Revisiting patient-related barriers to cancer pain management in the context of the US opioid crisis

The effectiveness of online pain management education on the patient related barriers to cancer pain management: A randomized controlled trial

PURPOSE

This study aimed to evaluate the effectiveness of an online individualized education program on patient-related barriers to cancer pain management.

METHODS

In this parallel randomized controlled trial, 110 participants were assigned to the intervention or control group. Online individualized education was conducted as the intervention. Depending on participants' preferences, online education sessions were completed via Microsoft Teams, Zoom, or WhatsApp. The primary outcome is patient-related barriers to cancer pain management, and the secondary outcome is pain intensity. The Patient Information Form, the Edmonton Symptom Assessment Scale (ESAS), the Brief Pain Inventory (BPI), and the Barriers Questionnaire II (BQ-II) were used for data collection. The statistical effects of the intervention on the outcomes were modeled in repeated measures ANOVA test.

RESULTS

The results show that both the group (F = 11.316, p = 0.001) and time effects (F = 63.878, p < 0.001) individually have significant effects on the BQII total score. Also, there is a significant difference between groups regarding BQII total score regardless of time. The interaction between group and time is also significant (F = 127.764, p < 0.001) and substantially affects the BQII total score. Regarding pain intensity, the results show that the interaction between group and time is statistically significant for all pain categories (p < 0.05). In contrast, the group effect is not statistically significant for all pain categories (p > 0.05). Time effects are statistically significant for the "least" and "average" pain only (p < 0.05).

CONCLUSION

The result of this study presents evidence that individualized online education of cancer patients positively impacts reducing patient-related barriers to pain management and pain intensity.

Opioid consumption by cancer patients in an Israeli Health Maintenance Organization from 2007-2018

PURPOSE

Opioids are the cornerstone of therapy for cancer patients with moderate to severe pain. The objective was to characterize opioid purchases by cancer patients in Clalit Health Services (CHS), the largest Health Maintenance Organization in Israel, over the years 2007-2018.

METHODS

Data for all CHS cancer patients aged 18 years old and above who purchased an opioid at least once during the 12-year study period were obtained from computerized databases. The amount of opioids was converted into oral morphine equivalents (OME).

RESULTS

108,543 cancer patients who purchased opioids at least once were enrolled. They comprised 30.5% of the CHS purchasers of opioids in the study period. The total number of cancer patients who purchased an opioid at least once increased gradually from 13,057 in 2007 to 20,675 (58% increase) in 2018, while the annual number of CHS cancer patients increased by only 39%. The annual OME per capita increased from 753 mg in 2007 to 1,432 mg in 2018 (91% increase). In 2007 8.1% of the cancer patients purchased opioids and 9.2% in 2018. Two thirds of all cancer patients purchased opioids for three months or less, 11.9% continued for more than one year, and 5.8% for more than two years.

CONCLUSIONS

There is a clinically non-significant increase in the rate of cancer patients purchasing opioids. About two thirds of the cancer patients purchased opioids for only three months, and 94% for up to two years. Under-treatment of cancer pain should still be of concern. While patients are prescribed higher doses, under-prescription may still be a problem..

The Stigma Surrounding Opioid Use as a Barrier to Cancer-Pain Management: An Overview of Experiences with Fear, Shame, and Poorly Controlled Pain in the Context of Advanced Cancer

Cancer-related pain affects a majority of patients with advanced cancer and is often undertreated. The treatment of this pain is largely reliant on the use of opioids, which are essential medicines for symptom management and the maintenance of quality of life (QoL) for patients with advanced cancer. While there are cancer-specific guidelines for the treatment of pain, widespread publication and policy changes in response to the opioid epidemic have drastically impacted perceptions of opioid use. This overview therefore aims to investigate how manifestations of opioid stigma impact pain management in cancer settings, with an emphasis on the experiences of patients with advanced cancer. Opioid use has been widely stigmatized in multiple domains, including public, healthcare, and patient populations. Physician hesitancy in prescribing and pharmacist vigilance in dispensing were identified as barriers to optimal pain management, and may contribute to stigma in the context of advanced cancer. Evidence in the literature suggests that opioid stigma may result in patient deviations from prescription instructions, which generally leads to pain undertreatment. Patients reflected on experiencing shame and fear surrounding their prescription opioid use and feeling uncomfortable communicating with their healthcare providers on these topics. Our findings indicate that future work is required to educate patients and providers in order to de-stigmatize opioid use. Through alleviating stigma, patients may be better able to make decisions regarding their pain management which lead to freedom from cancer-related pain and improved QoL.

"I Refused to Get Addicted to Opioids": Exploring Attitudes About Opioid Use Disorder in Patients With Advanced Cancer Pain and Their Support People

Patients with advanced cancer are commonly prescribed opioids, yet patient attitudes about opioid risks (eg, opioid use disorder, or OUD) are understudied. Our objective was to use in-depth qualitative interviews to understand perceptions of opioid prescribing and OUD in patients with advanced, solid-tumor cancers and their support people. We conducted a qualitative study using a rigorous inductive, qualitative descriptive approach to examine attitudes about OUD in patients with advanced cancer (n = 20) and support providers (n = 11). Patients with cancer hold 2 seemingly distinct views: prescription opioids are addictive, yet OUD cannot happen to me or my loved one. Participants described general concerns about the addictive nature of prescription opioids ("My biggest concern… would just be the risk of getting addicted to the medication or even like, overdosing it"), while separating cancer pain management from OUD when considering prescription opioid risks and benefits ("They need to make sure they get the right ones, when they're taking it away from you."). Finally, participants identified personal characteristics and behaviors that they felt were protective against developing OUD (commonly control, willpower, and responsibility). This rigorous qualitative study demonstrates that patients with advanced cancer and their support people simultaneously hold concerns about the addictive nature of prescription opioids, while distancing from perceptions of OUD risks when using opioids for cancer pain management. Given high rates of opioid exposure during advanced cancer treatment, it is important to explore opportunities to promote a balanced understanding of prescription opioid use and OUD risks in this population. PERSPECTIVE: Though prescription opioids carry risk of OUD, there is little data to help guide patients with advanced cancer. Findings suggest that there is a need to develop new, innovative strategies to promote effective pain management and minimize opioid risks in this complex population.

Manifestations of Opioid Stigma in Patients With Advanced Cancer: Perspectives From Patients and Their Support Providers

PURPOSE

Stigma surrounding prescription opioids, or opioid stigma, is increasingly recognized as a barrier to effective and guideline-concordant cancer pain management. Patients with advanced cancer report high rates of pain and prescription opioid exposure, yet little is known about how opioid stigma may manifest in this population.

METHODS

We conducted in-depth qualitative interviews with 20 patients with advanced cancer and 11 support providers between March 2020, and May 2021. We took a rigorous inductive, qualitative descriptive approach to characterize how opioid stigma manifests in the lives of patients with advanced cancer.

RESULTS

Patients and their support providers described three primary manifestations of opioid stigma: (1) direct experiences with opioid stigma and discrimination in health care settings (eg, negative, stigmatizing interactions in pharmacies or a pain clinic); (2) concerns about opioid stigma affecting patient care in the future, or anticipated stigma; and (3) opioid-restricting attitudes and behaviors that may reflect internalized stigma and fear of addiction (eg, feelings of guilt).

CONCLUSION

This qualitative study advances our understanding of opioid stigma manifestations in patients with advanced cancer, as well as coping strategies that patients may use to alleviate their unease (eg, minimizing prescription opioid use, changing clinicians, and distancing from perceptions of addiction). In recognition of the costs of undermanaged cancer pain, it is important to consider innovative treatment strategies to address opioid stigma and improve pain management for patients with advanced cancer. Future research should examine opportunities to build an effective, multilevel opioid stigma intervention targeting patients, clinicians, and health care systems.

Age-related changes in peripheral nociceptor function

Pain and pain management in the elderly population is a significant social and medical problem. Pain sensation is a complex phenomenon that typically involves activation of peripheral pain-sensing neurons (nociceptors) which send signals to the spinal cord and brain that are interpreted as pain, an unpleasant sensory experience. In this work, young (4-5 months) and aged (26-27 months) Fischer 344 x Brown Norway (F344xBN) rats were examined for nociceptor sensitivity to activation by thermal (cold and heat) and mechanical stimulation following treatment with inflammatory mediators and activators of transient receptor potential (TRP) channels. Unlike other senses that decrease in sensitivity with age, sensitivity of hindpaw nociceptors to thermal and mechanical stimulation was not different between young and aged F344xBN rats. Intraplantar injection of bradykinin (BK) produced greater thermal and mechanical allodynia in aged versus young rats, whereas only mechanical allodynia was greater in aged rats following injection of prostaglandin E₂ (PGE₂). Intraplantar injection of TRP channel activators, capsaicin (TRPV1), mustard oil (TRPA1) and menthol (TRPM8) each resulted in greater mechanical allodynia in aged versus young rats and capsaicin-induced heat allodynia was also greater in aged rats. A treatment-induced allodynia that was greater in young rats was never observed. The anti-allodynic effects of intraplantar injection of kappa and delta opioid receptor agonists, salvinorin-A and D-Pen²,D-Pen⁵]enkephalin (DPDPE), respectively, were greater in aged than young rats, whereas mu opioid receptor agonists, [D-Ala2, N-MePhe4, Gly-ol]-enkephalin (DAMGO) and morphine, were not effective in aged rats. Consistent with these observations, in primary cultures of peripheral sensory neurons, inhibition of cAMP signaling in response to delta and kappa receptor agonists was greater in cultures derived from aged rats. By contrast, mu receptor agonists did not inhibit cAMP signaling in aged rats. Thus, age-related changes in nociceptors generally favor increased pain signaling in aged versus young rats, suggesting that changes in nociceptor sensitivity may play a role in the increased incidence of pain in the elderly population. These results also suggest that development of peripherally-restricted kappa or delta opioid receptor agonists may provide safer and effective pain relief for the elderly.

The effect of anlotinib on the pharmacokinetic profile of oxycodone and the underlying mechanism

PURPOSE

Cancer patients experience pain during medical treatment. Therefore, anticancer drugs and painkillers are often prescribed together. This study aims to determine the interaction between anlotinib and oxycodone and reveal the underlying mechanism.

METHODS

UPLC-MS/MS, an efficient and sensitive method, was used for the simultaneous determination of oxycodone and oxycodone metabolites. Sprague-Dawley rats were given oxycodone with or without anlotinib. Then, UPLC-MS/MS was used to determine the blood concentration of oxycodone. To study the interaction mechanism, rat and human liver microsomes (HLMs) were used for determining enzyme kinetics.

RESULTS

Long-term administration of oxycodone combined with anlotinib resulted in significantly increased pharmacokinetic parameters AUC_(0-t), AUC_(0-∞), and C_max for oxycodone, indicating that anlotinib inhibited oxycodone. In vitro kinetic measurements indicated that anlotinib inhibited the metabolism of oxycodone through a mixed mechanism. Further studies indicated that in HLMs, anlotinib strongly inhibited the metabolism of oxycodone.

CONCLUSION

This study showed that anlotinib inhibited the metabolism of oxycodone both in vitro and in vivo. It is recommended that the dose of oxycodone should be reconsidered when oxycodone is combined with anlotinib in clinical practice.

Unacceptable pain in oncology: The patients' perspective on reasons for absence of pain interventions

Objective

Around 40% of oncology patients receive inadequate pain treatment. A previous study reported pain interventions for only 70% of patients who reported unacceptable pain at the self‐service registration desk. The aim of this study is to gain insight in reasons for the absence of pain intervention among oncology patients who reported unacceptable pain.

Methods

In this mixed methods study, 20 patients visiting the oncology outpatient clinic were selected via patient record assessment and interviewed about their perceived reasons for absence of pain intervention.

Results

The reasons mentioned by the patients for absence of pain intervention included reluctance of the patient to discuss pain, no treatment preferred by the patient, focus of the physician on treatment of the disease, pain treatment difficult or impossible, and the perception that pain is an inevitable consequence of the cancer treatment. Almost 50% of the patients considered the physician responsible for the absence of pain intervention.

Conclusion

In conclusion, a variety of reasons for absence of pain intervention are reported by patients, including patient‐related and health professional‐related reasons. Improvements can be made by promoting regular discussion of pain during hospital visits and empowerment of patients.

Prevalence of Opioid Misuse Risk in Patients With Cancer

BACKGROUND

Opioid misuse risk may be similar in individuals with chronic cancer and noncancer pain. However, risk screening is not uniformly used for patients with cancer, so its prevalence is unknown.

OBJECTIVES

The primary aim of this study was to estimate the level of risk for opioid misuse among patients with cancer. Secondary aims were to compare opioid misuse risk across cancer types and specialties and to explore psychosocial factors that may contribute to opioid misuse risk.

METHODS

Clinicians were trained to administer the Opioid Risk Tool during ambulatory visits. Data were retrieved from electronic health records and analyzed using descriptive statistics.

FINDINGS

Five percent of patients seen in the cancer center during the data collection period were screened for opioid misuse risk. Of the 226 patients screened, 163 were at low risk, 34 were at moderate risk, and 29 were at high risk for future opioid misuse. The most frequent cancer diagnoses for patients at moderate or high risk were lung (n = 15), breast (n = 16), gastrointestinal (n = 10), and genitourinary (n = 8). Of the 63 patients at moderate or high risk, 50 had a family history of substance misuse, 45 had a personal history of substance misuse, and 29 had a history of psychological disease.