 6 months included stage III disease (odds ratio [OR], 2.16; 95% CI, 1.49-3.12, and OR, 3.48; 95% CI, 1.58-7.67), surgery plus chemotherapy (OR, 1.44; 95% CI, 1.10-1.88, and OR, 2.28; 95% CI, 1.40-3.71), surgery plus chemoradiation therapy (OR, 1.47; 95% CI, 1.10-1.96, and OR, 2.34; 95% CI, 1.38-3.96), and initial tramadol use (OR, 2.66; 95% CI, 2.05-3.46, and OR, 3.12; 95% CI, 1.93-5.04). Among benzodiazepine-naïve patients, new benzodiazepine use was observed in 955 (10.3%), and 111 (11.6%) developed new persistent use at 3 months. Tamoxifen use was statistically significantly associated with new persistent benzodiazepine use at 3 months. CONCLUSIONS A large percentage of patients receiving curative-intent treatment of breast cancer were prescribed new opioids; however, only a small number developed new persistent opioid use. In contrast, a smaller proportion of patients received a new benzodiazepine prescription; however, new persistent use after completion of treatment was more likely and particularly related to concurrent treatment with tamoxifen.
Collapse
Affiliation(s)
| | - Megan Eguchi
- Department of Health Systems, Management, and Policy
| | | | | | - Christine M Fisher
- Department of Radiation Oncology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | | | | | - Peter Kabos
- Division of Medical Oncology, Department of Medicine, and
| |
Collapse
|
6
|
Boitano TK, Sanders LJ, Gentry ZL, Smith HJ, Leath CA, Xhaja A, Leal L, Todd A, Straughn JM. Decreasing opioid use in postoperative gynecologic oncology patients through a restrictive opioid prescribing algorithm. Gynecol Oncol 2020; 159:773-777. [DOI: 10.1016/j.ygyno.2020.09.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 09/07/2020] [Indexed: 01/09/2023]
|
7
|
Kim CH, Lefkowits C, Holschneider C, Bixel K, Pothuri B. Managing opioid use in the acute surgical setting: A society of gynecologic oncology clinical practice statement. Gynecol Oncol 2020; 157:563-569. [DOI: 10.1016/j.ygyno.2020.01.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 01/15/2020] [Indexed: 12/22/2022]
|
8
|
Ward K, Ramzan A, Sheeder J, Fischer S, Lefkowits C. Persistent opioid use after radiation therapy in opioid-naive cervical cancer survivors. Int J Gynecol Cancer 2019; 29:1105-1109. [DOI: 10.1136/ijgc-2019-000430] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 06/06/2019] [Accepted: 06/17/2019] [Indexed: 11/04/2022] Open
Abstract
ObjectivesOpioids are first-line therapy for cancer-related pain, but their use should be minimized in disease-free survivors. We sought to describe rates and identify predictors of persistent opioid use among previously opioid-naive cervical cancer survivors treated with radiation.MethodsOpioid-naive cervical cancer patients treated primarily with radiation and chemosensitization at a single institution, between January 2011 and December 2015, were identified. Charts were reviewed for demographics, disease, and treatment characteristics, and opioid prescriptions. Primary outcome was persistent opioid use, defined as continued opioid prescription use, 6 months after radiation; patients recurring within 6 months were excluded. Groups were compared using χ2 or Fisher’s exact test. Multivariable logistic regression identified predictors of persistent opioid use.ResultsA total of 96 patients were included, with a median age of 49 years (range 27–84). Most patients (59%) at diagnosis had International Federation of Gynecology and Obstetrics (FIGO) stage I or II cervical cancer. The most common histology was squamous cell carcinoma (72%) and most (94.7%) patients received radiation with chemosensitization. Rates of persistent opioid use at 3 and 6 months after treatment were 29% and 25%, respectively. Persistent users were more likely to be <40 years old, have disease outside the pelvis at diagnosis, and have had a history of substance abuse, depression or anxiety (p<0.05). In multivariable analysis, a history of substance abuse (adjusted OR 6.21, 95% CI 1.08 to 35.67) and depression or anxiety (aOR 6.28, 95% CI 1.70 to 23.30) were independently associated with persistent opioid use.ConclusionOur study showed that 25% of patients with cervical cancer were still using opioids 6 months after radiation. History of substance abuse and depression or anxiety, all known risk factors for opioid misuse, were associated with persistent use. The goal in the disease-free survivor population should be opioid independence.
Collapse
|
9
|
Qu N, Wang X, Meng Y, Shan F. Prospective oncotarget for gynecological cancer: Opioid growth factor (OGF) - opioid growth factor receptor (OGFr) axis. Int Immunopharmacol 2019; 75:105723. [PMID: 31408839 DOI: 10.1016/j.intimp.2019.105723] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 06/24/2019] [Indexed: 02/07/2023]
Abstract
The standard treatments for neoplasia include surgery, chemotherapy, hormone antagonists and radiotherapy, which can prolong survival, but rarely cure the tumors of gynecological cancer patients. OGF - OGFr expression, in various gynecologic cells and tissues, is an intersection point between cell development, neuroendocrine function and immune modulation. It has been identified that OGF and OGFr expression differs between gynecological tumor and normal cells. Further, exogenous or endogenous OGF and OGFr antagonists have been known to have a role in regulating cell viability and apoptosis. Moreover, the expression of proteins in the OGF - OGFr axis modulate differentiation and membrane expression of immune cells, which can enhance the immune response. In vivo and in vitro assays have shown that OGF and OGFr antagonists inhibit mitosis as well as induce apoptosis in gynecologic cancer cells. Although immune augmentation combination therapies can intensify cytotoxic activity, OGF or OGFr antagonists do not increase toxicities associated with dual-immune regulation. In conclusion, the OGF - OGFr axis provides significant strategies for antitumor efficiency in gynecological cancer.
Collapse
Affiliation(s)
- Na Qu
- Department of Gynecology, Cancer Hospital of China Medical University, Liaoning Cancer Hospital & Institute, No. 44, Xiaoheyan Road, Shenyang 110042, Liaoning Province, China
| | - Xiaobin Wang
- Department of Gynecology, Cancer Hospital of China Medical University, Liaoning Cancer Hospital & Institute, No. 44, Xiaoheyan Road, Shenyang 110042, Liaoning Province, China
| | - Yiming Meng
- Central Laboratory, Cancer Hospital of China Medical University, Liaoning Cancer Hospital & Institute, No. 44, Xiaoheyan Road, Shenyang 110042, Liaoning Province, China
| | - Fengping Shan
- Department of Immunology, School of Basic Medical Science, China Medical University, No. 77, Puhe Road, Shenyang 110122, China.
| |
Collapse
|