Aberrant opioid use behaviour in advanced cancer

Substance Use Disorder, Opioid Use Disorder, and Symptom Management in Palliative Care: A Rapid Review of Evidence

Substance use disorder (SUD) affects more than 1 in 6 Americans older than 12 years and has become an increasingly relevant topic in palliative care. Lack of clear guidelines and fragmented care results in patient safety concerns and poor outcomes. This rapid review aims to present the current literature on opioid contracts/agreements, prescription drug monitoring database access, opioid risk assessment tools, and urine drug screening in the palliative care setting. Through a systematic process, we identified 19 articles published between 2018 and 2023 that pertained to substance use disorder and palliative care. Current risk mitigation strategies include prescription drug monitoring, opioid use agreements, risk assessment tools, urine drug screening, and the use of buprenorphine to manage pain. Prescription drug monitoring programs are state-based electronic databases that track controlled substances, and there are numerous risk assessment tools. Urine drug screening involves the use of both immunoassay and confirmatory chromatography to determine the presence or absence of either the prescribed controlled substance or unexpected findings including illicit drugs or prescription-controlled substances that are not prescribed to the patient. The goal of mitigating risk and reducing harm while providing expert symptom management is the challenge that palliative care transdisciplinary teams face as they continue to care for patients with substance use disorder. This review points to the need for further research on how to incorporate these harm-reducing strategies into clinical practice.

Prevalence of opioid misuse in patients with cancer: a systematic review and meta-analysis

BACKGROUND/OBJECTIVES

Long-term consequences of opioid consumption, such as misuse, have been a major concern in patients with chronic non-cancer pain. Potentially opioid misuse may also be a consequence in patients with cancer in opioid treatment which encouraged us to undertake this systematic review assessing the frequency of opioid misuse in this population.

MATERIALS/METHODS

The search strategy comprised words related to cancer, opioid misuse, and frequency. PubMed, Embase, PsycInfo, and Cinahl were searched from inception to July 2023. Prospective studies were selected and analysed regarding frequency, study characteristics, and quality. A meta-analysis was possible to carry out for a sub-group (opioid misuse risk).

RESULTS

From 585 abstracts screened, six articles were included. Only prevalence data were found. The prevalence of opioid misuse ranged from 5.7% to 84%, while the prevalence of opioid misuse risk varied from 2.4% to 35.4%. The pooled prevalence of opioid misuse risk was 12.3% (95% CI: 0.8-36.3; I2 = 98.4%, 95% CI: 97.2-99.1). The studies differed regarding, e.g., methods, misuse definitions, and assessment instruments.

CONCLUSIONS

Few studies were identified and large differences in prevalence for opioid misuse and opioid misuse risk were observed. Methodological disparities and the studies quality underscore the importance of improved studies in the future.

Opioids in advanced cancer: use, storage and disposal in the home

OBJECTIVES

To determine the patterns of storing, using and disposing of opioids among patients with advanced cancer followed at home.

METHODS

Patients who were prescribed opioids were selected. Prescribed opioids and their doses used for background pain and breakthrough pain were collected, as well as CAGE (cut down, annoyed, guilty and eye opener) for alcohol and drugs, smoking and history of illicit substance use. Questions regarding the opioid use, storage and disposal were posed.

RESULTS

100 patients were surveyed. Fifty-one patients had unused opioids at home, 25 patients did not throw away the drugs, 40 patients saved opioids for future use and 35 patients were unaware of proper opioid disposal methods. A total of 28 patients reported unsafe use by sharing or losing their opioids; 12 patients were unaware that their opioid could be fatal when taken by others. Most patients acknowledged that pain medications could be dangerous when taken by others. Patients with a partner and who were married were more likely to keep their opioids locked (p=0.028 and p=0.025, respectively).

CONCLUSION

A large number of patients with advanced cancer followed at home do not store, use and dispose of opioids safely. Patient education programmes should be incorporated to decrease the availability of opioids at home for abuse, diversion, and accidental poisoning.

Prevalence of Opioid Use Disorder among Patients with Cancer-Related Pain: A Systematic Review

BACKGROUND

The opioid use disorder is an international public health problem. Over the past 20 years it has been the subject of numerous publications concerning patients treated for chronic pain other than cancer-related. Patients with cancer-related pain are also at risk of opioid use disorder. The primary objective of this literature review was to determine the prevalence of opioid use disorder in patients with cancer-related chronic pain. Its secondary objective was to identify the characteristics of these opioid users.

METHODS

This is a literature review of studies published over the last twenty years, from 1 January 2000 to 31 December 2020 identified by searching the three main medical databases: Pubmed, Cochrane, and Embase. A meta-analysis took account of between and within-study variability with the use of random-effects models estimated by the DerSimonian and Laird method.

RESULTS

The prevalence of opioid use disorder was 8% (1-20%) and of the risk of use disorder was 23.5% (19.5-27.8%) with I² values of 97.8% and 88.7%, respectively.

CONCLUSIONS

Further studies are now needed on the prevalence of opioid use disorder in patients treated for cancer-related chronic pain. A screening scale adapted to this patient population is urgently needed.