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Langmann GA, Childers J, Merlin JS. Caring for Patients With Opioid Misuse or Substance Use Disorders in Hospice: A National Survey. J Palliat Med 2024; 27:209-215. [PMID: 37824806 PMCID: PMC11074426 DOI: 10.1089/jpm.2023.0082] [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] [Accepted: 08/07/2023] [Indexed: 10/14/2023] Open
Abstract
Background: Opioid misuse and substance use disorders (SUDs) including opioid use disorder (OUD) are common and negatively impact quality of life. Hospice clinicians' experiences with these conditions have not been well described. Objectives: We sought to explore hospice clinicians' knowledge, practices, and comfort caring for patients with opioid misuse (e.g., a pattern of unsanctioned opioid use escalation, or concurrent illicit substance use) and SUDs. Design: We recruited hospice clinicians in the United States via national hospice and palliative care organizations to complete an online survey designed by the study authors and pilot tested with an interdisciplinary group of current/former hospice clinicians. Results: One hundred seventy-five clinicians (40% nurses, 40% physicians, 16% nurse practitioners) responded to the survey; most had cared for two or more hospice patients with opioid misuse or SUD in the past month. The majority felt confident identifying opioid misuse (94%) and taking SUD histories (79%). Most (62%) felt it is their role to treat hospice patients for SUD, though 56% lacked comfort in using buprenorphine for OUD treatment. While the majority felt it is their role to treat pain in hospice patients with SUDs (94%) and that hospice can help patients with SUDs (94%), many were not comfortable managing pain in patients taking buprenorphine (45%) or naltrexone (49%) for SUDs. Most felt comfortable managing pain in patients taking methadone for SUD (73%). Conclusions: Opioid misuse and SUD are common in hospice. Though clinicians are comfortable taking relevant histories, they feel less comfortable managing patients' opioid misuse or SUD, or these patients' pain.
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Affiliation(s)
- Gabrielle A. Langmann
- Supportive and Palliative Care Program, Division of General Internal Medicine, University of Utah Spencer Fox Eccles School of Medicine, Salt Lake City, Utah, USA
| | - Julie Childers
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jessica S. Merlin
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Center for Research on Health Care, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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2
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Ware O, McPherson ML, Barclay JS, Blackhall L, Emmett CP, Hilliard R, Schenker Y, Shega JW, Guralnik J, Cagle JG. Recommendations for Preventing Medication Diversion and Misuse in Hospice Care: A Modified Delphi Study. J Pain Symptom Manage 2021; 62:1175-1187. [PMID: 34119618 DOI: 10.1016/j.jpainsymman.2021.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 05/28/2021] [Accepted: 06/01/2021] [Indexed: 10/21/2022]
Abstract
CONTEXT Recommendations are needed to help minimize the risks of medication diversion and misuse in the hospice setting. OBJECTIVE To identify recommendations that could help prevent medication diversion and misuse in hospice care. METHODS A modified Delphi method was utilized. An interdisciplinary panel of ten experts engaged in three phases of online and in-person voting regarding recommendations. Consensus for recommendations required a minimum of 80% endorsement by the panel experts. After two rounds of voting and several rounds of informal voting, 15 total recommendations were endorsed. RESULTS Fifteen recommendations achieved at least 80% endorsement during the final round of voting. Each of the following recommendation topics received ≥ 80% endorsement, the need to balance prevention efforts with quality care, screening clinical job candidates, family education and screening, medication monitoring, responding to missing/diverted medications, and medication disposal. Panelists rated the Patient & Family Education recommendation as most important (M = 9.7; SD = 0.7) followed closely by Responding to Medication Diversion or Misuse (M = 9.5; SD = 1.1). CONCLUSION These recommendations were created by experts in the field to reduce the risk of medication diversion and misuse. Further steps towards implementation may appropriately reduce these risks.
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Affiliation(s)
- Orrin Ware
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Joshua S Barclay
- University of Virginia Health System, School of Medicine, Charlottesville, Virginia, USA
| | - Leslie Blackhall
- University of Virginia Health System, School of Medicine, Charlottesville, Virginia, USA
| | | | - Russell Hilliard
- Seasons Hospice and Palliative Care, Fort Lauderdale, Florida, USA
| | - Yael Schenker
- University of Pittsburgh, Division of General Internal Medicine, Pittsburgh, USA
| | - Joseph W Shega
- Vitas Healthcare, Miami, Florida, USA; University of Central Florida College of Medicine, Orlando, Florida, USA
| | - Jack Guralnik
- University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - John G Cagle
- University of Maryland School of Social Work, Baltimore, Maryland, USA.
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3
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Furuno JP, Noble BN, Fromme EK, Hartung DM, Tjia J, Lynn M, Teno JM. Decreasing Trends in Opioid Prescribing on Discharge to Hospice Care. J Pain Symptom Manage 2021; 62:1026-1033. [PMID: 33848567 PMCID: PMC8502178 DOI: 10.1016/j.jpainsymman.2021.03.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 03/17/2021] [Accepted: 03/28/2021] [Indexed: 10/21/2022]
Abstract
CONTEXT There are concerns that policies aimed to prevent opioid misuse may unintentionally reduce access to opioids for patients at end-of-life. OBJECTIVE We assessed trends in opioid prescribing among patients on discharge from the hospital to hospice care. METHODS This was a retrospective cohort study among adult (age ≥18 years) patients discharged from a 544-576 bed, academic medical center to hospice care between January 1, 2010 to December 31, 2018. Study data were collected from a repository of patients' electronic health record data. Our primary outcome was the frequency of opioid prescribing on discharge to hospice care. Our primary exposure was the calendar year of discharge. We also investigated non-opioid analgesic prescribing and stratified opioid prescribing trends by patient characteristics (e.g., demographics, cancer diagnosis, and location of hospice care). RESULTS Among 2,648 discharges to hospice care, mean (standard deviation) age was 65.8 (16.0) years, 46.3% were female, and 58.7% had a cancer diagnosis. Opioid prescribing on discharge to hospice care decreased significantly from 91.2% (95% confidence interval (CI) = 87.1%-94.1%) in 2010 to 79.3% (95% CI = 74.3%-83.5%) in 2018 adjusting for age, sex, cancer diagnosis, and location of hospice care. Prescribing of non-opioid analgesic medications increased over the same time period. CONCLUSIONS We observed a statistically significant decreasing trend in opioid prescribing on discharge to hospice care. Further research should aim to confirm these findings and to identify opportunities to ensure optimal pain management among patients transitioning to hospice care.
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Affiliation(s)
- Jon P Furuno
- Department of Pharmacy Practice, Oregon State University College of Pharmacy, Portland, Oregon, USA.
| | - Brie N Noble
- Department of Pharmacy Practice, Oregon State University College of Pharmacy, Portland, Oregon, USA
| | - Erik K Fromme
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, Massachusetts, USA; Ariadne Labs at Brigham and Women's Hospital and the Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Daniel M Hartung
- Department of Pharmacy Practice, Oregon State University College of Pharmacy, Portland, Oregon, USA
| | - Jennifer Tjia
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Mary Lynn
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Joan M Teno
- Division of General Internal Medicine & Geriatrics, Department of Medicine, Oregon Health & Science University, Portland, Oregon, USA
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4
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Bauer MR, Shamas T, Gillespie-Heyman S, Ruskin A. Feasibility of Safe Opioid Prescribing in Outpatient Palliative Care: A Quality Improvement Project. J Pain Symptom Manage 2021; 62:410-415. [PMID: 33647421 DOI: 10.1016/j.jpainsymman.2021.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 02/04/2021] [Accepted: 02/05/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND No guidelines for safe opioid prescribing in palliative care exist, which contributes to limited monitoring of opioid misuse in palliative care. MEASURES Feasibility of a safe opioid prescribing standard operating protocol (SOP) was determined by assessing the percentage of patients in an outpatient cancer center who completed each component of a five-component SOP. INTERVENTION A five-component SOP included: risk stratification for misuse, consent form, prescription drug monitoring program review, urine drug testing, and Naloxone for high-risk individuals. OUTCOMES After one year, compliance rates on four of the of the five-component SOP were greater or equal to 93%. Naloxone co-prescription for high-risk patients never reached over 78%, largely due to clinical decision not to co-prescribe if transition to hospice was imminent. CONCLUSIONS/LESSONS LEARNED Safe opioid prescribing measures are feasible in outpatient palliative care and can facilitate identification of individuals at risk for opioid misuse and prompt early interventions for misuse.
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Affiliation(s)
| | - Tracy Shamas
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | | | - Andrea Ruskin
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
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5
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Tedesco A, Brown J, Hannon B, Hutton L, Lau J. Managing Opioids and Mitigating Risk: A Survey of Attitudes, Confidence and Practices of Oncology Health Care Professionals. Curr Oncol 2021; 28:873-878. [PMID: 33617504 PMCID: PMC7985764 DOI: 10.3390/curroncol28010086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 02/04/2021] [Accepted: 02/05/2021] [Indexed: 11/18/2022] Open
Abstract
In response to Canada's opioid crisis, national strategies and guidelines have been developed but primarily focus on opioid use for chronic noncancer pain. Despite the well-established utility of opioids in cancer care, and the growing emphasis on early palliative care, little attention has been paid to opioid risk in this population, where evidence increasingly shows a higher risk of opioid-related harms than was previously thought. The primary objective of this study was to assess oncology clinicians' attitudes, confidence, and practices in managing opioids in outpatients with cancer. This was explored using pilot-tested, profession-specific surveys for physicians/nurse practitioners, nurses and pharmacists. Descriptive analyses were conducted in aggregate and separately based on discipline. Univariate and multiple linear regression analyses were performed to explore relationships between confidence and practices within and across disciplines. The survey was distributed to approximately 400 clinicians in January 2019. Sixty-five responses (27 physicians/nurse practitioners, 31 nurses, 7 pharmacists) were received. Participants endorsed low confidence, differing attitudes, and limited and varied practice in managing and mitigating opioid risks in the cancer population. This study provides valuable insights into knowledge gaps and clinical practices of oncology healthcare professionals in managing opioids and mitigating associated risks for patients with cancer.
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Affiliation(s)
- Alissa Tedesco
- Temmy Latner Centre for Palliative Care, Sinai Health System, Toronto, ON M5T 3L9, Canada
| | - Jocelyn Brown
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON M5G 2C1, Canada; (J.B.); (B.H.); (J.L.)
| | - Breffni Hannon
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON M5G 2C1, Canada; (J.B.); (B.H.); (J.L.)
| | - Lauren Hutton
- Pharmacy Services, Queen Elizabeth II Health Science Centre, Nova Scotia Health, Halifax, NS B3H 2Y9, Canada;
| | - Jenny Lau
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON M5G 2C1, Canada; (J.B.); (B.H.); (J.L.)
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6
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Controlled substances in hospices after patient death: a cross-sectional survey of Ontario hospices. Int J Clin Pharm 2020; 42:1344-1353. [DOI: 10.1007/s11096-020-01097-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 07/02/2020] [Indexed: 10/23/2022]
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7
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How I treat pain in hematologic malignancies safely with opioid therapy. Blood 2020; 135:2354-2364. [PMID: 32352512 DOI: 10.1182/blood.2019003116] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 04/04/2020] [Indexed: 12/25/2022] Open
Abstract
The field of malignant hematology has experienced extraordinary advancements with survival rates doubling for many disorders. As a result, many life-threatening conditions have since evolved into chronic medical ailments. Paralleling these advancements have been increasing rates of complex hematologic pain syndromes, present in up to 60% of patients with malignancy who are receiving active treatment and up to 33% of patients during survivorship. Opioids remain the practice cornerstone to managing malignancy-associated pain. Prevention and management of opioid-related complications have received significant national attention over the past decade, and emerging data suggest that patients with cancer are at equal if not higher risk of opioid-related complications when compared with patients without malignancy. Numerous tools and procedural practice guides are available to help facilitate safe prescribing. The recent development of cancer-specific resources directing algorithmic use of validated pain screening tools, prescription drug monitoring programs, urine drug screens, opioid use disorder risk screening instruments, and controlled substance agreements have further strengthened the framework for safe prescribing. This article, which integrates federal and organizational guidelines with known risk factors for cancer patients, offers a case-based discussion for reviewing safe opioid prescribing practices in the hematology setting.
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8
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Anandarajah G, Mennillo HA, Rachu G, Harder T, Ghosh J. Lifestyle Medicine Interventions in Patients With Advanced Disease Receiving Palliative or Hospice Care. Am J Lifestyle Med 2020; 14:243-257. [PMID: 32477022 PMCID: PMC7232901 DOI: 10.1177/1559827619830049] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Revised: 01/18/2019] [Accepted: 01/21/2019] [Indexed: 01/01/2023] Open
Abstract
Background: Lifestyle medicine interventions have the potential to improve symptom management, daily function, and quality of life (QOL) in patients with advanced or terminal disease receiving palliative or hospice care. The goal of this review is to summarize the current state of the literature on this subject. Methods: The authors used a broad search strategy to identify relevant studies, reviews, and expert opinions, followed by narrative summary of available information. Results: Four main categories of lifestyle interventions feature prominently in the palliative care literature: exercise, nutrition, stress management, and substance use. High-quality studies in this vulnerable population are relatively sparse. Some interventions show promise. However, most show mixed results or inadequate evidence. For some interventions, risks in this generally frail population outweigh the benefits. Clinical decision making involves balancing research findings, including the risks and benefits of interventions, with a clear understanding of patients' prognosis, goals of care, and current physical, emotional, and spiritual state. Achieving optimum QOL, safety, and ethical care are emphasized. Conclusions: The use of lifestyle interventions in patients receiving palliative or hospice care is a complex undertaking, requiring tailoring recommendations to individual patients. There is potential for considerable benefits; however, more research is needed.
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Affiliation(s)
- Gowri Anandarajah
- Gowri Anandarajah, MD, Office of Medical Education, Warren Alpert Medical School of Brown University, 222 Richmond Street, Providence, RI 02912; e-mail:
| | - Haran Asher Mennillo
- Warren Alpert Medical School of Brown University, Providence, Rhode Island (GA, HAM, JG)
- Hope Hospice and Palliative Care Rhode Island, Providence, Rhode Island (GA, GR)
- Brown University, Providence, Rhode Island (TH)
| | - Gregory Rachu
- Warren Alpert Medical School of Brown University, Providence, Rhode Island (GA, HAM, JG)
- Hope Hospice and Palliative Care Rhode Island, Providence, Rhode Island (GA, GR)
- Brown University, Providence, Rhode Island (TH)
| | - Tyler Harder
- Warren Alpert Medical School of Brown University, Providence, Rhode Island (GA, HAM, JG)
- Hope Hospice and Palliative Care Rhode Island, Providence, Rhode Island (GA, GR)
- Brown University, Providence, Rhode Island (TH)
| | - Jyotsna Ghosh
- Warren Alpert Medical School of Brown University, Providence, Rhode Island (GA, HAM, JG)
- Hope Hospice and Palliative Care Rhode Island, Providence, Rhode Island (GA, GR)
- Brown University, Providence, Rhode Island (TH)
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9
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Ulker E, Del Fabbro E. Best Practices in the Management of Nonmedical Opioid Use in Patients with Cancer-Related Pain. Oncologist 2019; 25:189-196. [PMID: 31872911 DOI: 10.1634/theoncologist.2019-0540] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 11/06/2019] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Nonmedical opioid use (NMOU) in patients with cancer is a term covering a spectrum of nonprescribed opioid use. The extent to which an individual uses opioids in a nonprescribed manner will influence propensity for adverse effects such as neurotoxicity, substance use disorder, overdose, and death. OBJECTIVES The objectives of this study were to (A) evaluate current literature regarding management of NMOU in patients with cancer-related pain; (B) provide best practice recommendations based on evidence; and (C) integrate practices derived from the management of noncancer pain, where clinically appropriate or when the oncology literature is limited. METHODS This study is a narrative review. IMPLICATIONS Although harm from NMOU was thought to be rare among oncology patients, about one in five patients with cancer is at risk of adverse outcomes including prolonged opioid use, high opioid doses, and increased health care utilization. The management of NMOU can be challenging because pain is a multidimensional experience encompassing physical, psychological, and spiritual domains. An interdisciplinary team approach is most effective, and management strategies may include (A) education of patients and families; (B) harm reduction, including opioid switching, decreasing the overall daily dose, avoiding concurrent sedative use, and using adjuvant medications for their opioid-sparing potential; (C) managing psychological and spiritual distress with an interdisciplinary team and techniques such as brief motivational interviewing; and (D) risk mitigation by pill counts, frequent clinic visits, and accessing statewide prescription drug monitoring plans. CONCLUSION Although many of the management strategies for NMOU in patients with cancer-related pain are modeled on those for chronic non-cancer-related pain, there is emerging evidence that education and harm-reduction initiatives specifically for cancer-related pain are effective. IMPLICATIONS FOR PRACTICE Nonmedical opioid use (NMOU) in patients with cancer is a term covering a broad spectrum of nonprescribed opioid use. The extent to which an individual uses opioids in a nonprescribed manner will influence propensity for adverse effects such as neurotoxicity, substance use disorder, overdose, and death. This review evaluates the evidence for best practices in oncology and addresses limitations in the literature with supplemental evidence from noncancer chronic pain. Management recommendations for NMOU are provided, based on a combination of literature-based evidence and best clinical practice. Effective management of NMOU in oncology has the potential to improve quality of life, decrease health utilization, and improve survival.
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Affiliation(s)
- Esad Ulker
- Virginia Commonwealth University, Richmond, Virginia, USA
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10
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LeBaron VT, Camacho F, Balkrishnan R, Yao N(A, Gilson AM. Opioid Epidemic or Pain Crisis? Using the Virginia All Payer Claims Database to Describe Opioid Medication Prescribing Patterns and Potential Harms for Patients With Cancer. J Oncol Pract 2019; 15:e997-e1009. [DOI: 10.1200/jop.19.00149] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE: A key challenge regarding the current opioid epidemic is understanding how concerns regarding opioid-related harms affect access to pain management, an essential element of cancer care. In certain regions of the United States where disproportionately high cancer mortality and opioid fatality rates coexist (such as southwest Virginia in central Appalachia), this dilemma is particularly pronounced. METHODS: This longitudinal, exploratory, secondary analysis used the Commonwealth of Virginia All Payer Claims Database to describe prescription opioid medication (POM) prescribing patterns and potential harms for adult patients with cancer living in rural southwest Virginia between 2011 and 2015. Descriptive and inferential statistical analyses were conducted at the patient, prescriber, and prescription levels to identify patterns and predictors of POM prescribing and potential harms. To explore geographic patterns, choropleth and heat maps were created. RESULTS: Of the total sample of patients with cancer (n = 4,324), less than 25% were prescribed a Controlled Substance Schedule II POM at least three times in any study year. More than 60% of patients never received a Controlled Substance Schedule II POM prescription. Six hundred fifty-two patients (15.1%) experienced 1,599 hospitalizations for any reason; 10 or fewer patients were admitted for 11 opioid use disorder–related hospitalizations. The main findings suggest potential undertreatment of cancer-related pain; no difference in risk for opioid-related hospitalization on the basis of frequency of POM prescriptions; and geographic disparities where opioid overdoses are occurring versus where POM prescription use is highest. CONCLUSION: These findings have significant opioid policy and practice implications related to the need for cancer-specific prescribing guidelines, how to optimally allocate health delivery services, and the urgent need to improve data interoperability and access related to POMs.
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Affiliation(s)
| | - Fabian Camacho
- University of Virginia School of Medicine, Charlottesville, VA
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11
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Mitchell JL, Blackhall LJ, Barclay JS. Screening for Opioid Misuse in the Nonhospitalized Seriously Ill Patient. J Palliat Med 2019; 22:1115-1119. [DOI: 10.1089/jpm.2018.0638] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Julie L. Mitchell
- Division of Hospital Medicine, Department of Medicine, Emory Palliative Care Center, Emory University School of Medicine, Atlanta, Georgia
| | - Leslie J. Blackhall
- Division of General Internal Medicine, Geriatrics, and Palliative Care, Department of Medicine, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Joshua S. Barclay
- Division of General Internal Medicine, Geriatrics, and Palliative Care, Department of Medicine, University of Virginia School of Medicine, Charlottesville, Virginia
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12
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Arthur J, Bruera E. Balancing opioid analgesia with the risk of nonmedical opioid use in patients with cancer. Nat Rev Clin Oncol 2019; 16:213-226. [PMID: 30514978 DOI: 10.1038/s41571-018-0143-7] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The current opioid crisis has brought renewed attention and scrutiny to opioid prescriptions. When patients receiving opioid therapy for pain engage in nonmedical opioid use (NMOU) or diversion, untoward consequences can occur. New evidence suggests that patients with cancer might be at a higher risk of NMOU than was previously thought, but clinical evidence still supports the use of opioid analgesics as the gold standard to treat cancer-related pain, creating a dilemma in patient management. Clinicians are encouraged to adopt a universal precautions approach to patients with cancer receiving opioids, which includes screening all patients; discussing the risks, benefits, adverse effects and alternatives of opioid therapy; and providing education on safe use, storage and disposal. Use of urine drug tests, prescription drug monitoring programmes and close observation of behaviours related to opioid use help to ensure treatment adherence, detect NMOU and support therapeutic decision-making. These measures can optimize the risk-benefit ratio while supporting safe opioid use. In this Review, we examine the role of opioids in cancer pain, the risk of substance use disorder and methods to achieve the right balance between the two in order to ensure safe opioid use.
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Affiliation(s)
- Joseph Arthur
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer, Houston, TX, USA
| | - Eduardo Bruera
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer, Houston, TX, USA.
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13
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Reddy A, de la Cruz M. Safe Opioid Use, Storage, and Disposal Strategies in Cancer Pain Management. Oncologist 2019; 24:1410-1415. [PMID: 31097618 DOI: 10.1634/theoncologist.2019-0242] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 04/17/2019] [Indexed: 11/17/2022] Open
Abstract
Opioids are required by a majority of patients with advanced cancer. Oncologists and palliative care clinicians are faced with the challenge of safely prescribing opioids in the current environment of an opioid crisis. Many patients with cancer use opioids unsafely, store them in unsecure locations, and do not dispose of unused opioids, leading to increased availability of these opioids for others to misuse. More than 50% of people who misuse opioids obtain the drugs from a friend or relative with or without their consent. Patient and provider education has been shown to improve safe opioid use, promote secure storage, and also increase disposal of unused opioids safely in drug take-back programs that are now widely available. This article highlights the importance of patient education and cautious opioid prescribing in patients with cancer. IMPLICATIONS FOR PRACTICE: The current opioid crisis makes it challenging to effectively manage cancer pain. Providers play a prominent role in minimizing opioid misuse. Cautious prescribing with limits enforced on the quantity of opioids prescribed, close follow-up, and consistent and frequent provision of opioid education are a must. Evidence points to the impact of patient education in promoting safety around opioid use. Most people who misuse prescription opioids obtain them from family or friends. Storing opioids in the open or not disposing of unused opioids increases the availability of these opioids for misuse by others. The importance of not sharing, always locking up, and disposing of unused and expired opioids must be highlighted as part of the opioid education that must be delivered every time that opioids are prescribed. Information about local drug take-back programs may also help increase disposal of unused opioids.
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Affiliation(s)
- Akhila Reddy
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Maxine de la Cruz
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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14
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Briscoe J, Kamal AH, Casarett DJ. Top Ten Tips Palliative Care Clinicians Should Know About Medical Cannabis. J Palliat Med 2019; 22:319-325. [DOI: 10.1089/jpm.2018.0641] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Joshua Briscoe
- Department of Medicine and Duke University School of Medicine, Durham, North Carolina
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Arif H. Kamal
- Department of Medicine and Duke University School of Medicine, Durham, North Carolina
- Duke Cancer Institute, Duke University, Durham, North Carolina
- Duke Fuqua School of Business, Duke University, Durham, North Carolina
| | - David J. Casarett
- Department of Medicine and Duke University School of Medicine, Durham, North Carolina
- Duke Cancer Institute, Duke University, Durham, North Carolina
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15
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McPherson ML, Walker KA, Davis MP, Bruera E, Reddy A, Paice J, Malotte K, Lockman DK, Wellman C, Salpeter S, Bemben NM, Ray JB, Lapointe BJ, Chou R. Safe and Appropriate Use of Methadone in Hospice and Palliative Care: Expert Consensus White Paper. J Pain Symptom Manage 2019; 57:635-645.e4. [PMID: 30578934 DOI: 10.1016/j.jpainsymman.2018.12.001] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 11/28/2018] [Accepted: 12/01/2018] [Indexed: 01/11/2023]
Abstract
Methadone has several unique characteristics that make it an attractive option for pain relief in serious illness, but the safety of methadone has been called into question after reports of a disproportionate increase in opioid-induced deaths in recent years. The American Pain Society, College on Problems of Drug Dependence, and the Heart Rhythm Society collaborated to issue guidelines on best practices to maximize methadone safety and efficacy, but guidelines for the end-of-life scenario have not yet been developed. A panel of 15 interprofessional hospice and palliative care experts from the U.S. and Canada convened in February 2015 to evaluate the American Pain Society methadone recommendations for applicability in the hospice and palliative care setting. The goal was to develop guidelines for safe and effective management of methadone therapy in hospice and palliative care. This article represents the consensus opinion of the hospice and palliative care experts for methadone use at end of life, including guidance on appropriate candidates for methadone, detail in dosing, titration, and monitoring of patients' response to methadone therapy.
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Affiliation(s)
| | - Kathryn A Walker
- University of Maryland School of Pharmacy, Baltimore, Maryland, USA; MedStar Health, Baltimore, Maryland, USA
| | | | - Eduardo Bruera
- Palliative, Rehabilitation & Integrative Medicine Department, University of Texas MD Anderson Cancer Center, Houston, Texas, USA; F. T. McGraw Chair in the Treatment of Cancer, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA; The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Akhila Reddy
- The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Judith Paice
- Division of Hematology-Oncology, Northwestern University, Chicago, Illinois, USA; Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Kasey Malotte
- Advanced Practice Pharmacist Supportive Care Medicine Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Dawn Kashelle Lockman
- Hospice & Palliative Care, University of Iowa College of Pharmacy, Iowa City, Iowa, USA; Internal Medicine-Palliative Care Program, Iowa City, Iowa, USA
| | | | - Shelley Salpeter
- Stanford University School of Medicine, Stanford, California, USA; Mission Hospice and Home Care, San Mateo, California, USA
| | | | - James B Ray
- University of Iowa College of Pharmacy, Iowa City, Iowa, USA; Supportive and Palliative Care Consult Service, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Bernard J Lapointe
- Eric M. Flanders Chair in Palliative Medicine, McGill University, Montreal, Canada; Chief Supportive and Palliative Care Division, Jewish General Hospital, Montreal, Canada
| | - Roger Chou
- Division of General Internal Medicine and Geriatrics, OHSU, USA
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Gabbard J, Jordan A, Mitchell J, Corbett M, White P, Childers J. Dying on Hospice in the Midst of an Opioid Crisis: What Should We Do Now? Am J Hosp Palliat Care 2018; 36:273-281. [DOI: 10.1177/1049909118806664] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
The current opioid crisis in the United States is a major problem facing health-care providers, even at the end of life. Opioids continue to be the mainstay treatment for pain at the end of life, with the prevalence of pain reported in up to 80% of patients and tends to increase as one gets closer toward the end of life. In the past year, 20.2 million Americans had a substance use disorder (SUD) and SUDs are disabling disorders that largely go untreated. In addition, the coexistence of both a mental health and SUD is very common with the use of opioids often as a means of chemical coping. Most hospice programs do not have standardized SUD policies/guidelines in place despite the increasing concerns about substance abuse within the United States. The goal of this article is to review the literature on this topic and offer strategies on how to manage pain in patients who have active SUD or who are at risk for developing SUD in those dying on hospice.
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Affiliation(s)
- Jennifer Gabbard
- Department of Internal Medicine, Internal Medicine Section of Gerontology and Geriatrics, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Allison Jordan
- Department of Palliative Medicine, Christian and Alton Memorial Hospitals, BJC Hospice, Washington University School of Medicine, St. Louis, MO, USA
| | - Julie Mitchell
- Department of Internal Medicine, Division of Hospital Medicine, Emory Palliative Care Center, Emory University School of Medicine, Atlanta, GA, USA
| | | | - Patrick White
- Department of Internal Medicine, BJC Home Care, Washington University School of Medicine, St. Louis, MO, USA
| | - Julie Childers
- Section of Palliative Care and Medical Ethics and Section of Treatment, Research and Education in Addiction Medicine, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Adler JA, Mallick-Searle T. An overview of abuse-deterrent opioids and recommendations for practical patient care. J Multidiscip Healthc 2018; 11:323-332. [PMID: 30026658 PMCID: PMC6045950 DOI: 10.2147/jmdh.s166915] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Despite advances in the treatment of severe intractable pain, opioids remain a critical and appropriate component of treatment. However, abuse, misuse, and diversion of prescription opioids are significant public health concerns. Opioid abuse-deterrent formulations (ADFs) are one component of an opioid risk management plan to manage patient’s pain relief and quality of life while offering some protection against potentially harmful consequences of opioids from misuse and abuse. Opioid ADFs are designed to make manipulation more difficult and administration via non-oral routes less appealing. There are currently nine extended-release and one immediate-release opioid pain medications with US Food and Drug Administration-approved ADF labeling. All use physical/chemical barriers or agonist/antagonist combinations to deter manipulation and abuse. Evidence suggests that opioid ADFs decrease rates of abuse and diversion of opioids in the USA; however, some opioid ADFs are not yet commercially available or have not been on the market long enough to undergo post-marketing data analyses. Opioid ADFs along with the use of prescription drug monitoring programs, clinical assessment tools, toxicology testing, and co-prescribing of naloxone are all tools that can be used to reduce opioid abuse. Patient education on the risks of abuse and diversion is vital and includes a discussion of appropriate use of medication and proper storage. Physician assistants and nurse practitioners are on the “front lines” in battling opioid abuse and serve a key role in recognizing and mitigating the risks of prescription opioid diversion, abuse, and misuse (intentional and unintentional) and in identifying patients at risk for abuse while still providing pain relief to patients.
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Ramzan AA, Fischer S, Buss MK, Urban RR, Patsner B, Duska LR, Fisher CM, Lefkowits C. Opioid use in gynecologic oncology in the age of the opioid epidemic: Part II – Balancing safety & accessibility. Gynecol Oncol 2018; 149:401-409. [DOI: 10.1016/j.ygyno.2018.02.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Revised: 02/09/2018] [Accepted: 02/12/2018] [Indexed: 12/15/2022]
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Copenhaver DJ, Karvelas NB, Fishman SM. Risk Management for Opioid Prescribing in the Treatment of Patients With Pain From Cancer or Terminal Illness. Anesth Analg 2017; 125:1610-1615. [DOI: 10.1213/ane.0000000000002463] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Thienprayoon R, Porter K, Tate M, Ashby M, Meyer M. Risk Stratification for Opioid Misuse in Children, Adolescents, and Young Adults: A Quality Improvement Project. Pediatrics 2017; 139:peds.2016-0258. [PMID: 27980029 DOI: 10.1542/peds.2016-0258] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/30/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The Pediatric Palliative and Comfort Care Team (PACT) at Cincinnati Children's Hospital Medical Center (CCHMC) provides opioids to a large population of patients in the ambulatory setting. Before this project, PACT had no reliable system to risk stratify patients for opioid misuse. METHODS The global aim was safe opioid prescribing by the palliative care team. The specific, measurable, achievable, realistic, and timely aim was as follows: "In patients who present for follow up with PACT, we will use the "opioid bundle" to increase risk stratification for opioid misuse from 0% to 90% over 5 months." The opioid bundle includes a urine drug screen, Ohio Automated Rx Reporting System report, pill count, and screening history for drug abuse and mental health disorders. The setting was multiple CCHMC ambulatory clinics. Participants included all PACT members. RESULTS Since implementing the new system, we have increased risk stratification for opioid misuse among outpatients from 0% to >90%. Results have been sustained for 12 months. Key processes have become reliable: obtaining informed consent and controlled substance agreements for all new patients and obtaining the opioid bundle to enable risk stratification in a consistent and timely fashion. A total of 34% of patients have been stratified as high risk, and an additional 27% have been stratified as moderate risk. CONCLUSIONS A system to ensure safe opioid prescribing practices to all patients is critical for providers. Identifying key processes and executing them reliably has enabled the palliative care team at CCHMC to risk stratify >90% of patients receiving opioids in the ambulatory setting for opioid misuse.
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Affiliation(s)
- Rachel Thienprayoon
- The Pediatric Palliative and Comfort Care Team, Division of Pain, Department of Anesthesiology, .,Cancer and Blood Diseases Institute, Department of Pediatrics, and
| | - Kelly Porter
- The Pediatric Palliative and Comfort Care Team, Division of Pain, Department of Anesthesiology
| | - Michelle Tate
- The Pediatric Palliative and Comfort Care Team, Division of Pain, Department of Anesthesiology
| | - Marshall Ashby
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Mark Meyer
- The Pediatric Palliative and Comfort Care Team, Division of Pain, Department of Anesthesiology
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Walsh AF, Broglio K. Pain Management in the Individual with Serious Illness and Comorbid Substance Use Disorder. Nurs Clin North Am 2016; 51:433-47. [DOI: 10.1016/j.cnur.2016.05.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Carmichael AN, Morgan L, Del Fabbro E. Identifying and assessing the risk of opioid abuse in patients with cancer: an integrative review. Subst Abuse Rehabil 2016; 7:71-9. [PMID: 27330340 PMCID: PMC4898427 DOI: 10.2147/sar.s85409] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background The misuse and abuse of opioid medications in many developed nations is a health crisis, leading to increased health-system utilization, emergency department visits, and overdose deaths. There are also increasing concerns about opioid abuse and diversion in patients with cancer, even at the end of life. Aims To evaluate the current literature on opioid misuse and abuse, and more specifically the identification and assessment of opioid-abuse risk in patients with cancer. Our secondary aim is to offer the most current evidence of best clinical practice and suggest future directions for research. Materials and methods Our integrative review included a literature search using the key terms “identification and assessment of opioid abuse in cancer”, “advanced cancer and opioid abuse”, “hospice and opioid abuse”, and “palliative care and opioid abuse”. PubMed, PsycInfo, and Embase were supplemented by a manual search. Results We found 691 articles and eliminated 657, because they were predominantly non cancer populations or specifically excluded cancer patients. A total of 34 articles met our criteria, including case studies, case series, retrospective observational studies, and narrative reviews. The studies were categorized into screening questionnaires for opioid abuse or alcohol, urine drug screens to identify opioid misuse or abuse, prescription drug-monitoring programs, and the use of universal precautions. Conclusion Screening questionnaires and urine drug screens indicated at least one in five patients with cancer may be at risk of opioid-use disorder. Several studies demonstrated associations between high-risk patients and clinical outcomes, such as aberrant behavior, prolonged opioid use, higher morphine-equivalent daily dose, greater health care utilization, and symptom burden.
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Affiliation(s)
- Ashley-Nicole Carmichael
- School of Pharmacy, Oncology, and Palliative Care, Virginia Commonwealth University, Richmond, VA, USA
| | - Laura Morgan
- School of Pharmacy, Oncology, and Palliative Care, Virginia Commonwealth University, Richmond, VA, USA
| | - Egidio Del Fabbro
- Division of Hematology, Oncology, and Palliative Care, Virginia Commonwealth University, Richmond, VA, USA
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Tan PD, Barclay JS, Blackhall LJ. Do Palliative Care Clinics Screen for Substance Abuse and Diversion? Results of a National Survey. J Palliat Med 2015; 18:752-7. [PMID: 26302425 DOI: 10.1089/jpm.2015.0098] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Opioids are the mainstay of treatment of cancer pain. With increased use there have been concerns about rising rates of prescription drug abuse and diversion. Although there has been an increase in research and practice guidelines about the scope of the problem for chronic, nonmalignant pain, less information is available about both the frequency of the problem and current practices regarding screening for substance abuse and diversion in patients and family members seen in palliative care clinics. OBJECTIVE The aim of this study was to evaluate the degree to which palliative programs felt that substance abuse and diversion was an issue, and to identify practices regarding care of patients with potential substance misuse issues. METHODS We sent a survey regarding substance abuse perception, policies, training, and screening to 94 accredited palliative medicine fellowship program directors as obtained by the Accreditation Council for Graduate Medical Education (ACGME) directory. RESULTS We received usable responses from 38 (40.4%) programs. Policies for screening patients (40.5%) or family members (16.2%), dealing with diversion (27%), and use of a screening tool (32.4%) were reported infrequently. Despite this, one-half of respondents indicated that substance abuse and diversion was an issue for their clinics, with only 25% indicating substance abuse was not an issue. Additionally, the majority of fellows (83%) and about half (47%) of staff received mandatory training for dealing with substance misuse. All programs provided some screening of patients, with 48.7% screening all patients for abuse. Screening of family members was relatively rare, as was routine use of the urine drug screen (UDS). CONCLUSION Despite increased concerns about substance abuse, the majority of programs did not have substance abuse and diversion policies or report screening all patients, with screening of caregivers rarely reported. Consensus guidelines addressing substance abuse and diversion for palliative patients are needed to address this growing problem.
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Affiliation(s)
- Paul D Tan
- 1 Department of Medicine, Division of General Medicine, Geriatrics, and Palliative Care, University of Virginia , Charlottesville, Virginia.,2 Department of Medicine, Eastern Maine Medical Center , Veazie, Maine
| | - Joshua S Barclay
- 1 Department of Medicine, Division of General Medicine, Geriatrics, and Palliative Care, University of Virginia , Charlottesville, Virginia
| | - Leslie J Blackhall
- 1 Department of Medicine, Division of General Medicine, Geriatrics, and Palliative Care, University of Virginia , Charlottesville, Virginia
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Abstract
Pain remains a serious consequence of cancer and its treatment. Although significant advances have been made in providing effective cancer pain control, barriers persist. Lack of knowledge, limited time, financial restrictions, and diminished availability of necessary medications serve as significant obstacles. Safe and effective opioid use in a patient with cancer requires skill to overcome these challenges. Understanding the mechanism of action, along with the pharmacokinetics and pharmacodynamics, of opioids will lead to appropriate selection, dosing, and titration of these agents. Rotation from one opioid or route to another is an essential proficiency for oncologists. As opioid-related adverse effects often occur, the oncology team must be expert in preventing and managing constipation, nausea, sedation, and neurotoxicities. An emerging concern is overtreatment-the excessive and prolonged use of opioids in patients when these agents may produce more harm than benefit. This can occur when opioids are used inappropriately to treat comorbid psychologic issues such as anxiety and depression. Recognizing risk factors for overuse along with key components of universal precautions will promote safe use of these medications, supporting adherence and preventing diversion, thereby protecting the patient, the prescriber, and the community. Because substance use disorders are not rare in the oncology setting, attention must be given to the balance of providing analgesia while limiting harm. Caring for patients with substance misuse requires compassionate, multidisciplinary care, with input from supportive oncology/palliative care as well as addiction specialists.
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Affiliation(s)
- Eduardo Bruera
- From the The University of Texas MD Anderson Cancer Center, Houston, TX; Feinberg School of Medicine, Northwestern University, Chicago, IL; Feinberg School of Medicine, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
| | - Judith A Paice
- From the The University of Texas MD Anderson Cancer Center, Houston, TX; Feinberg School of Medicine, Northwestern University, Chicago, IL; Feinberg School of Medicine, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
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Del Fabbro E. Assessment and Management of Chemical Coping in Patients With Cancer. J Clin Oncol 2014; 32:1734-8. [DOI: 10.1200/jco.2013.52.5170] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Chemical coping is a working definition that describes patients' intake of opioids on a scale that spans the range between normal nonaddictive opioid use for pain all the way to opioid addiction. Most patients will fall somewhere between the two extremes in using opioid analgesics to cope with their psychological or spiritual distress. The degree to which patients use their medications in a maladaptive manner will determine their susceptibility to drug toxicity and harm. When there are no obvious cancer-related causes for increased pain intensity, chemical coping and other patient-related factors such as delirium, somatization, and depression should be considered. As part of the initial evaluation of patients with cancer-related pain, a brief screening tool such as the CAGE questionnaire should be used to identify patients who may be at risk for chemical coping. Identifying patients at risk will allow clinicians to avoid unnecessary opioid toxicity, control pain, and improve quality of life. A structured approach for managing opioid use should be adopted, including standardized documentation, opioid treatment agreements, urine drug screens, frequent visits, and restricted quantities of breakthrough opioids. All patients at risk should receive brief motivational interviewing with an objective, nonjudgmental, and empathic style that includes personalized feedback, particularly about markers of risk or harm. For chemical copers approaching the addiction end of the spectrum, with evidence of compulsive use and destructive behavior, referral should be made to substance abuse specialists.
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Affiliation(s)
- Egidio Del Fabbro
- From Virginia Commonwealth University, Massey Cancer Center, Richmond, VA
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Reddy A, de la Cruz M, Rodriguez EM, Thames J, Wu J, Chisholm G, Liu D, Frisbee-Hume S, Yennurajalingam S, Hui D, Cantu H, Marin A, Gayle V, Shinn N, Xu A, Williams J, Bruera E. Patterns of storage, use, and disposal of opioids among cancer outpatients. Oncologist 2014; 19:780-5. [PMID: 24868100 DOI: 10.1634/theoncologist.2014-0071] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
PURPOSE Improper storage, use, and disposal of prescribed opioids can lead to diversion or accidental poisoning. Our objective was to determine the patterns of storage, utilization, and disposal of opioids among cancer outpatients. PATIENTS AND METHODS We surveyed 300 adult cancer outpatients receiving opioids in our supportive care center and collected information regarding opioid use, storage, and disposal, along with scores on the CAGE (cut down, annoyed, guilty, eye-opener) alcoholism screening questionnaire. Unsafe use was defined as sharing or losing opioids; unsafe storage was defined as storing opioids in plain sight. RESULTS The median age was 57 years. CAGE was positive in 58 of 300 patients (19%), and 26 (9%) had a history of illicit drug use. Fifty-six (19%) stored opioids in plain sight, 208 (69%) kept opioids hidden but unlocked, and only 28 (9%) locked their opioids. CAGE-positive patients (p = .007) and those with a history of illicit drug use (p = .0002) or smoking (p = .03) were more likely to lock their opioids. Seventy-eight (26%) reported unsafe use by sharing (9%) or losing (17%) their opioids. Patients who were never married or single (odds ratio: 2.92; 95% confidence interval: 1.48-5.77; p = .006), were CAGE positive (40% vs. 21%; p = .003), or had a history of illicit drug use (42% vs. 23%; p = .031) were more likely to use opioids unsafely. Overall, 223 of 300 patients (74%) were unaware of proper opioid disposal methods, and 138 (46%) had unused opioids at home. CONCLUSION A large proportion of cancer patients improperly and unsafely use, store, and dispose of opioids, highlighting the need for establishment of easily accessed patient education and drug take-back programs.
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Affiliation(s)
- Akhila Reddy
- Departments of Palliative Care and Rehabilitation Medicine and Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Maxine de la Cruz
- Departments of Palliative Care and Rehabilitation Medicine and Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Eden Mae Rodriguez
- Departments of Palliative Care and Rehabilitation Medicine and Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jessica Thames
- Departments of Palliative Care and Rehabilitation Medicine and Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jimin Wu
- Departments of Palliative Care and Rehabilitation Medicine and Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Gary Chisholm
- Departments of Palliative Care and Rehabilitation Medicine and Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Diane Liu
- Departments of Palliative Care and Rehabilitation Medicine and Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Susan Frisbee-Hume
- Departments of Palliative Care and Rehabilitation Medicine and Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sriram Yennurajalingam
- Departments of Palliative Care and Rehabilitation Medicine and Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - David Hui
- Departments of Palliative Care and Rehabilitation Medicine and Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Hilda Cantu
- Departments of Palliative Care and Rehabilitation Medicine and Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Alejandra Marin
- Departments of Palliative Care and Rehabilitation Medicine and Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Vicki Gayle
- Departments of Palliative Care and Rehabilitation Medicine and Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Nancy Shinn
- Departments of Palliative Care and Rehabilitation Medicine and Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Angela Xu
- Departments of Palliative Care and Rehabilitation Medicine and Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Janet Williams
- Departments of Palliative Care and Rehabilitation Medicine and Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Eduardo Bruera
- Departments of Palliative Care and Rehabilitation Medicine and Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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