A pilot study to investigate adherence to long-acting opioids among patients with advanced lung cancer

Psychological Evaluation of Patients With Cancer Presenting to the Emergency Department With Pain: Independent Predictors of Worse Pain Severity, Interference, and Higher Hourly Opioid Administration

PURPOSE

Pain is a common complaint in patients with cancer presenting to the emergency department (ED). This prospective study evaluated whether biopsychosocial factors could help predict cancer patients with risk of higher pain severity, pain interference, and opioid consumption.

METHODS

Patients with cancer presenting to the ED with a complaint of moderate-severe pain (≥ 4/10-numeric rating scale) completed validated self-report measures assessing sociodemographics, cancer-related treatments, pain severity and interference, medication use, and psychological symptoms (depression, anxiety, pain catastrophizing, and sleep disturbance). Opioids administered and subsequent hospitalization were abstracted. Univariable and multivariable regression analyses assessed factors associated with pain-related outcomes.

RESULTS

Participants (n = 175) presented with a variety of cancer types, with 76% having metastatic disease and 42% reporting current outpatient opioid use. Higher pain catastrophizing, lower depressive symptoms, lower income, outpatient opioid use, and historical chronic pain were independently associated with worse pain (P ≤ .05). Higher pain catastrophizing, anxiety, sleep disturbance, outpatient opioid use, and education were independently associated with worse pain interference (P ≤ .05). The sole independent predictor of ED opioid administration was outpatient opioid use. Patients taking outpatient opioids were younger, had lower health literacy, worse pain catastrophizing, sleep disturbance, depression/anxiety, and greater rates of metastatic cancer and cancer-related surgery (P ≤ .05).

CONCLUSION

Biopsychosocial factors, particularly pain catastrophizing, remained significantly associated with worse pain outcomes for patients with cancer in the ED even after controlling for demographic and clinical variables. Patient outpatient opioid use was independently associated with worse pain, interference, and greater opioid administration, identifying this as a marker for who may benefit most from adjuvant pharmacologic and behavioral interventions.

Adherence to Analgesics Among Outpatients Seriously Ill With Cancer

BACKGROUND

Adherence to prescribed analgesics for patients seriously ill with cancer pain is essential for comfort.

OBJECTIVE

The objective of this study was to determine the analgesic adherence in seriously ill patients with cancer and its association with clinical and demographic characteristics.

METHODS

This is a cross-sectional study. At home, 202 patients with cancer (mean age, 59.9 ± 14.2 years; 58% female, 48% Black, and 42% White) admitted to hospice/palliative care completed measures on a pen tablet: PAIN Report It, Symptom Distress Scale, mood state item, Pittsburgh Sleep Quality Index item, and Pain Management Index.

RESULTS

The mean current pain intensity was 4.4 ± 2.9, and the mean worst pain in the past 24 hours was 7.2 ± 2.7. More than one-half of participants were not satisfied with their pain level (54%) and reported their pain was more intense than they wanted to tolerate for 18 hours or longer in the last 24 hours (51%). Only 12% were not prescribed analgesics appropriate for the intensity of their pain. Adherence rates were variable: nonsteroidal anti-inflammatory drugs (0.63 ± 0.50), adjuvants (0.93 ± 0.50), World Health Organization step 2 opioids (0.63 ± 0.49), and step 3 opioids (0.80 ± 0.40). With setting/clinical/demographic variables in the model, dose intervals of less than 8 hours were associated with less adherence ( P < .001).

CONCLUSION

Little progress has been made toward improving analgesic adherence even in settings providing analgesics without cost. Research focused on targeting analgesic dose intervals and barriers not related to cost is needed.

IMPLICATION FOR PRACTICE

Dose intervals of 8 hours or longer were significantly associated with higher adherence rates; therefore, use of longer-acting analgesics is one strategy to improve pain control at the end of life.

Naturalistic assessment of patterns and predictors of acute headache medication use among women with comorbid migraine and overweight or obesity

Given the potential for obesity to complicate migraine treatment outcomes, there is a need to understand patterns and correlates of acute medication use among individuals with this comorbidity. Experience sampling methodology (ESM) was used to characterize patterns of acute medication use among those with migraine and overweight/obesity and to examine individual and momentary factors related to medication use (both migraine-specific and nonspecific medications). Women with migraine and overweight/obesity (N = 170) seeking behavioral migraine treatment completed questionnaires followed by 28 days of daily ESM headache diaries. Participants used medications to treat 71.9% of attacks, 20% of which were treated with migraine-specific medications. Participants were more likely to use medication in the context of longer and more severe attacks that started earlier in the day. Presence of aura and greater work-related pain interference uniquely related to migraine-specific medication use. Questionnaire-assessed factors were not related to medication use, although older age and higher educational attainment related to more frequent use. A substantial proportion of attacks were left untreated, suggesting unmet treatment needs in this population. Results also suggest that ESM-assessed factors are more salient correlates of medication use compared to questionnaires. Additional investigation of barriers to medication use is needed.

Gaps in the Use of Long-Acting Opioids Within Intervals of Consecutive Days Among Cancer Outpatients Using Electronic Pill Caps

OBJECTIVE

This study describes individual cancer patients' nonuse of extended-release or long-acting (ER/LA) opioids, including periods of gap between opioid doses taken.

DESIGN

Secondary analysis of a three-month observational study of prescribed ER/LA opioids monitored using electronic pill caps.

SETTING

Two outpatient oncology clinics of a large health system in the Mid-Atlantic region.

PARTICIPANTS

Inclusion was based on self-identified African Americans and whites, at least 18 years old, diagnosed with solid tumors or multiple myeloma. For the current analysis, the additional inclusion criterion was prescription of an oral ER/LA opioid for cancer pain to be taken around the clock.

METHODS

The electronic monitoring period for each study participant was partitioned into intervals of days between days with one or more openings (using medication event monitoring systems) representing rates of ER/LA opioid nonuse over consecutive days and over time.

RESULTS

Of the sample (N = 109), two-thirds of the cancer patients had some nonuse of prescribed ER/LA opioids, with one in four having nonuse during 31.5-87.5% of their electronic-monitoring periods. Nonuse over periods of five or more, six or more, and seven or more consecutive days occurred for 37.6%, 34.9%, and 30.3% of the participants, respectively.

CONCLUSIONS

About one in three ambulatory cancer patients in this study had substantial gaps between days of ER/LA opioid use, potentially resulting in risk of overdose depending upon the prescribed ER/LA opioid type, dose, and length of the time the opioid was stopped and resumed at the previous dose. This phenomenon has received little to no attention in the opioid safety discourse.

When Patients Take Charge of Opioids: Self-Management Concerns and Practices Among Cancer Outpatients in the Context of Opioid Crisis

CONTEXT

With concerns about opioid prescribing practices prominent in the professional and lay literature, there is less focus on patients' self-management of opioids for cancer pain and potential safety risks.

OBJECTIVES

To investigate reports of opioid self-management practices and concerns among patients undergoing active cancer treatments-a group excluded from the scope of most policy initiatives on prescription opioids.

METHODS

This sequential multimethod study used freelisting (n = 65) and open-ended semistructured interviews with a racially diverse subgroup (n = 32). Adult ambulatory patients with solid malignancies or multiple myeloma and pain (≥4 on a scale of 0-10) were recruited from an urban National Cancer Institute-designated cancer center in Philadelphia. Freelists were analyzed using consensus analysis and semistructured interview data were analyzed using thematic analysis.

RESULTS

In freelisting, "pain relief" emerged as the primary term in relation to taking pain medications preceding "addiction" concerns. In interviews, patients described several heuristics and some potentially unsafe practices to minimize opioid use to a self-defined "normal." These included reducing opioid dose by cutting pills; self-tapering off opioids; using extended-release/long-acting opioids on an as-needed basis; mixing over-the-counter, nonopioid analgesics; and using illicit drugs to avoid "harder medicines" (opioids). Many patients preferred nonopioid treatments for pain but invariably faced access barriers. Some described assuming stewardship of their prescribed opioids and felt that oncology clinicians are quick to prescribe opioids without providing workable alternatives.

CONCLUSIONS

Risks related to self-management of opioids among cancer outpatients, including potential overdose risks, need urgent attention. Interventions are needed for improving clinician-patient communication, patient education, safety, and access to effective nonopioid alternatives.

Patient Patterns and Perspectives on Using Opioid Regimens for Chronic Cancer Pain

CONTEXT

With increasing attention to the undertreatment of cancer pain in parallel with concerns about opioid misuse, little is known about how patients with advanced cancer adhere to opioid regimens for chronic cancer pain.

OBJECTIVES

We explored patient approaches to managing chronic cancer pain with long-acting opioids.

METHODS

In a multimethods study at an academic medical center, adult patients with chronic cancer pain (n = 17) used electronic pill caps to record adherence to prescribed long-acting opioid regimens. After eight weeks, patients viewed their adherence records and completed a semistructured interview about their opioid use. With a framework approach, we coded interview data (Kappa >0.95) and identified themes in how patients perceived and used opioids to manage cancer pain.

RESULTS

Patients (59% female; 94% non-Hispanic white; median age = 65 years) felt grateful about pain benefit from opioids yet concerned about opioid side effects and addiction/tolerance. Main reasons for nonadherence included both intentional decisions (e.g., skipping doses) and unintentional barriers (e.g., missing doses due to inconsistent sleep schedules). Overall, patients set their own opioid adherence goals and developed routines to achieve them. Residual pain varied and was not consistently linked with opioid adherence.

CONCLUSION

Patients commonly felt conflicted about using prescribed long-acting opioids to manage cancer pain due to concurrent perceptions of their risks and benefits, and they set their own parameters for opioid-taking practices. Intentional and unintentional deviations from prescribed opioid schedules highlight the need to enhance adherence communication, education, and counseling, to optimize the use of long-acting opioids as a component of cancer pain management.

Salient concerns in using analgesia for cancer pain among outpatients: A cluster analysis study

AIM

To identify unique clusters of patients based on their concerns in using analgesia for cancer pain and predictors of the cluster membership.

METHODS

This was a 3-mo prospective observational study (n = 207). Patients were included if they were adults (≥ 18 years), diagnosed with solid tumors or multiple myelomas, and had at least one prescription of around-the-clock pain medication for cancer or cancer-treatment-related pain. Patients were recruited from two outpatient medical oncology clinics within a large health system in Philadelphia. A choice-based conjoint (CBC) analysis experiment was used to elicit analgesic treatment preferences (utilities). Patients employed trade-offs based on five analgesic attributes (percent relief from analgesics, type of analgesic, type of side-effects, severity of side-effects, out of pocket cost). Patients were clustered based on CBC utilities using novel adaptive statistical methods. Multiple logistic regression was used to identify predictors of cluster membership.

RESULTS

The analyses found 4 unique clusters: Most patients made trade-offs based on the expectation of pain relief (cluster 1, 41%). For a subset, the main underlying concern was type of analgesic prescribed, i.e., opioid vs non-opioid (cluster 2, 11%) and type of analgesic side effects (cluster 4, 21%), respectively. About one in four made trade-offs based on multiple concerns simultaneously including pain relief, type of side effects, and severity of side effects (cluster 3, 28%). In multivariable analysis, to identify predictors of cluster membership, clinical and socioeconomic factors (education, health literacy, income, social support) rather than analgesic attitudes and beliefs were found important; only the belief, i.e., pain medications can mask changes in health or keep you from knowing what is going on in your body was found significant in predicting two of the four clusters [cluster 1 (-); cluster 4 (+)].

CONCLUSION

Most patients appear to be driven by a single salient concern in using analgesia for cancer pain. Addressing these concerns, perhaps through real time clinical assessments, may improve patients’ analgesic adherence patterns and cancer pain outcomes.

Increasing Complexity in Rule-Based Clinical Decision Support: The Symptom Assessment and Management Intervention

BACKGROUND

Management of uncontrolled symptoms is an important component of quality cancer care. Clinical guidelines are available for optimal symptom management, but are not often integrated into the front lines of care. The use of clinical decision support (CDS) at the point-of-care is an innovative way to incorporate guideline-based symptom management into routine cancer care.

OBJECTIVE

The objective of this study was to develop and evaluate a rule-based CDS system to enable management of multiple symptoms in lung cancer patients at the point-of-care.

METHODS

This study was conducted in three phases involving a formative evaluation, a system evaluation, and a contextual evaluation of clinical use. In Phase 1, we conducted iterative usability testing of user interface prototypes with patients and health care providers (HCPs) in two thoracic oncology clinics. In Phase 2, we programmed complex algorithms derived from clinical practice guidelines into a rules engine that used Web services to communicate with the end-user application. Unit testing of algorithms was conducted using a stack-traversal tree-spanning methodology to identify all possible permutations of pathways through each algorithm, to validate accuracy. In Phase 3, we evaluated clinical use of the system among patients and HCPs in the two clinics via observations, structured interviews, and questionnaires.

RESULTS

In Phase 1, 13 patients and 5 HCPs engaged in two rounds of formative testing, and suggested improvements leading to revisions until overall usability scores met a priori benchmarks. In Phase 2, symptom management algorithms contained between 29 and 1425 decision nodes, resulting in 19 to 3194 unique pathways per algorithm. Unit testing required 240 person-hours, and integration testing required 40 person-hours. In Phase 3, both patients and HCPs found the system usable and acceptable, and offered suggestions for improvements.

CONCLUSIONS

A rule-based CDS system for complex symptom management was systematically developed and tested. The complexity of the algorithms required extensive development and innovative testing. The Web service-based approach allowed remote access to CDS knowledge, and could enable scaling and sharing of this knowledge to accelerate availability, and reduce duplication of effort. Patients and HCPs found the system to be usable and useful.

Patterns of analgesic adherence predict health care utilization among outpatients with cancer pain

BACKGROUND

Studies in chronic noncancer pain settings have found that opioid use increases health care utilization. Despite the key role of analgesics, specifically opioids, in the setting of cancer pain, there is no literature to our knowledge about the relationship between adherence to prescribed around-the-clock (ATC) analgesics and acute health care utilization (hospitalization) among patients with cancer pain.

PURPOSE

To identify adherence patterns over time for cancer patients taking ATC analgesics for pain, cluster these patterns into adherence types, combine the types into an adherence risk factor for hospitalization, identify other risk factors for hospitalization, and identify risk factors for inconsistent analgesic adherence.

MATERIALS AND METHODS

Data from a 3-month prospective observational study of patients diagnosed with solid tumors or multiple myeloma, having cancer-related pain, and having at least one prescription of oral ATC analgesics were collected. Adherence data were collected electronically using the medication event-monitoring system. Analyses were conducted using adaptive modeling methods based on heuristic search through alternative models controlled by likelihood cross-validation scores.

RESULTS

Six adherence types were identified and combined into the risk factor for hospitalization of inconsistent versus consistent adherence over time. Twenty other individually significant risk factors for hospitalization were identified, but inconsistent analgesic adherence was the strongest of these predictors (ie, generating the largest likelihood cross-validation score). These risk factors were adaptively combined into a model for hospitalization based on six pairwise interaction risk factors with exceptional discrimination (ie, area under the receiver-operating-characteristic curve of 0.91). Patients had from zero to five of these risk factors, with an odds ratio of 5.44 (95% confidence interval 3.09-9.58) for hospitalization, with a unit increase in the number of such risk factors.

CONCLUSION

Inconsistent adherence to prescribed ATC analgesics, specifically the interaction of strong opioids and inconsistent adherence, is a strong risk factor for hospitalization among cancer outpatients with pain.

Adherence to Analgesics for Cancer Pain: A Comparative Study of African Americans and Whites Using an Electronic Monitoring Device

Despite well-documented disparities in cancer pain outcomes among African Americans, surprisingly little research exists on adherence to analgesia for cancer pain in this group. We compared analgesic adherence for cancer-related pain over a 3-month period between African Americans and whites using the Medication Event Monitoring System (MEMS). Patients (N = 207) were recruited from outpatient medical oncology clinics of an academic medical center in Philadelphia (≥18 years of age, diagnosed with solid tumors or multiple myeloma, with cancer-related pain, and at least 1 prescription of oral around-the-clock analgesic). African Americans reported significantly greater cancer pain (P < .001), were less likely than whites to have a prescription of long-acting opioids (P < .001), and were more likely to have a negative Pain Management Index (P < .001). There were considerable differences between African Americans and whites in the overall MEMS dose adherence, ie, percentage of the total number of prescribed doses that were taken (53% vs 74%, P < .001). On subanalysis, analgesic adherence rates for African Americans ranged from 34% (for weak opioids) to 63% (for long-acting opioids). Unique predictors of analgesic adherence varied by race; income levels, analgesic side effects, and fear of distracting providers predicted analgesic adherence for African Americans but not for whites. Perspective: Despite evidence of disparities in cancer pain outcomes among African Americans, surprisingly little research exists on African Americans' adherence to analgesia for cancer pain. This prospective study uses objective measures to compare adherence to prescribed pain medications between African American and white patients with cancer pain.

Understanding the cancer pain experience

Cancer pain management is a major element of successful cancer survivorship. Regardless of where someone is along the cancer experience, from a newly diagnosed patient to long-term survivor, pain is a potential treatment-related effect that can have a significant impact on a survivor's life. Quality pain management for cancer survivors is complicated by the fact that cancer-related pain can be due to the tumor, surgery, radiation, and/or chemotherapy. Additionally, the pain experience is related to many psychosocial/spiritual factors. Despite almost 40 years of attention devoted to improving cancer pain management, many cancer survivors are less than optimally treated, often owing to survivor and healthcare provider knowledge barriers. This article reviews some of the latest research related to cancer pain management treatment options, measurement/assessment, and interventions. Progress has been made in understanding new aspects of the pain experience, but more work is yet to be done.

Self-monitoring of lower leg skin temperature: accuracy of self-reported data and adherence to a cooling protocol for the prevention of venous leg ulcers

BACKGROUND

For intervention studies that require the use of participant self-reports, the quality and accuracy of recorded data and variability in participant adherence rates to the treatment can cause significant outcome bias.

PURPOSE

To assess the quality and accuracy of participant documentation of daily self-monitoring of leg skin temperature, adherence to a graduated cooling treatment protocol to prevent venous leg ulcers, and the potential for bias in treatment effect in a randomized controlled trial that included a population with chronic venous disease.

METHODS

Individuals were randomized to a leg cooling intervention or placebo treatment group to daily self-monitor and record lower leg skin temperature over a 9-month period on monthly paper study logs. Returned study logs for the first 100 completed participants (n=54 cooling intervention, n=46 control) were reviewed for quality and accuracy. Adherence was determined from evaluating the accuracy of participant documentation. To examine potential outcome bias in treatment effect, mean between group and within group comparisons of the before and after treatment differences were conducted using an intention-to-treat (ITT) versus a modified intention-to-treat (mITT) analysis approach with an 85% accuracy cut-off rate. Data were collected in 2011-2014.

RESULTS

Of the expected 900 study logs, 91.8% (826/900) were returned and 8.2% (74/900) were not. Non-mutually exclusive main error types in returned documentation included: 59.2% (489/826) white-outs, cross-off and/or overwrites, 34.9% (288/826) entries omitted, 29.4% (243/826) no performance of daily self-monitoring, 28.7% (237/826) no performance of the treatment intervention per the prescribed protocol regime, 26.8% (221/826) extraneous data, 8.6% (71/826) suspected fabrication, and 7.6% (63/826) questionable validity. Under ITT analysis, 38.4% (346/900) of all returned logs were <85% accurate, 25.0% (225/900) were 85%-99% accurate, and 36.6% (329/900) were 100% accurate. Mean overall participant adherence rates were: 22.0% at <85% accuracy, 53.0% at 85%-99% accuracy, and 25.0% at 100% accuracy. Under the mITT analysis, 54.0% (483/900) of returned logs were deemed adherent with ≥85% accuracy.

CONCLUSION

This study found good rates of adherence. Under ITT analysis, 78.0% of participants were deemed adherent to the study protocol with ≥85% accuracy in documenting daily self-monitoring of skin temperatures in response to a topically applied experimental cooling cuff intervention for the prevention of venous leg ulcers.

Overcoming barriers in cancer pain management

Pain is a devastating symptom of cancer that affects the quality of life of patients, families, and caregivers. It is a multidimensional symptom that includes physical, psychosocial, emotional, and spiritual components. Despite the development of novel analgesics and updated pain guidelines, cancer pain remains undermanaged, and some patients with moderate to severe pain do not receive adequate pain treatment. Inadequate pain management can be attributed to barriers related to health care professionals, patients, and the health care system. Common professional-related barriers include poor pain assessment, lack of knowledge and skill, and the reluctance of physicians to prescribe opioids. Patient-related barriers include cognitive factors, affective factors, and adherence to analgesic regimens. System-related barriers such as limits on access to opioids and the availability of pain and palliative care specialists present additional challenges, particularly in resource-poor regions. Given the multidimensional nature of cancer pain and the multifaceted barriers involved, effective pain control mandates multidisciplinary interventions from interprofessional teams. Educational interventions for patients and health care professionals may improve the success of pain management.