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Jones KF, Khodyakov D, Han BH, Arnold RM, Dao E, Morrison J, Kapo J, Meier DE, Paice JA, Liebschutz JM, Ritchie CS, Merlin JS, Bulls HW. Expert consensus-based guidance on approaches to opioid management in individuals with advanced cancer-related pain and nonmedical stimulant use. Cancer 2023; 129:3978-3986. [PMID: 37691479 PMCID: PMC10910244 DOI: 10.1002/cncr.34921] [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] [Received: 02/13/2023] [Revised: 03/19/2023] [Accepted: 04/17/2023] [Indexed: 09/12/2023]
Abstract
BACKGROUND Clinicians treating cancer-related pain with opioids regularly encounter nonmedical stimulant use (i.e., methamphetamine, cocaine), yet there is little evidence-based management guidance. The aim of the study is to identify expert consensus on opioid management strategies for an individual with advanced cancer and cancer-related pain with nonmedical stimulant use according to prognosis. METHODS The authors conducted two modified Delphi panels with palliative care and addiction experts. In Panel A, the patient's prognosis was weeks to months and in Panel B the prognosis was months to years. Experts reviewed, rated, and commented on the case using a 9-point Likert scale from 1 (very inappropriate) to 9 (very appropriate) and explained their responses. The authors applied the three-step analytical approach outlined in the RAND/UCLA to determine consensus and level of clinical appropriateness of management strategies. To better conceptualize the quantitative results, they thematically analyzed and coded participant comments. RESULTS Consensus was achieved for all management strategies. The 120 Experts were mostly women (47 [62%]), White (94 [78%]), and physicians (115 [96%]). For a patient with cancer-related and nonmedical stimulant use, regardless of prognosis, it was deemed appropriate to continue opioids, increase monitoring, and avoid opioid tapering. Buprenorphine/naloxone transition was inappropriate for a patient with a short prognosis and of uncertain appropriateness for a patient with a longer prognosis. CONCLUSION Study findings provide urgently needed consensus-based guidance for clinicians managing cancer-related pain in the context of stimulant use and highlight a critical need to develop management strategies to address stimulant use disorder in people with cancer. PLAIN LANGUAGE SUMMARY Among palliative care and addiction experts, regardless of prognosis, it was deemed appropriate to continue opioids, increase monitoring, and avoid opioid tapering in the context of cancer-related pain and nonmedical stimulant use. Buprenorphine/naloxone transition as a harm reduction measure was inappropriate for a patient with a short prognosis and of uncertain appropriateness for a patient with a longer prognosis.
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Affiliation(s)
- Katie Fitzgerald Jones
- New England Geriatric Research, Education and Clinical Center and Division of Palliative Care, VA Boston Healthcare System, Boston, Massachusetts, USA
| | | | - Benjamin H. Han
- Division of Geriatrics, Gerontology, and Palliative Care, University of California, San Diego, California, USA
| | - Robert M. Arnold
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Emily Dao
- RAND Corporation, Santa Monica, California, USA
| | - Jeni Morrison
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jennifer Kapo
- Palliative Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Diane E. Meier
- Department of Geriatrics and Palliative Medicine, Center to Advance Palliative Care, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Judith A. Paice
- Division Hematology-Oncology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
| | - Jane M. Liebschutz
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Christine S. Ritchie
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jessica S. Merlin
- Challenges in Managing and Preventing Pain Clinical Research Center, Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Hailey W. Bulls
- Challenges in Managing and Preventing Pain Clinical Research Center, Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Gould Rothberg BE, Quest TE, Yeung SCJ, Pelosof LC, Gerber DE, Seltzer JA, Bischof JJ, Thomas CR, Akhter N, Mamtani M, Stutman RE, Baugh CW, Anantharaman V, Pettit NR, Klotz AD, Gibbs MA, Kyriacou DN. Oncologic emergencies and urgencies: A comprehensive review. CA Cancer J Clin 2022; 72:570-593. [PMID: 35653456 DOI: 10.3322/caac.21727] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 02/15/2022] [Accepted: 02/23/2022] [Indexed: 12/12/2022] Open
Abstract
Patients with advanced cancer generate 4 million visits annually to emergency departments (EDs) and other dedicated, high-acuity oncology urgent care centers. Because of both the increasing complexity of systemic treatments overall and the higher rates of active therapy in the geriatric population, many patients experiencing acute decompensations are frail and acutely ill. This article comprehensively reviews the spectrum of oncologic emergencies and urgencies typically encountered in acute care settings. Presentation, underlying etiology, and up-to-date clinical pathways are discussed. Criteria for either a safe discharge to home or a transition of care to the inpatient oncology hospitalist team are emphasized. This review extends beyond familiar conditions such as febrile neutropenia, hypercalcemia, tumor lysis syndrome, malignant spinal cord compression, mechanical bowel obstruction, and breakthrough pain crises to include a broader spectrum of topics encompassing the syndrome of inappropriate antidiuretic hormone secretion, venous thromboembolism and malignant effusions, as well as chemotherapy-induced mucositis, cardiomyopathy, nausea, vomiting, and diarrhea. Emergent and urgent complications associated with targeted therapeutics, including small molecules, naked and drug-conjugated monoclonal antibodies, as well as immune checkpoint inhibitors and chimeric antigen receptor T-cells, are summarized. Finally, strategies for facilitating same-day direct admission to hospice from the ED are discussed. This article not only can serve as a point-of-care reference for the ED physician but also can assist outpatient oncologists as well as inpatient hospitalists in coordinating care around the ED visit.
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Affiliation(s)
- Bonnie E Gould Rothberg
- Yale Cancer Center Innovations Laboratory, Yale Comprehensive Cancer Center, New Haven, Connecticut
| | - Tammie E Quest
- Department of Emergency Medicine, Emory University, Atlanta, Georgia
| | - Sai-Ching J Yeung
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Lorraine C Pelosof
- Office of Oncologic Diseases, US Food and Drug Administration, Silver Spring, Maryland
| | - David E Gerber
- Division of Hematology-Oncology, Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical School, Dallas, Texas
| | - Justin A Seltzer
- Department of Emergency Medicine, University of California San Diego, San Diego, California
| | - Jason J Bischof
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Charles R Thomas
- Department of Radiation Oncology, Geisel School of Medicine at Dartmouth, Norris Cotton Cancer Center, Lebanon, New Hampshire
| | - Nausheen Akhter
- Department of Medicine, Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Mira Mamtani
- Department of Emergency Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Robin E Stutman
- Department of Medicine, Division of Urgent Care Services, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Christopher W Baugh
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Venkataraman Anantharaman
- Department of Emergency Medicine, Singapore General Hospital, SingHealth Duke-National University of Singapore Academic Medical Center, Singapore, Singapore
| | - Nicholas R Pettit
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Adam D Klotz
- Department of Medicine, Division of Urgent Care Services, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Michael A Gibbs
- Department of Emergency Medicine, Atrium Health-Carolinas Medical Center, Charlotte, North Carolina
| | - Demetrios N Kyriacou
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Opioid-Related Side Effects and Management. Cancer Treat Res 2021; 182:97-105. [PMID: 34542878 DOI: 10.1007/978-3-030-81526-4_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The following areas will be discussed in relation to opioid-related side effects and approaches to their management in the cancer patient.
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Kral L, Ku J, Kematick BS, Fudin J. Pearls for opioid use in seriously ill patients. J Pain Palliat Care Pharmacother 2019; 33:54-58. [PMID: 31592735 DOI: 10.1080/15360288.2019.1650870] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
Opioids are often the foundation of pain management in seriously ill patients. Unfortunately, even experienced providers carry with them information that they consider "fact", when this information is not based on scientific evidence, but on "myth". Several topics were elicited based on common beliefs and misconceptions in clinical practice. These were identified via a survey of pharmacist pain and palliative care providers. Pearls from these topics were chosen that were based on evidence and would have the greatest bearing on clinical practice. The pearls address topics such as not using opioids as first-line analgesics for all types of pain, opioid-induced hyperalgesia, opioid risk management in cancer patients, use of buprenorphine in hospice and palliative care settings and use of naloxone in seriously ill patients. The pearls are supported by clinical evidence extracted from several references. They are intended to make readers give thought to opioid therapy which is strictly evidence-based, and not historical or anecdote-based. Practical recommendations are provided to give readers a starting point to base clinical decisions going forward. Readers may discover that "facts" they once learned about opioid use in seriously ill patients are actually "myths" that are a figment of the past.
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Tian C, Wang JY, Wang ML, Jiang B, Zhang LL, Liu F. Morphine versus methylprednisolone or aminophylline for relieving dyspnea in patients with advanced cancer in China: a retrospective study. SPRINGERPLUS 2016; 5:1945. [PMID: 27917339 PMCID: PMC5102996 DOI: 10.1186/s40064-016-3651-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 11/04/2016] [Indexed: 12/12/2022]
Abstract
Context Dyspnea is one of the most common and distressing symptoms that occurs in terminal cancer patients. However, there are no existing treatment guidelines for this condition in China. Objective This single-center, retrospective, observational study aimed to compare the efficacy of using morphine, methylprednisolone, or aminophylline to relieve the symptom of breathlessness in patients with advanced malignant tumors and to investigate the safety of these regimens during the treatment of dyspnea. Methods Between August 2011 and January 2015 we retrospectively reviewed the medical records of 343 terminally ill cancer patients with dyspnea who received morphine, methylprednisolone, or aminophylline. The therapeutic effect of each treatment by means of visual analogue scale (VAS) scores was assessed and compared. Statistical methods included Chi square and analysis of variance tests. Differences were considered significant when P < 0.05. Results VAS scores after treatment were (16.82 ± 10.89), (25.72 ± 15.03), and (31.95 ± 16.00) points in the morphine, methylprednisolone, and aminophylline group, respectively. These differences were found to be significantly different (P < 0.05). The effectiveness ratings were 86.44, 62.16, and 49.12%, respectively (P < 0.05). Conclusions We found that morphine subcutaneous injection for advanced cancer patients with dyspnea was safe and typically more effective than methylprednisolone or aminophylline. Therefore, morphine treatment could significantly improve the quality of life in terminal cancer patients with short life expectancies who are experiencing shortness of breath.
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Affiliation(s)
- Cong Tian
- Department of Medical Oncology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University of Medicine, Shanghai, 201900 China
| | - Jiong-Yi Wang
- Department of Medical Oncology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University of Medicine, Shanghai, 201900 China
| | - Mei-Ling Wang
- Department of Medical Oncology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University of Medicine, Shanghai, 201900 China
| | - Bin Jiang
- Department of Medical Oncology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University of Medicine, Shanghai, 201900 China
| | - Lu-Lu Zhang
- Department of Medical Oncology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University of Medicine, Shanghai, 201900 China
| | - Feng Liu
- Department of Medical Oncology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University of Medicine, Shanghai, 201900 China
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Facey C, Brooks D, Boland JW. Assessment of the appropriateness of naloxone administration to patients receiving long-term opioid therapy. Hosp Pract (1995) 2016; 44:86-91. [PMID: 26837434 DOI: 10.1080/21548331.2016.1149016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND The most dangerous adverse effect of opioids is respiratory depression. Naloxone is used to reverse this, although in patients receiving long-term opioid therapy it can cause acute opioid withdrawal and opioid-refractory pain. OBJECTIVE To determine if naloxone is appropriately administered to patients receiving long-term opioid therapy. METHODS This retrospective case series based on chart reviews systematically identified patients over one year in a district general hospital. All patients aged 18 years or older receiving long-term opioid therapy admitted to medicine, surgery or the high dependency unit who were administered naloxone during their admission were included. RESULTS A total of 1206 patient drug administration records were reviewed. Sixteen patients receiving long-term opioid therapy were administered naloxone. Twelve of these did not have opioid-induced respiratory depression and four did not have respiratory rate and oxygen saturations documented in the medical notes. All naloxone doses administered were higher than those recommended by national guidelines for this patient group. CONCLUSIONS No patient receiving long-term opioid therapy who was administered naloxone had evidence of respiratory depression. More thorough assessment and documentation are needed. Verbal and physical stimulation as well as oxygenation should be considered prior to naloxone administration; this should be followed by close observation, hydration, renal function tests and opioid dose review.
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Affiliation(s)
- Caroline Facey
- a Department of Palliative Medicine , Chesterfield Royal Hospital , Chesterfield , UK
| | - David Brooks
- a Department of Palliative Medicine , Chesterfield Royal Hospital , Chesterfield , UK
| | - Jason W Boland
- b Hull York Medical School , University of Hull , Hull , UK
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