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Winston GM, Zimering JH, Newman CW, Reiner AS, Manalil N, Kharas N, Gulati A, Rakesh N, Laufer I, Bilsky MH, Barzilai O. Safety and Efficacy of Surgical Implantation of Intrathecal Drug Delivery Pumps in Patients With Cancer With Refractory Pain. Neurosurgery 2024:00006123-990000000-01156. [PMID: 38700319 DOI: 10.1227/neu.0000000000002978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 03/12/2024] [Indexed: 05/05/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Pain management in patients with cancer is a critical issue in oncology palliative care as clinicians aim to enhance quality of life and mitigate suffering. Most patients with cancer experience cancer-related pain, and 30%-40% of patients experience intractable pain despite maximal medical therapy. Intrathecal pain pumps (ITPs) have emerged as an option for achieving pain control in patients with cancer. Owing to the potential benefits of ITPs, we sought to study the long-term outcomes of this form of pain management at a cancer center. METHODS We retrospectively reviewed medical records of all adult patients with cancer who underwent ITP placement at a tertiary comprehensive cancer center between 2013 and 2021. Baseline characteristics, preoperative and postoperative pain control, and postoperative complication rate data were collected. RESULTS A total of 193 patients were included. We found that the average Numerical Rating Scale (NRS) score decreased significantly by 4.08 points (SD = 2.13, P < .01), from an average NRS of 7.38 (SD = 1.64) to an average NRS of 3.27 (SD = 1.66). Of 185 patients with preoperative and follow-up NRS pain scores, all but 9 experienced a decrease in NRS (95.1%). The median overall survival from time of pump placement was 3.62 months (95% CI: 2.73-4.54). A total of 42 adverse events in 33 patients were reported during the study period. The 1-year cumulative incidence of any complication was 15.6% (95% CI: 10.9%-21.1%) and for severe complication was 5.7% (95% CI: 3.0%-9.7%). Eleven patients required reoperation during the study period, with a 1-year cumulative incidence of 4.2% (95% CI: 2.0%-7.7%). CONCLUSION Our study demonstrates that ITP implantation for the treatment of cancer-related pain is a safe and effective method of pain palliation with a low complication rate. Future prospective studies are required to determine the optimal timing of ITP implantation.
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Affiliation(s)
- Graham M Winston
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York , New York , USA
| | - Jeffrey H Zimering
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York , New York , USA
- Current affiliation: Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York , New York , USA
| | - Christopher W Newman
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York , New York , USA
| | - Anne S Reiner
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York , New York , USA
| | - Noel Manalil
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York , New York , USA
| | - Natasha Kharas
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York , New York , USA
| | - Amitabh Gulati
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York , New York , USA
| | - Neal Rakesh
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York , New York , USA
| | - Ilya Laufer
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York , New York , USA
- Current affiliation: Department of Neurosurgery, NYU Langone Health, New York , New York , USA
| | - Mark H Bilsky
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York , New York , USA
| | - Ori Barzilai
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York , New York , USA
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2
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Cuomo A. Fentanyl in cancer pain management: avoiding hasty judgments and discerning its potential benefits. Drugs Context 2023; 12:2023-10-2. [PMID: 38148830 PMCID: PMC10751104 DOI: 10.7573/dic.2023-10-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 11/14/2023] [Indexed: 12/28/2023] Open
Abstract
Cancer pain is an important challenge in treatment and requires a rapid onset of action for its control. In particular, breakthrough cancer pain (BTcP) should be adequately controlled with a stable dose of a short-acting oral opioid. Fentanyl is a synthetic, highly selective opioid with many advantageous chemical properties, including high lipophilicity and distinct pharmacokinetic properties. It is recommended for pain management in a variety of settings, including acute pain, chronic pain and BTcP. To date, its variously designed formulations allow non-invasive administration; amongst others, sublingual fentanyl has proven useful in the management of BTcP and in improving the quality of life of patients with cancer. This review provides an update on the management of BTcP with fentanyl, with consideration of safety, as it remains an important tool in the treatment of cancer pain.
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Affiliation(s)
- Arturo Cuomo
- Istituto Nazionale dei Tumori, IRCCS Fondazione G. Pascale, Naples,
Italy
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3
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Párraga JP, Castellanos A. A Manifesto in Defense of Pain Complexity: A Critical Review of Essential Insights in Pain Neuroscience. J Clin Med 2023; 12:7080. [PMID: 38002692 PMCID: PMC10672144 DOI: 10.3390/jcm12227080] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 11/10/2023] [Accepted: 11/10/2023] [Indexed: 11/26/2023] Open
Abstract
Chronic pain has increasingly become a significant health challenge, not just as a symptomatic manifestation but also as a pathological condition with profound socioeconomic implications. Despite the expansion of medical interventions, the prevalence of chronic pain remains remarkably persistent, prompting a turn towards non-pharmacological treatments, such as therapeutic education, exercise, and cognitive-behavioral therapy. With the advent of cognitive neuroscience, pain is often presented as a primary output derived from the brain, aligning with Engel's Biopsychosocial Model that views disease not solely from a biological perspective but also considering psychological and social factors. This paradigm shift brings forward potential misconceptions and over-simplifications. The current review delves into the intricacies of nociception and pain perception. It questions long-standing beliefs like the cerebral-centric view of pain, the forgotten role of the peripheral nervous system in pain chronification, misconceptions around central sensitization syndromes, the controversy about the existence of a dedicated pain neuromatrix, the consciousness of the pain experience, and the possible oversight of factors beyond the nervous system. In re-evaluating these aspects, the review emphasizes the critical need for understanding the complexity of pain, urging the scientific and clinical community to move beyond reductionist perspectives and consider the multifaceted nature of this phenomenon.
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Affiliation(s)
- Javier Picañol Párraga
- Laboratory of Neurophysiology, Biomedicine Department, Faculty of Medicine and Health Sciences, Institute of Neurosciences, University of Barcelona, 08036 Barcelona, Spain
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4
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Owusu-Agyemang P, Feng L, Cata JP. Race, Ethnicity, and Sustained Opioid Use After Major Abdominal Surgery for Cancer. J Pain Res 2023; 16:3759-3774. [PMID: 37954473 PMCID: PMC10638919 DOI: 10.2147/jpr.s427411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 10/30/2023] [Indexed: 11/14/2023] Open
Abstract
Purpose Sustained opioid use is a well-known complication after surgery. Our objective was to determine whether there is any association between a patient's race or ethnicity and the sustained use of opioids in the year following surgery. Opioid use over the initial 3, 6, and 12 postoperative months was categorized as "sustained early", persistent, and chronic, respectively. Patients and Methods Single-institution retrospective study of adults (≥18 years) who had undergone open abdominal surgery for cancer. Multivariable logistic regression was used to evaluate the association between race/ethnicity and opioid use. Results Of the 3523 patients included in the study, 2543 (72.2%) were non-Hispanic (NH) White, 476 (13.5%) were Hispanic or Latino, 262 (7.4%) were NH-Black, 186 (5.3%) were Asian, and 56 (1.6%) belonged to other racial or ethnic groups. The overall rates of sustained early, persistent, and chronic opioid use were 15.9%, 7.1%, and 2.6%, respectively. In the multivariable analysis, patient race/ethnicity was associated with sustained early postoperative opioid use (p-value=0.037), with Hispanics/Latinos having significantly higher odds than NH-Whites (OR = 1.382 [95% CI: 1.057-1.808]; p = 0.018). However, neither persistent nor chronic opioid use was associated with race/ethnicity (p = 0.697 and p = 0.443, respectively). Conclusion In this retrospective study of adults who had undergone open abdominal surgery, patient race/ethnicity was not consistently associated with the development of sustained opioid use over the first 12 postoperative months.
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Affiliation(s)
- Pascal Owusu-Agyemang
- Department of Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Anesthesiology and Surgical Oncology Research Group, Houston, TX, USA
| | - Lei Feng
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Juan P Cata
- Department of Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Anesthesiology and Surgical Oncology Research Group, Houston, TX, USA
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5
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Derricks V, Gainsburg I, Shields C, Fiscella K, Epstein R, Yu V, Griggs JJ. Examining the effects of physician burnout on pain management for patients with advanced lung cancer. Support Care Cancer 2023; 31:469. [PMID: 37458824 DOI: 10.1007/s00520-023-07899-w] [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: 01/11/2023] [Accepted: 06/21/2023] [Indexed: 07/20/2023]
Abstract
PURPOSE Physician burnout is generally associated with worse clinical outcomes. The purpose of this study is to examine the effects of physician burnout on the quality of physicians' pain assessment and opioid prescribing for patients with advanced lung cancer. Moreover, we test whether these relationships are moderated by patient-level factors, such as patient race and activation level, that have a demonstrated impact on clinical encounters. METHODS We conducted a secondary analysis of data from a multisite randomized field experiment. From 2012 to 2016, 96 primary care physicians and oncologists who treated solid tumors were recruited from hospitals and medical sites in three small metropolitan and rural areas in the USA. Physicians saw two unannounced standardized patients who presented with advanced lung cancer. Standardized patients varied across race (Black or White) and activation level (activated, typical). Visits were audio recorded and transcribed. Pain management was evaluated by the quality of pain assessment and opioid prescribing during these visits. RESULTS Mixed-effects linear regression and generalized mixed-effects modeling showed that higher levels of burnout were associated with a greater likelihood of prescribing an opioid and prescribing stronger opioid doses for patients. These effects were not moderated by patient race or activation level. CONCLUSION Findings from this work inform our understanding of physician-level factors that impact clinical decision-making in the context of cancer pain management. Specifically, this study identifies the role of physician burnout on the quality of prescribing for patients with advanced lung cancer.
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Affiliation(s)
- Veronica Derricks
- Department of Psychology, Indiana University-Purdue University Indianapolis, 402 N Blackford St., Indianapolis, IN, 46202, USA.
- Department of Psychology, University of Michigan, Ann Arbor, MI, USA.
| | - Izzy Gainsburg
- Department of Psychology, University of Michigan, Ann Arbor, MI, USA
- Ross School of Business, University of Michigan, Ann Arbor, MI, USA
- John F. Kennedy School of Government, Harvard University, Cambridge, MA, USA
| | - Cleveland Shields
- Human Development & Family Studies, Purdue University, West Lafayette, IN, USA
| | - Kevin Fiscella
- Department of Family Medicine, University of Rochester School of Medicine, Rochester, NY, USA
| | - Ronald Epstein
- Department of Family Medicine, University of Rochester School of Medicine, Rochester, NY, USA
| | - Veronica Yu
- Department of Family Medicine, University of Rochester School of Medicine, Rochester, NY, USA
| | - Jennifer J Griggs
- Division of Hematology and Oncology, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor, MI, USA
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
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Buskbjerg C, O'Toole MS, Zachariae R, Jensen AB, Frederiksen Y, Johansen C, von Heymann A, Speckens A, Johannsen M. Optimising psychological treatment for pain after breast cancer: a factorial design study protocol in Denmark. BMJ Open 2023; 13:e066505. [PMID: 36948567 PMCID: PMC10040060 DOI: 10.1136/bmjopen-2022-066505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/24/2023] Open
Abstract
INTRODUCTION One in five breast cancer (BC) survivors are affected by persistent pain years after completing primary treatment. While the efficacy of psychological interventions for BC-related pain has been documented in several meta-analyses, reported effect sizes are generally modest, pointing to a need for optimisation. Guided by the Multiphase Optimization Strategy, the present study aims to optimise psychological treatment for BC-related pain by identifying active treatment components in a full factorial design. METHODS AND ANALYSIS The study uses a 2×3 factorial design, randomising 192 women with BC-related pain (18-75 years) to eight experimental conditions. The eight conditions consist of three contemporary cognitive-behavioural therapy components, namely: (1) mindful attention, (2) decentring, and (3) values and committed action. Each component is delivered in two sessions, and each participant will receive either zero, two, four or six sessions. Participants receiving two or three treatment components will be randomised to receive them in varying order. Assessments will be conducted at baseline (T1), session by session, every day for 6 days following the first session in each treatment component, at post-intervention (T2) and at 12-week follow-up (T3). Primary outcomes are pain intensity (Numerical Rating Scale) and pain interference (Brief Pain Inventory interference subscale) from T1 to T2. Secondary outcomes are pain burden, pain quality, pain frequency, pain catastrophising, psychological distress, well-being and fear of cancer recurrence. Possible mediators include mindful attention, decentring, and pain acceptance and activity engagement. Possible moderators are treatment expectancy, treatment adherence, satisfaction with treatment and therapeutic alliance. ETHICS AND DISSEMINATION Ethical approval for the present study was received from the Central Denmark Region Committee on Health Research Ethics (no: 1-10-72-309-40). Findings will be made available to the study funders, care providers, patient organisations and other researchers at international conferences, and published in international, peer-reviewed journals. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Registry (NCT05444101).
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Affiliation(s)
- Cecilie Buskbjerg
- Department of Psychology and Behavioural Sciences, Aarhus University, Aarhus, Denmark
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Mia Skytte O'Toole
- Department of Psychology and Behavioural Sciences, Aarhus University, Aarhus, Denmark
| | - Robert Zachariae
- Department of Psychology and Behavioural Sciences, Aarhus University, Aarhus, Denmark
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Yoon Frederiksen
- Deparment of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
- The Sexology Unit, Aarhus University Hospital Psychiatry, Aarhus, Denmark
| | - Christoffer Johansen
- CASTLE Cancer Late Effects Research Unit, Department of Oncology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Annika von Heymann
- CASTLE Cancer Late Effects Research Unit, Department of Oncology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Anne Speckens
- Department of Psychiatry, Centre for Mindfulness, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Maja Johannsen
- Department of Psychology and Behavioural Sciences, Aarhus University, Aarhus, Denmark
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
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7
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Iezzi R, Kovács G, Dimov V, Contegiacomo A, Posa A, Efthymiou E, Lancellotta V, Rodolfino E, Punzi E, Trajkovski ZB, Valentini V, Manfredi R, Filippiadis D. Multimodal locoregional procedures for cancer pain management: a literature review. Br J Radiol 2023; 96:20220236. [PMID: 36318237 PMCID: PMC9975366 DOI: 10.1259/bjr.20220236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 10/18/2022] [Accepted: 10/21/2022] [Indexed: 11/27/2022] Open
Abstract
Pain is the most common and fearsome symptom in cancer patients, particularly in the advanced stage of disease. In cancer pain management, the first option is represented by analgesic drugs, whereas surgery is rarely used. Prior to considering surgical intervention, less invasive locoregional procedures are available from the wide pain management arsenal. In this review article, comprehensive information about the most commonly used locoregional options available for treating cancer pain focusing on interventional radiology (neurolysis, augmentation techniques, and embolization) and interventional radiotherapy were provided, also highlighting the potential ways to increase the effectiveness of treatments.
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Affiliation(s)
| | - György Kovács
- Università Cattolica del Sacro Cuore, Gemelli-INTERACTS, Rome, Italy
| | - Vladimir Dimov
- Acibadem Sistina Hospital Skopje, Skopje, North Macedonia
| | - Andrea Contegiacomo
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia - Istituto di Radiologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Alessandro Posa
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia - Istituto di Radiologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | | | - Valentina Lancellotta
- UOC Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Roma, Italy
| | - Elena Rodolfino
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia - Istituto di Radiologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
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8
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Hu X, Kaplan CM, Martin MY, Walker MS, Stepanski E, Schwartzberg LS, Vidal GA, Graetz I. Race Differences in Patient-Reported Symptoms during Chemotherapy among Women with Early-Stage Hormone Receptor-Positive Breast Cancer. Cancer Epidemiol Biomarkers Prev 2023; 32:167-174. [PMID: 36166516 PMCID: PMC9905215 DOI: 10.1158/1055-9965.epi-22-0692] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 08/22/2022] [Accepted: 09/20/2022] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Symptom burden differences may contribute to racial disparities in breast cancer survival. We compared symptom changes from before to during chemotherapy among women with breast cancer. METHODS This observational study followed a cohort of Black and White women diagnosed with Stage I-III, hormone receptor-positive breast cancer from a large cancer center in 2007 to 2015, and reported symptoms before and during chemotherapy. We identified patients who experienced a one-standard deviation (SD) increase in symptom burden after starting chemotherapy using four validated composite scores (General Physical Symptoms, Treatment Side Effects, Acute Distress, and Despair). Kitagawa-Blinder-Oaxaca decomposition was used to quantify race differences in symptom changes explained by baseline characteristics (sociodemographic, baseline scores, cancer stage) and first-line chemotherapy regimens. RESULTS Among 1,273 patients, Black women (n = 405, 31.8%) were more likely to report one-SD increase in General Physical Symptoms (55.6% vs. 48.2%, P = 0.015), Treatment Side Effects (74.0% vs. 63.4%, P < 0.001), and Acute Distress (27.4% vs. 20.0%, P = 0.010) than White women. Baseline characteristics and first-line chemotherapy regimens explained a large and significant proportion of the difference in Acute Distress changes (93.7%, P = 0.001), but not General Physical Symptoms (25.7%, P = 0.25) or Treatment Side Effects (16.4%, P = 0.28). CONCLUSIONS Black women with early-stage breast cancer were more likely to experience significant increases in physical and psychological symptom burden during chemotherapy. Most of the difference in physical symptom changes remained unexplained by baseline characteristics, which suggests inadequate symptom management among Black women. IMPACT Future studies should identify strategies to improve symptom management among Black women and reduce differences in symptom burden. See related commentary by Rosenzweig and Mazanec, p. 157.
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Affiliation(s)
- Xin Hu
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Cameron M Kaplan
- Gehr Family Center for Health Systems Science and Innovation, Keck School of Medicine of USC, Los Angeles, California
| | - Michelle Y Martin
- Center for Innovation in Health Equity Research, Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | | | | | | | - Gregory A Vidal
- West Cancer Center and Research Institute, Germantown, Tennessee.,School of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Ilana Graetz
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, Georgia
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9
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LeBaron V, Homdee N, Ogunjirin E, Patel N, Blackhall L, Lach J. Describing and visualizing the patient and caregiver experience of cancer pain in the home context using ecological momentary assessments. Digit Health 2023; 9:20552076231194936. [PMID: 37654707 PMCID: PMC10467200 DOI: 10.1177/20552076231194936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 07/28/2023] [Indexed: 09/02/2023] Open
Abstract
Background Pain continues to be a difficult and pervasive problem for patients with cancer, and those who care for them. Remote health monitoring systems (RHMS), such as the Behavioral and Environmental Sensing and Intervention for Cancer (BESI-C), can utilize Ecological Momentary Assessments (EMAs) to provide a more holistic understanding of the patient and family experience of cancer pain within the home context. Methods Participants used the BESI-C system for 2-weeks which collected data via EMAs deployed on wearable devices (smartwatches) worn by both patients with cancer and their primary family caregiver. We developed three unique EMA schemas that allowed patients and caregivers to describe patient pain events and perceived impact on quality of life from their own perspective. EMA data were analyzed to provide a descriptive summary of pain events and explore different types of data visualizations. Results Data were collected from five (n = 5) patient-caregiver dyads (total 10 individual participants, 5 patients, 5 caregivers). A total of 283 user-initiated pain event EMAs were recorded (198 by patients; 85 by caregivers) over all 5 deployments with an average severity score of 5.4/10 for patients and 4.6/10 for caregivers' assessments of patient pain. Average self-reported overall distress and pain interference levels (1 = least distress; 4 = most distress) were higher for caregivers (x ¯ 3.02, x ¯ 2.60 , respectively ) compared to patients (x ¯ 2.82, x ¯ 2.25, respectively) while perceived burden of partner distress was higher for patients (i.e., patients perceived caregivers to be more distressed, x ¯ 3.21, than caregivers perceived patients to be distressed, x ¯ 2.55 ). Data visualizations were created using time wheels, bubble charts, box plots and line graphs to graphically represent EMA findings. Conclusion Collecting data via EMAs is a viable RHMS strategy to capture longitudinal cancer pain event data from patients and caregivers that can inform personalized pain management and distress-alleviating interventions.
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Affiliation(s)
- Virginia LeBaron
- University of Virginia School of Nursing, Charlottesville, VA, USA
| | - Nutta Homdee
- Center for Research Innovation and Biomedical Informatics, Faculty of Medical Technology, Mahidol University, Nakhon Pathom, Thailand
| | - Emmanuel Ogunjirin
- University of Virginia School of Engineering & Applied Science, Charlottesville, VA, USA
| | - Nyota Patel
- University of Virginia School of Engineering & Applied Science, Charlottesville, VA, USA
| | - Leslie Blackhall
- University of Virginia School of Medicine, Charlottesville, VA, USA
| | - John Lach
- The George Washington University School of Engineering & Applied Science, Washington, DC, USA
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10
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A nationwide study on consumption of opioid analgesics in Iran from 2000 to 2018. Int J Clin Pharm 2022; 45:397-405. [PMID: 36469216 DOI: 10.1007/s11096-022-01518-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Accepted: 11/01/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND Opioid analgesics play a unique role in pain management. National opioid consumption studies could provide indirect evidence of pain management in a country. National, regional, and global opioid consumption have been studied in other countries so far; however, conducting a focused study to illuminate the consumption of opioid analgesics over the past decades in Iran seemed necessary. AIM The main objective of this study was to determine the consumption of opioid analgesics and explore the trend of their use during 19 years in Iran. METHOD Iran pharmaceutical wholesale data were used to extract the annual consumption figures of the opioid analgesics in group N02A of the World Health Organization (WHO) Anatomical Therapeutic Chemical classification and were available in Iran (morphine, fentanyl, pethidine, and oxycodone as strong opioids and, tramadol and pentazocine as weak opioids), from 2000 to 2018. Using Defined Daily Dose (DDD) by WHO and Oral Morphine Equivalent (OMEQ), the amount of annual consumption was determined in DDD/1000 inhabitants/Day (DID) and OMEQ (mg)/1000 inhabitants/Day (OID). RESULTS Total opioid analgesic utilization based on DID and OID increased 31.12-fold (from 0.0196 to 0.61) and 21.06-fold (from 1.97 to 41.5 mg) over 19 years, respectively with a significant sharp increase from 2003 to 2006 (ß = 1.78 (DID), P value < 0.001). Medications that constituted 70% of annual opioid analgesics utilization were morphine in 2000, compared to tramadol in 2018. The annual weak and strong opioids share were 86.7% and 13.2% in 2018, respectively. CONCLUSION Despite considerable growth in the consumption of opioid analgesics in Iran over nearly two decades, the consumption amount remained low, which might signal sub-optimal pain management. On the other hand, misuse and abuse seem to be the main reason behind significant increases in the consumption of opioid analgesics with less controlled distribution.
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11
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Fang R, Zhang R, Hosseini E, Orooji M, Homayoun H, Hosseini SM, Faghih M, Rafatirad S, Rafatirad S. ATLAS: An Adaptive Transfer Learning Based Pain Assessment System: A Real Life Unsupervised Pain Assessment Solution. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2022; 2022:1331-1337. [PMID: 36085672 DOI: 10.1109/embc48229.2022.9871536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Undertreatment or overtreatment of pain will cause severe consequences physiologically and psychologically. Thus, researchers have made great efforts to develop automatic pain assessment approaches based on physiological signals using machine learning techniques. However, state-of-art research mainly focuses on verifying the hypothesis that physiological signals can be used to assess pain. The critical assumption of these studies is that training data and testing data have the same distribution. However, this assumption may not hold in reallife scenarios, for instance, the adoption of machine learning model by a new patient. Such real-life scenarios in which user's data is unlabeled is largely neglected in literature. This study compensates for the rift by proposing an adaptive transfer learning based pain assessment system (ATLAS), a novel adaptive learning system based on the transfer learning algorithm Transfer Components Analysis (TCA) to minimize the distance between training data and unlabeled testing data. Experiments were conducted on BioVid database, and the results showed our approach outperforms three existing traditional machine learning-based approaches and achieves an accuracy just 2.0% below the accuracy with labeled data.
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12
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Gilley DR, Clark AD, Wieser ME, Bollig CA, Dooley LM, Biedermann GB. Effectiveness of gabapentin in reducing opioid requirements after radiation in head and neck cancer in a single institution. Head Neck 2022; 44:1368-1376. [PMID: 35315549 DOI: 10.1002/hed.27035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Revised: 02/03/2022] [Accepted: 03/09/2022] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Gabapentin has been shown to reduce opioid use in head and neck cancer patients. Here, we examine the efficacy of prophylactic gabapentin at reducing opioid use in these patients at our institution. METHODS A retrospective study of patients receiving radiation was performed, using patients from our previous study as controls. Risk factors for opioid use at 3 and 6 months were determined using univariate and multivariate analyses. RESULTS In total, 53/185 patients were treated with gabapentin, 39.6% of which took opioids at 3 months vs. 58.3% in the non-gabapentin cohort (p = 0.021). Gabapentin was independently associated with less opioid use on multivariate analysis at 3 months (OR 0.47, 95% CI 0.24-0.9). Gastrostomy tube dependence and pretreatment opioid use were associated with chronic opioid use despite gabapentin. CONCLUSIONS Gabapentin is effective at expediting opioid tapering in head and neck cancer patients who are not gastrostomy tube dependent or taking opioids pretreatment.
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Affiliation(s)
- David R Gilley
- Department of Otolaryngology-Head and Neck Surgery, University of Missouri School of Medicine, Columbia, Missouri, USA
| | - Andrew D Clark
- Department of General Surgery, University of Missouri School of Medicine, Columbia, Missouri, USA
| | - Maggie E Wieser
- Degree Program, University of Missouri School of Medicine, Columbia, Missouri, USA
| | - Craig A Bollig
- Department of Otolaryngology-Head and Neck Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Laura M Dooley
- Department of Otolaryngology-Head and Neck Surgery, University of Missouri School of Medicine, Columbia, Missouri, USA
| | - Gregory B Biedermann
- Department of Radiology, Division of Radiation Oncology, Ellis Fischel Cancer Center, University of Missouri School of Medicine, Columbia, Missouri, USA
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13
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LeBaron V, Boukhechba M, Edwards J, Flickinger T, Ling D, Barnes LE. Exploring the use of wearable sensors and natural language processing technology to improve patient-clinician communication: Protocol for a feasibility study (Preprint). JMIR Res Protoc 2022; 11:e37975. [PMID: 35594139 PMCID: PMC9166632 DOI: 10.2196/37975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 03/24/2022] [Accepted: 03/30/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
- Virginia LeBaron
- School of Nursing, University of Virginia, Charlottesville, VA, United States
| | - Mehdi Boukhechba
- School of Engineering & Applied Science, University of Virginia, Charlottesville, VA, United States
| | - James Edwards
- School of Nursing, University of Virginia, Charlottesville, VA, United States
| | - Tabor Flickinger
- School of Medicine, University of Virginia, Charlottesville, VA, United States
| | - David Ling
- School of Medicine, University of Virginia, Charlottesville, VA, United States
| | - Laura E Barnes
- School of Engineering & Applied Science, University of Virginia, Charlottesville, VA, United States
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14
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Melucci AD, Lynch OF, Wright MJ, Baran A, Temple LK, Poles GC, Moalem J. Evaluating Age as a Predictor of Postoperative Opioid Use and Prescribing Habits in Older Adults With Cancer. J Am Med Dir Assoc 2022; 23:678-683.e1. [PMID: 35247360 DOI: 10.1016/j.jamda.2022.01.081] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 01/23/2022] [Accepted: 01/29/2022] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To assess the narcotic use of older patients after oncologic resection. DESIGN Retrospective review. SETTING AND PARTICIPANTS Adults with neoplasms undergoing resection at a tertiary academic medical center. METHODS Open and minimally invasive resections of the pancreas, bowel, rectum, lung, breast, and skin were included. Emergent procedures, chronic opioid users, and benign pathology were excluded. Narcotic use was measured using morphine equivalents (MEQs, milligrams of morphine) at multiple time points and compared between younger and older (aged ≥65 years) patients. Refill requests were within 30 days of index procedure. RESULTS A total of 445 patients were eligible, and 245 were ≥65 years old. Despite longer length of stay (3 vs 2 days, P = .01), older patients used less narcotic medication [39.8 (150) mg vs 84 (229) mg, P = .004], and reported lower pain scores [1.3 (3.3) vs 2.8 (4.5), P = .0001] over the course of their hospitalization. Additionally, older patients had lower normalized narcotic use [15.3 (150) mg vs 77.4 (240) mg, P = .0001] in the last 48 hours of their admission. Following discharge, older patients had a lower median discharge MEQ (DC MEQ) compared with younger patients, 75 (150) mg vs 112.5 (102.5) mg, P = .002. Further stratifying older patients into age cohorts (65-74 years, 75-84 years, ≥85 years) revealed progressively less narcotic use as measured by total inpatient MEQ and final 48 hours. Additionally, progressively older patients were discharged with progressively lower DC MEQ compared with younger patients, 90 (112.5) mg, 50 (131.3) mg, and 0 (60) mg vs 112.5 (102.5) mg, P < .0001, respectively. Finally, older patients requested refills less often than younger counterparts, 6.5% vs 14.5%, P = .006. CONCLUSIONS AND IMPLICATIONS Older patients with cancer reported lower pain scores, consumed less narcotics, were discharged with significantly less narcotics, and called for refills less often compared with younger patients after surgery. These data suggest this population may require less opioids for satisfactory pain control, and development of a guideline targeting postoperative multimodal analgesia in older adults is warranted.
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Affiliation(s)
- Alexa D Melucci
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA.
| | - Olivia F Lynch
- University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Michael J Wright
- University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Andrea Baran
- James P Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY, USA
| | - Larissa K Temple
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Gabriela C Poles
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Jacob Moalem
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
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15
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Vitzthum LK, Nalawade V, Riviere P, Marar M, Furnish T, Lin LA, Thompson R, Murphy JD. Impacts of an Opioid Safety Initiative on US Veterans Undergoing Cancer Treatment. J Natl Cancer Inst 2022; 114:753-760. [PMID: 35078240 PMCID: PMC9086780 DOI: 10.1093/jnci/djac017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 12/10/2021] [Accepted: 01/18/2022] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND There is limited research on how the opioid epidemic and consequent risk reduction policies have affected pain management among cancer patients. The purpose of this study was to analyze how the Opioid Safety Initiative (OSI) implemented at the Veterans Health Administration affected opioid prescribing patterns and opioid-related toxicity. METHODS We performed an interrupted time series analysis of 42 064 opioid-naïve patients treated at the Veterans Health Administration for prostate, lung, breast, and colorectal cancer from 2011 to 2016. Segmented regression was used to evaluate the impact of the OSI on the incidence of any new opioid prescriptions, high-risk prescriptions, persistent use, and pain-related emergency department (ED) visits. We compared the cumulative incidence of adverse opioid events including an opioid-related admission or diagnosis of misuse before and after the OSI. All statistical tests were 2-sided. RESULTS The incidence of new opioid prescriptions was 26.7% (95% confidence interval [CI] = 25.0% to 28.4%) in 2011 and increased to 50.6% (95% CI = 48.3% to 53.0%) by 2013 before OSI implementation (monthly rate of change: +3.3%, 95% CI = 1.3% to 4.2%, P < .001). After the OSI, there was a decrease in the monthly rate of change for new prescriptions (-3.4%, 95% CI = -3.9 to -2.9%, P < .001). The implementation of the OSI was associated with a decrease in the monthly rate of change of concomitant benzodiazepines and opioid prescriptions (-2.5%, 95% CI = -3.2% to -1.8%, P < .001), no statistically significant change in high-dose opioids (-1.2%, 95% CI = -3.2% to 0.9%, P = .26), a decrease in persistent opioid use (-5.7%, 95% CI = -6.8% to -4.7%, P < .001), and an increase in pain-related ED visits (+3.0%, 95% CI = 1.0% to 5.0%, P = .003). The OSI was associated with a decreased incidence of opioid-related admissions (3-year cumulative incidence: 0.9% [95% CI = 0.7% to 1.0%] vs 0.5% [95% CI = 0.4% to 0.6%], P < .001) and no statistically significant change in the incidence of opioid misuse (3-year cumulative incidence: 1.2% [95% CI = 1.0% to 1.3%] vs 1.2% [95% CI = 1.1% to 1.4%], P = .77). CONCLUSIONS The OSI was associated with a relative decline in the rate of new, persistent, and certain high-risk opioid prescribing as well as a slight increase in the rate of pain-related ED visits. Further research on patient-centered outcomes is required to optimize opioid prescribing policies for patients with cancer.
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Affiliation(s)
- Lucas K Vitzthum
- Correspondence to: Lucas K. Vitzthum, MD, MAS, Department of Radiation Oncology, Stanford University, 875 Blake Wilbur Dr, Stanford, CA 94305, USA (e-mail: )
| | - Vinit Nalawade
- Office of Research and Development, Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA, USA
| | - Paul Riviere
- Office of Research and Development, Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA, USA,San Diego Veterans Affairs Medical Center, La Jolla, CA, USA
| | - Mallika Marar
- Department of Radiation Oncology, Stanford University, Stanford, CA, USA
| | - Timothy Furnish
- Division of Pain Medicine, Department of Internal Medicine, University of California San Diego, La Jolla, CA, USA
| | - Lewei A Lin
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System and Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA,Addiction Center and Mental Health Innovations, Services and Outcomes Program, Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Reid Thompson
- Department of Radiation Medicine, Oregon Health and Sciences University, Portland, OR, USA,Office of Research and Development, Portland Veterans Affairs Medical Center, Portland, OR, USA
| | - James D Murphy
- Office of Research and Development, Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA, USA,San Diego Veterans Affairs Medical Center, La Jolla, CA, USA
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16
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Higami Y, Higuchi A, Tanaka H, Moriki Y, Utsumi M, Yamakawa M, Ito Y, Hatano Y, Maeda I, Fukui S. Nonwearable actigraphy to assess changes in motor activity before and after rescue analgesia in terminally ill patients with cancer: A pilot study. Int J Nurs Pract 2021; 28:e13019. [PMID: 34651388 DOI: 10.1111/ijn.13019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 05/16/2021] [Accepted: 09/17/2021] [Indexed: 11/28/2022]
Abstract
AIMS This study aimed to investigate the usefulness of nonwearable actigraphy to assess changes in motor activity before and after rescue analgesic administration in terminally ill cancer patients. BACKGROUND Evaluating pain in terminally ill cancer patients is difficult; pain assessment tools are needed. METHODS This was an exploratory descriptive study conducted within a palliative care unit. A nonwearable actigraph was used to measure the activity score and movement index of terminally ill patients with weeks-long prognosis and pain. The actigraph and medical data were integrated, and data were compared 6 h before and after rescue analgesic administration. RESULTS Among 10 patients (age: 75.8 ± 12.3 years; six men), we evaluated 28 pain episodes (mean activity score: 130.9 ± 180.5 counts per minute; movement index: 68.8%). When pain was relieved at night following rescue analgesic administration, activity score and movement index decreased significantly (6 h before vs. 6 h after analgesics, respectively: 113.1 to 69.7 counts per minute; 64.3% to 41.8%; both p < 0.0001). With no relief after rescue analgesic administration, activity score did not differ significantly 6 h before and after analgesics: 147.3 to 137.7 counts per minute. CONCLUSION Pain in terminally ill cancer patients could be assessed using a nonwearable actigraph to capture motor activity and improve pain assessment.
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Affiliation(s)
- Yoko Higami
- Department of Nursing, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| | - Akarai Higuchi
- Department of Human Health Sciences, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Haruka Tanaka
- Department of Health Sciences, Graduate School of Medicine, Nagoya University, Nagoya, Aichi, Japan
| | - Yuki Moriki
- Department of Health Sciences, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Momoe Utsumi
- Department of Health Sciences, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Miyae Yamakawa
- Department of Health Sciences, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Yuri Ito
- Department of Medical Statistics, Research & Development Center, Osaka Medical and Pharmaceutical University, Takatsuki, Japan
| | - Yutaka Hatano
- Department of Palliative Care, Daini Kyoritsu Hospital, Kawanishi, Hyogo, Japan
| | - Isseki Maeda
- Department of Palliative Care, Senri-chuo Hospital, Toyonaka, Osaka, Japan
| | - Sakiko Fukui
- Department of Health Sciences, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan.,Department of Health Sciences, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
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17
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Yu W, Li D, Lu Y, Yang H, Ma X. Knowledge and Attitudes of Chinese Oncology Nurses Regarding Cancer Pain Management-a Cross-Sectional Study. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2021; 36:1115-1123. [PMID: 32318978 DOI: 10.1007/s13187-020-01743-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
OBJECTIVE To measure the knowledge and attitudes of Chinese oncology nurses regarding cancer pain management and explore related factors. METHODS A cross-sectional survey was conducted. A convenience sample of 505 Chinese oncology nurses from 20 provinces, 4 municipalities, and 4 autonomous regions was recruited between April and October 2018. A Chinese version of the Knowledge and Attitudes Survey Regarding Pain (KASRP) was used. Socio-demographic characteristics were also measured by a multi-item questionnaire. RESULTS The mean accuracy of KASRP in all participants was 56.11% ± 11.05%. According to univariate analysis, oncology nurses' cancer pain knowledge and attitudes were positively correlated with age, region, education level, years of oncology nursing, clinical practice of cancer pain management, average monthly number of patients with cancer pain, and the experience of cancer pain-related training. The results of multiple linear regression revealed that nurses' age, education level, experience of cancer pain-related training and clinical practice of cancer pain management were independent influencing factors (all p < 0.05). CONCLUSIONS Most Chinese oncology nurses had misconceptions about cancer pain management and lacked relevant knowledge. We should assign importance to targeted cancer pain training and develop training methods that closely relate to clinical practices.
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Affiliation(s)
- Wenhua Yu
- Nursing Department, Key laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital & Institute, 52 Fucheng road, Haidian district, Beijing, 100142, China
| | - Dan Li
- Department of Radiotherapy, The Fifth Medical Center, PLA General Hospital, 100 West Fourth Ring Road, Fengtai District, Beijing, 100039, China
| | - Yuhan Lu
- Nursing Department, Key laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital & Institute, 52 Fucheng road, Haidian district, Beijing, 100142, China.
| | - Hong Yang
- Nursing Department, Key laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital & Institute, 52 Fucheng road, Haidian district, Beijing, 100142, China
| | - Xiaoxiao Ma
- Nursing Department, Key laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital & Institute, 52 Fucheng road, Haidian district, Beijing, 100142, China
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18
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Dupoiron D. Cancer Pain Management-A European Perspective. Cancer Treat Res 2021; 182:39-55. [PMID: 34542875 DOI: 10.1007/978-3-030-81526-4_4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Cancer pain management is a major challenge in both Europe and the United States. Recent studies show that the incidence of cancer pain remains high and even increases at an advanced stage of the disease.
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Affiliation(s)
- Denis Dupoiron
- Anesthesia and Pain Department, Institut de Cancérologie de l'Ouest, Rue Boquel, 49055, Angers, France.
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19
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Vitzthum LK, Riviere P, Sheridan P, Nalawade V, Deka R, Furnish T, Mell LK, Rose B, Wallace M, Murphy JD. Predicting Persistent Opioid Use, Abuse, and Toxicity Among Cancer Survivors. J Natl Cancer Inst 2021; 112:720-727. [PMID: 31754696 DOI: 10.1093/jnci/djz200] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 09/08/2019] [Accepted: 09/27/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Although opioids play a critical role in the management of cancer pain, the ongoing opioid epidemic has raised concerns regarding their persistent use and abuse. We lack data-driven tools in oncology to understand the risk of adverse opioid-related outcomes. This project seeks to identify clinical risk factors and create a risk score to help identify patients at risk of persistent opioid use and abuse. METHODS Within a cohort of 106 732 military veteran cancer survivors diagnosed between 2000 and 2015, we determined rates of persistent posttreatment opioid use, diagnoses of opioid abuse or dependence, and admissions for opioid toxicity. A multivariable logistic regression model was used to identify patient, cancer, and treatment risk factors associated with adverse opioid-related outcomes. Predictive risk models were developed and validated using a least absolute shrinkage and selection operator regression technique. RESULTS The rate of persistent opioid use in cancer survivors was 8.3% (95% CI = 8.1% to 8.4%); the rate of opioid abuse or dependence was 2.9% (95% CI = 2.8% to 3.0%); and the rate of opioid-related admissions was 2.1% (95% CI = 2.0% to 2.2%). On multivariable analysis, several patient, demographic, and cancer and treatment factors were associated with risk of persistent opioid use. Predictive models showed a high level of discrimination when identifying individuals at risk of adverse opioid-related outcomes including persistent opioid use (area under the curve [AUC] = 0.85), future diagnoses of opioid abuse or dependence (AUC = 0.87), and admission for opioid abuse or toxicity (AUC = 0.78). CONCLUSION This study demonstrates the potential to predict adverse opioid-related outcomes among cancer survivors. With further validation, personalized risk-stratification approaches could guide management when prescribing opioids in cancer patients.
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Affiliation(s)
- Lucas K Vitzthum
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA.,Center for Precision Radiation Medicine, University of California San Diego, La Jolla, CA
| | - Paul Riviere
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA
| | - Paige Sheridan
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA
| | - Vinit Nalawade
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA
| | - Rishi Deka
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA
| | - Timothy Furnish
- Department of Family Medicine and Public Health and Division of Pain Medicine, Department of Internal Medicine, University of California San Diego, La Jolla, CA
| | - Loren K Mell
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA.,Center for Precision Radiation Medicine, University of California San Diego, La Jolla, CA
| | - Brent Rose
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA.,Center for Precision Radiation Medicine, University of California San Diego, La Jolla, CA
| | | | - James D Murphy
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA.,Center for Precision Radiation Medicine, University of California San Diego, La Jolla, CA
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20
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Riviere P, Vitzthum LK, Nalawade V, Deka R, Furnish T, Mell LK, Rose BS, Wallace M, Murphy JD. Validation of an oncology-specific opioid risk calculator in cancer survivors. Cancer 2020; 127:1529-1535. [PMID: 33378556 DOI: 10.1002/cncr.33410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 10/19/2020] [Accepted: 11/25/2020] [Indexed: 11/06/2022]
Abstract
BACKGROUND Clinical guidelines recommend that providers risk-stratify patients with cancer before prescribing opioids. Prior research has demonstrated that a simple cancer opioid risk score might help identify to patients with cancer at the time of diagnosis with a high likelihood of long-term posttreatment opioid use. This current project validates this cancer opioid risk score in a generalizable, population-based cohort of elderly cancer survivors. METHODS This study identified 44,932 Medicare beneficiaries with cancer who had received local therapy. Longitudinal opioid use was ascertained from Medicare Part D data. A risk score was calculated for each patient, and patients were categorized into low-, moderate-, and high-risk groups on the basis of the predicted probability of persistent opioid use. Model discrimination was assessed with receiver operating characteristic curves. RESULTS In the study cohort, 5.2% of the patients were chronic opioid users 1 to 2 years after the initiation of cancer treatment. The majority of the patients (64%) were at low risk and had a 1.2% probability of long-term opioid use. Moderate-risk patients (33% of the cohort) had a 5.6% probability of long-term opioid use. High-risk patients (3.5% of the cohort) had a 75% probability of long-term opioid use. The opioid risk score had an area under the receiver operating characteristic curve of 0.869. CONCLUSIONS This study found that a cancer opioid risk score could accurately identify individuals with a high likelihood of long-term opioid use in a large, generalizable cohort of cancer survivors. Future research should focus on the implementation of these scores into clinical practice and how this could affect prescriber behavior and patient outcomes. LAY SUMMARY A novel 5-question clinical decision tool allows physicians treating patients with cancer to accurately predict which patients will persistently be using opioid medications after completing therapy.
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Affiliation(s)
- Paul Riviere
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California
| | - Lucas K Vitzthum
- Department of Radiation Oncology, Stanford Medicine, Stanford, California
| | - Vinit Nalawade
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California
| | - Rishi Deka
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California
| | - Timothy Furnish
- Division of Pain Medicine, Department of Anesthesiology, University of California San Diego, La Jolla, California
| | - Loren K Mell
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California.,Center for Precision Radiation Medicine, University of California San Diego, La Jolla, California
| | - Brent S Rose
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California.,Center for Precision Radiation Medicine, University of California San Diego, La Jolla, California
| | - Mark Wallace
- Division of Pain Medicine, Department of Anesthesiology, University of California San Diego, La Jolla, California
| | - James D Murphy
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California.,Center for Precision Radiation Medicine, University of California San Diego, La Jolla, California
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21
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Brown JH, Torres HP, Maddi RD, Williams JL, Dibaj SS, Liu D, Bruera E. Cancer Patients' Perceived Difficulties Filling Opioid Prescriptions After Receiving Outpatient Supportive Care. J Pain Symptom Manage 2020; 60:915-922. [PMID: 32569832 PMCID: PMC7305512 DOI: 10.1016/j.jpainsymman.2020.06.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 06/09/2020] [Accepted: 06/11/2020] [Indexed: 11/16/2022]
Abstract
CONTEXT Limited access to opioids for patients with cancer has been reported as a potential unintended consequence of recent regulations restricting opioid use and prescribing practices. To our knowledge, there are a limited number of peer-reviewed studies that evaluate the perceived difficulties of the patients with cancer when filling their opioid prescription. To understand these difficulties, we surveyed patients receiving opioids in our outpatient supportive care center (SCC). OBJECTIVES The primary objective of this study was to evaluate cancer patients' perceptions of overall difficulties when filling their opioid prescription. Secondary objectives included determining associations between patient characteristics and difficulty and comparing difficulty between filling opioid and nonopioid prescriptions. METHODS Patients with cancer receiving opioids that had been seen two times or more at our SCC were asked to complete a survey. The information collected included patient demographics, clinical characteristics, and patients' experiences filling their opioid prescription. RESULTS The patients' median age was 60 years; 54% were female and 69% were white. Forty-four patients (32%) reported that they have experienced difficulty filling their opioid prescription. More than 25% of those 44 patients perceived difficulty from interactions with the pharmacy and/or pharmacist. Forty-six patients (33%) reported more difficulty filling their opioid prescriptions than filling their nonopioid prescriptions. CONCLUSION This study provides evidence that patients with cancer visiting our SCC perceived difficulties obtaining their opioid prescriptions. The results suggest that negative interactions with the pharmacy and/or pharmacist contribute to their perceived difficulty. Additional research is needed to further characterize the contributors of the difficulties patients with cancer face in filling their opioid prescriptions.
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Affiliation(s)
- Jessica H Brown
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Hilda P Torres
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Rama D Maddi
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Janet L Williams
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Seyedeh S Dibaj
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Diane Liu
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Eduardo Bruera
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.
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22
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LeBaron V, Bennett R, Alam R, Blackhall L, Gordon K, Hayes J, Homdee N, Jones R, Martinez Y, Ogunjirin E, Thomas T, Lach J. Understanding the Experience of Cancer Pain From the Perspective of Patients and Family Caregivers to Inform Design of an In-Home Smart Health System: Multimethod Approach. JMIR Form Res 2020; 4:e20836. [PMID: 32712581 PMCID: PMC7481872 DOI: 10.2196/20836] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 07/11/2020] [Accepted: 07/25/2020] [Indexed: 01/20/2023] Open
Abstract
Background Inadequately managed pain is a serious problem for patients with cancer and those who care for them. Smart health systems can help with remote symptom monitoring and management, but they must be designed with meaningful end-user input. Objective This study aims to understand the experience of managing cancer pain at home from the perspective of both patients and family caregivers to inform design of the Behavioral and Environmental Sensing and Intervention for Cancer (BESI-C) smart health system. Methods This was a descriptive pilot study using a multimethod approach. Dyads of patients with cancer and difficult pain and their primary family caregivers were recruited from an outpatient oncology clinic. The participant interviews consisted of (1) open-ended questions to explore the overall experience of cancer pain at home, (2) ranking of variables on a Likert-type scale (0, no impact; 5, most impact) that may influence cancer pain at home, and (3) feedback regarding BESI-C system prototypes. Qualitative data were analyzed using a descriptive approach to identity patterns and key themes. Quantitative data were analyzed using SPSS; basic descriptive statistics and independent sample t tests were run. Results Our sample (n=22; 10 patient-caregiver dyads and 2 patients) uniformly described the experience of managing cancer pain at home as stressful and difficult. Key themes included (1) unpredictability of pain episodes; (2) impact of pain on daily life, especially the negative impact on sleep, activity, and social interactions; and (3) concerns regarding medications. Overall, taking pain medication was rated as the category with the highest impact on a patient’s pain (=4.79), followed by the categories of wellness (=3.60; sleep quality and quantity, physical activity, mood and oral intake) and interaction (=2.69; busyness of home, social or interpersonal interactions, physical closeness or proximity to others, and emotional closeness and connection to others). The category related to environmental factors (temperature, humidity, noise, and light) was rated with the lowest overall impact (=2.51). Patients and family caregivers expressed receptivity to the concept of BESI-C and reported a preference for using a wearable sensor (smart watch) to capture data related to the abrupt onset of difficult cancer pain. Conclusions Smart health systems to support cancer pain management should (1) account for the experience of both the patient and the caregiver, (2) prioritize passive monitoring of physiological and environmental variables to reduce burden, and (3) include functionality that can monitor and track medication intake and efficacy; wellness variables, such as sleep quality and quantity, physical activity, mood, and oral intake; and levels of social interaction and engagement. Systems must consider privacy and data sharing concerns and incorporate feasible strategies to capture and characterize rapid-onset symptoms.
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Affiliation(s)
- Virginia LeBaron
- University of Virginia School of Nursing, Charlottesville, VA, United States
| | - Rachel Bennett
- University of Virginia School of Nursing, Charlottesville, VA, United States
| | - Ridwan Alam
- University of Virginia School of Engineering & Applied Science, Charlottesville, VA, United States
| | - Leslie Blackhall
- University of Virginia School of Medicine, Charlottesville, VA, United States
| | - Kate Gordon
- Virginia Commonwealth University Health, Richmond, VA, United States
| | - James Hayes
- University of Virginia School of Engineering & Applied Science, Charlottesville, VA, United States
| | - Nutta Homdee
- University of Virginia School of Engineering & Applied Science, Charlottesville, VA, United States
| | - Randy Jones
- University of Virginia School of Nursing, Charlottesville, VA, United States
| | - Yudel Martinez
- University of Virginia School of Engineering & Applied Science, Charlottesville, VA, United States
| | - Emmanuel Ogunjirin
- University of Virginia School of Engineering & Applied Science, Charlottesville, VA, United States
| | - Tanya Thomas
- University of Virginia School of Nursing, Charlottesville, VA, United States
| | - John Lach
- The George Washington University School of Engineering & Applied Science, Washington, DC, United States
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Montgomery LS. Pain management with opioids in adults. J Neurosci Res 2020; 100:10-18. [PMID: 32770580 DOI: 10.1002/jnr.24695] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 06/18/2020] [Accepted: 06/26/2020] [Indexed: 12/11/2022]
Abstract
Given the ubiquitous nature of opioids in the treatment of pain, it is an interesting paradox that this class of medications also represents one of the least understood components of clinical pain medicine. For many years, there has been intense interest in the mechanisms of opioid activity, but this has not resulted in a corresponding increase in convincing clinical data. This review focuses primarily on the evidence surrounding the long-term use of opioids in chronic pain, but discussions of this research are often conflated with the very different data governing acute and cancer-related pain, where evidence of efficacy is clearer. It is therefore important to clarify the evidence-based indications for opioid therapy. There remains very little evidence that opioids improve function or quality of life beyond 3 months in people with chronic pain conditions. In all three patient populations, the development of tolerance, dependence, hyperalgesia and withdrawal are key phenomena that affect the patient experience, and in particular the decision to remain on opioids in the long term. This is a common thread that connects the opioid literature in all of these spheres, and justifies the burgeoning interest in these phenomena in the basic science literature. There is an urgent need to address these negative consequences of opioid use, in order to maximize the therapeutic benefit that opioids can offer.
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Affiliation(s)
- Lori S Montgomery
- Departments of Family Medicine and Anesthesiology, Perioperative and Pain Medicine, Cumming School of Medicine, Calgary, AB, Canada
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Chineke I, Adams Curry M, Bell W, Flood D, Mishra P, Power S, Bernal-Mizrachi L. Improving Documentation of Pain and Constipation Management Within the Cancer Center of a Large Urban Academic Hospital. JCO Oncol Pract 2020; 16:e251-e256. [DOI: 10.1200/jop.19.00332] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE: Pain and constipation are common among patients with cancer and remain inadequately controlled in many. The Quality Oncology Practice Initiative assessment of pain and constipation at the Georgia Cancer Center for Excellence at Grady Health System identified documentation to be below benchmark levels. A quality improvement initiative to improve pain and constipation management was conducted. METHODS: Given the low baseline documentation rates for pain (60%) and constipation (20%), we aimed for an increase of 20 percentage points within 1 year. On the basis of cause-and-effect analysis and provider questionnaires to understand fully the causal factors, our multidisciplinary team developed a new provider note template to integrate nurse’s assessment of pain and constipation into the provider’s documentation. A new order panel was developed in the electronic medical record to link appropriate orders with the pain and constipation plan. RESULTS: The integration of the initial nursing assessment into the provider note template increased pain score documentation from 66.7% to 100% ( P < .01), and the pain management plan improved from 65.3% to 86.4% ( P = .06). Similarly, constipation assessment documentation improved from 20.4% to 100% ( P < .01), and a documented constipation plan improved accordingly from 11.2% to 29.1% ( P < .01). As a result of this intervention, pain control at the third clinic visit improved from 61.5% to 86.8% ( P < .01). Emergency department visits related to pain and constipation decreased (16.2% to 14.9%; P = .19), and hospitalizations marginally increased (1.6% to 3.6%) during the study period ( P =.28). CONCLUSION: A standardized visit template and hardwired assessment of pain and constipation exceeded the goal for improvement in documentation and positively affected outcomes.
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Affiliation(s)
- Iloabueke Chineke
- Grady Memorial Hospital, Atlanta, GA
- Morehouse School of Medicine, Atlanta, GA
| | - Marjorie Adams Curry
- Grady Memorial Hospital, Atlanta, GA
- Winship Cancer Institute of Emory University, Atlanta, GA
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Lau J, Flamer D, Murphy-Kane P. Interventional anesthesia and palliative care collaboration to manage cancer pain: a narrative review. Can J Anaesth 2020; 67:235-246. [PMID: 31571119 DOI: 10.1007/s12630-019-01482-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 06/12/2019] [Accepted: 06/13/2019] [Indexed: 12/20/2022] Open
Abstract
Pain is a common symptom associated with advanced cancer. An estimated 66.4% of people with advanced cancer experience pain from their disease or treatment. Pain management is an essential component of palliative care. Opioids and adjuvant therapies are the mainstay of cancer pain management. Nevertheless, a proportion of patients may experience complex pain that is not responsive to conventional analgesia. Interventional analgesia procedures may be appropriate and necessary to manage complex, cancer-related pain. This narrative review uses a theoretical case to highlight core principles of palliative care and interventional anesthesia, and the importance of collaborative, interdisciplinary care. An overview and discussion of pragmatic considerations of peripheral nervous system interventional analgesic procedures and neuraxial analgesia infusions are provided.
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Affiliation(s)
- Jenny Lau
- Department of Supportive Care, University Health Network, Toronto, ON, Canada.
- Acute Palliative Care Unit, Princess Margaret Cancer Center, Toronto, ON, Canada.
- Division of Palliative Care, Department of Family and Community Medicine, Toronto, ON, Canada.
| | - David Flamer
- Department of Anesthesia and Pain Medicine, University Health Network, Toronto, ON, Canada
- Toronto Western Hospital, Toronto, ON, Canada
- Mount Sinai Hospital, Toronto, ON, Canada
| | - Patricia Murphy-Kane
- Department of Supportive Care, University Health Network, Toronto, ON, Canada
- Acute Palliative Care Unit, Princess Margaret Cancer Center, Toronto, ON, Canada
- Department of Nursing, Princess Margaret Cancer Center, Toronto, ON, Canada
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Cox-Martin E, Anderson-Mellies A, Borges V, Bradley C. Chronic pain, health-related quality of life, and employment in working-age cancer survivors. J Cancer Surviv 2019; 14:179-187. [PMID: 31828603 DOI: 10.1007/s11764-019-00843-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 11/29/2019] [Indexed: 12/23/2022]
Abstract
PURPOSE This study estimated the prevalence of cancer-related pain in working-age cancer survivors (age 25-64 years) and evaluated differences in demographic and clinical variables in those with and without pain. We also investigated the impact of cancer-related pain on health-related quality of life (HRQoL) and employment outcomes in this population. METHODS We used cross-sectional data from the 2016 Behavioral Risk Factor Surveillance System (BRFSS). Analyses were conducted with a sample of 1702 cancer survivors who completed treatment. All analyses were conducted using procedures to account for the complex sampling design of the BRFSS. RESULTS Nearly 17% (95% CI [13.94-19.58]) of working-age cancer survivors reported experiencing cancer-related pain. Among those who experienced pain, the majority were female, white, non-Hispanic, married/partnered, and non-employed, with breast as the most common cancer disease site. Those with cancer-related pain experienced more physically unhealthy days (adjusted rate ratio [aRR] 1.63, 95% CI [1.16-2.28]), mentally unhealthy days (aRR 1.52, 95% CI [1.02-2.26]), and activity interference (aRR 2.15, 95% CI [1.53-3.02]). Cancer-related pain decreased the odds of being employed, but only in female survivors (adjusted odds ratio 0.34, 95% CI [0.22-0.54]). CONCLUSION Cancer-related chronic pain is a prevalent, long-term condition that is negatively associated with HRQoL and employment in working-age cancer survivors. IMPLICATIONS FOR CANCER SURVIVORS Clinical interventions targeting chronic pain may improve HRQoL in working-age cancer survivors and employment outcomes, particularly in women.
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Affiliation(s)
- Emily Cox-Martin
- Division of Medical Oncology, Department of Medicine, School of Medicine, University of Colorado Anschutz Medical Campus, 12801 E 17th Ave., Aurora, CO, 80045, USA.
| | - Amy Anderson-Mellies
- Cancer Prevention and Control, University of Colorado Cancer Center, Aurora, CO, 80045, USA
| | - Virginia Borges
- Division of Medical Oncology, Department of Medicine, School of Medicine, University of Colorado Anschutz Medical Campus, 12801 E 17th Ave., Aurora, CO, 80045, USA
| | - Cathy Bradley
- University of Colorado School of Public Health, Department of Health Systems, Management, and Policy, University of Colorado Cancer Center, 13001 E. 17th Pl, Aurora, CO, 80045, USA
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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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Is pain part of a systemic syndrome in head and neck cancer? Support Care Cancer 2019; 28:451-459. [PMID: 31713692 DOI: 10.1007/s00520-019-05147-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 10/21/2019] [Indexed: 12/13/2022]
Abstract
Head and neck cancers (HNC) represent 5% of all malignancies worldwide with about 180,000 cancer deaths per year. Patients with HNC are characterized by a systemic inflammatory state, generally associated with worse outcomes. Treatment-related toxicity is common among HNC patients and causes systemic consequences such as fatigue or cognitive dysfunction. The therapeutic treatments of HNC involve the release in circulation of inflammatory systemic mediators, whose effects trigger a vicious circle that may lead to functional and behavioral alterations. The areas of the head and neck are highly sensitive to pain. Literature data confirm that in HNC patients, pain is one of the most distressing symptoms across all the phases of treatment. Pain is associated with worse general conditions, depression, fatigue, impaired cognitive functions, and lower survival rate. The treatment of advanced HNC cases is multimodal and requires a multidisciplinary psycho-socio-pharmacological approach mediated by a team of experts. The pharmacological approach in management of HNC patients with pain is fundamental and involves the use of opioids, NSAIDs, steroids, or other drugs. Opioids in pain management therapy in patients with HNC could allow the pain level to be adequately monitored, thus improving quality of life. The integration of opioid and non-opioid therapy as well as non-pharmacological interventions is essential for the rehabilitation of physical, social, and psychological functions and to achieve pain control in patients with HNC. Opioid treatment is the mainstay for pain control, being used both for background and breakthrough cancer pain (BTcP) episodes. Fentanyl, easily absorbed and generally well tolerated, appears to be a possible choice due to its versatility. Non-pharmacological interventions, such as tailored yoga, physical exercise, and acupuncture, may have a role in pain management in patients with HNC.
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Reis-Pina P, Sabri E, Birkett NJ, Barbosa A, Lawlor PG. Cancer-Related Pain: A Longitudinal Study of Time to Stable Pain Control and Its Clinicodemographic Predictors. J Pain Symptom Manage 2019; 58:812-823.e2. [PMID: 31252066 DOI: 10.1016/j.jpainsymman.2019.06.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 06/14/2019] [Accepted: 06/17/2019] [Indexed: 02/06/2023]
Abstract
CONTEXT Multidimensional assessment is pivotal in managing cancer-related pain. OBJECTIVES The objectives of this study were to determine time to stable pain control (SPC) and identify its baseline clinicodemographic predictors in patients with cancer pain. METHODS This is a prospective longitudinal study of patients attending a cancer pain clinic. Scheduled clinic attendances and weekly investigator-led phone calls enabled monitoring of patients' daily pain diary, opioid use, and other analgesic interventions. Baseline clinicodemographic variables were examined in survival analyses, which included the construction of accelerated failure time models with time ratios [TRs, (95% CIs)], based on time to SPC (pain intensity ≤3 and <3 breakthrough opioid doses over three consecutive days) for variable categories. RESULTS Of 319 participants, 22 died before achieving SPC and were censored in the survival analysis. The median survival time (95% CI) to SPC was 22 (19-25) days. In multivariable analysis, compared to their respective reference categories, female sex (P = 0.001), substance abuse (P < 0.001), a neuropathic pain component (P < 0.001), and use of ≥1 adjuvant analgesic (P = 0.022) each had TRs > 1 (1.03-2.54), whereas soft tissue pain (P < 0.001) had a TR = 0.71 (0.62-0.82), reflecting longer and shorter time to SPC, respectively. CONCLUSION SPC is achievable for most patients with cancer pain. Recognition of strong predictors of time to SPC, such as substance abuse, a neuropathic pain component, soft tissue pain, and current use of adjuvant analgesia, may help to triage care services based on therapeutic need and guide analgesic interventions.
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Affiliation(s)
- Paulo Reis-Pina
- Palliative Care Unit, Casa de Saúde da Idanha, Sintra, Portugal; Formerly Instituto Português de Oncologia de Lisboa, Lisbon, Portugal
| | - Elham Sabri
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Nicholas J Birkett
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Antonio Barbosa
- Department of Psychiatry, Centro Hospitalar Lisboa Norte, Centre of Bioethics & Palliative Care Studies Division, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Peter G Lawlor
- Bruyère Research Institute, Bruyère Continuing Care, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Canada; Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.
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Bulls HW, Hoogland AI, Craig D, Paice J, Chang YD, Oberoi-Jassal R, Rajasekhara S, Haas M, Bobonis M, Gonzalez BD, Portman D, Jim HSL. Cancer and Opioids: Patient Experiences With Stigma (COPES)-A Pilot Study. J Pain Symptom Manage 2019; 57:816-819. [PMID: 30703463 PMCID: PMC6433506 DOI: 10.1016/j.jpainsymman.2019.01.013] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 01/22/2019] [Accepted: 01/23/2019] [Indexed: 11/17/2022]
Abstract
CONTEXT Cancer-related pain is a common symptom that is often treated with opioids. However, legislation aimed at containing the opioid crisis, coupled with public fears about opioid risks, may contribute to opioid stigma in cancer patients. To our knowledge, no prior research has examined opioid stigma and stigma-related behavior in this population. OBJECTIVE The objectives of this study were to describe opioid use, including reasons for use and overuse and underuse behavior; characterize opioid stigma; and identify potentially maladaptive stigma-related behaviors. METHODS Participants were 125 adults undergoing active cancer treatment seen at the Moffitt Supportive Care Medicine Clinic. Patients completed a brief, anonymous questionnaire evaluating opioid use, opioid stigma, and stigma-related behaviors. RESULTS Patients were primarily women (65%) aged 45-64 years (49%), most commonly diagnosed with breast (23%) and hematologic (15%) cancer. Among patients who reported opioid use (n = 109), the most common reason for use was pain relief (94%), followed by improved sleep (25%). A subset of patients reported using less (13%) or more (8%) opioid medication than advised. Opioid stigma was endorsed by 59/97 patients prescribed opioids (61%), including fear of addiction (36%), difficulty filling prescriptions (22%), and awkwardness communicating with providers (15%). Stigma-related behaviors were endorsed by 28 (29%) respondents prescribed opioids, with "taking less opioid medication than needed" as the most commonly endorsed behavior (20%). CONCLUSION To our knowledge, this study provides the first evidence of opioid stigma and its consequences in cancer patients and offers potential targets for interventions aimed at reducing stigma and encouraging safe, effective opioid use.
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Yeager KA, Williams B, Bai J, Cooper HLF, Quest T, Meghani SH, Bruner DW. Factors Related to Adherence to Opioids in Black Patients With Cancer Pain. J Pain Symptom Manage 2019; 57:28-36. [PMID: 30316809 PMCID: PMC6310640 DOI: 10.1016/j.jpainsymman.2018.10.491] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 10/03/2018] [Accepted: 10/05/2018] [Indexed: 11/15/2022]
Abstract
CONTEXT Cancer pain relief is often inadequate because of poor adherence to pain medication, especially for black patients. OBJECTIVES The purpose of this study is to describe factors related to adherence to around-the-clock opioids among 110 black patients being treated for cancer pain. METHODS Sociodemographic, clinical, symptoms, and social support data were collected at baseline; pain and adherence data were collected at 30 days. Associations between these variables and opioid adherence measured by Medication Event Monitoring System were estimated using multiple regression. RESULTS Mean age was 56 (±10.1), the majority were women (63%) and college educated (56%). Mean pain severity at baseline equaled 4.6 (±2.3). Mean dose adherence was 60% (±28.5), while mean schedule adherence was 33.0% (±31.0). In adjusted analysis, 26% of the variance in dose adherence was explained by recent chemotherapy, changes in pain, concerns about nausea, and doctors' focus on cure versus pain control (P<0.001); 27% of the variance in schedule adherence was explained by recent chemotherapy, changes in pain, symptom burden, and concerns about doctors focus on cure versus pain control (P<0.001). CONCLUSION Findings confirm pain medication adherence is poor and pain was not well relieved. Multiple factors influence adherence to around-the-clock opioids. Clinicians need to partner with patients by providing a personalized pain treatment plan including an in-depth assessment of treatment choices and adherence.
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Affiliation(s)
- Katherine A Yeager
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia, USA; Winship Cancer Institute, Emory University, Atlanta, Georgia, USA.
| | - Bryan Williams
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia, USA
| | - Jinbing Bai
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia, USA
| | - Hannah L F Cooper
- Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Tammie Quest
- School of Medicine, Emory University, Atlanta, Georgia, USA
| | - Salimah H Meghani
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Deborah W Bruner
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia, USA; Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
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Xiao H, Liu H, Liu J, Zuo Y, Liu L, Zhu H, Yin Y, Song L, Yang B, Li J, Ye L. Pain Prevalence and Pain Management in a Chinese Hospital. Med Sci Monit 2018; 24:7809-7819. [PMID: 30382075 PMCID: PMC6225731 DOI: 10.12659/msm.912273] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Background Pain prevalence has been investigation in many developed countries, but integrated information about pain prevalence in Chinese hospitals is lacking. To achieve better pain treatment of hospitalized patients, pain management needs to be investigated. The present descriptive and cross-sectional study was performed to demonstrate the prevalence of pain by comparison with the 4 traditional vital signs, and to investigate pain management in a Chinese teaching hospital. Material/Methods Structured and systematic interviews were undertaken by independent researchers. During a patient’s hospitalization, the prevalence of pain and the 4 vital signs were recorded. Then, the catalog, severity, causes, duration of pain, and pain management were assessed. Results We found: (1) 63.36% of patients (3248 in total) suffered from pain while in hospital, which was 1.8~2.8 times higher than the prevalence of abnormality of the 4 vital signs. (2) 76% of patients had moderate pain and 21.98% had severe pain. (3) Pain intensity differed among patients with different diseases, but did not differ by demographic factors. (4) Acute and chronic pain were present in 68% and 26% of patients, respectively. In addition, 16% of the patients had neuropathic pain. (5) More than half of the patients with pain refused to receive pain-relief medication because they worried about addiction to opioids and the adverse effects of analgesics. (6) Most medical staff properly understood the 3 ladder analgesics. Conclusions The prevalence of pain is higher than the abnormality of the 4 traditional vital signs in a Chinese hospital. Although pain management has broadly improved, more patient education is necessary.
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Affiliation(s)
- Hong Xiao
- Department of Pain Management, West China Hospital of Sichuan University, Chengdu, Sichuan, China (mainland)
| | - Hui Liu
- Department of Pain Management, West China Hospital of Sichuan University, Chengdu, Sichuan, China (mainland)
| | - Jin Liu
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, Sichuan, China (mainland)
| | - Yunxia Zuo
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, Sichuan, China (mainland)
| | - Li Liu
- Department of Pain Management, West China Hospital of Sichuan University, Chengdu, Sichuan, China (mainland)
| | - Hong Zhu
- Department of Orthopedics, West China Hospital of Sichuan University, Chengdu, Sichuan, China (mainland)
| | - Yan Yin
- Department of Pain Management, West China Hospital of Sichuan University, Chengdu, Sichuan, China (mainland)
| | - Li Song
- Department of Pain Management, West China Hospital of Sichuan University, Chengdu, Sichuan, China (mainland)
| | - Bangxiang Yang
- Department of Pain Management, West China Hospital of Sichuan University, Chengdu, Sichuan, China (mainland)
| | - Jun Li
- Department of Pain Management, West China Hospital of Sichuan University, Chengdu, Sichuan, China (mainland)
| | - Ling Ye
- Department of Pain Management, West China Hospital of Sichuan University, Chengdu, Sichuan, China (mainland)
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Ahmedzai SH, Bautista MJ, Bouzid K, Gibson R, Gumara Y, Hassan AAI, Hattori S, Keefe D, Kraychete DC, Lee DH, Tamura K, Wang JJ. Optimizing cancer pain management in resource-limited settings. Support Care Cancer 2018; 27:2113-2124. [PMID: 30242544 PMCID: PMC6499735 DOI: 10.1007/s00520-018-4471-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 09/10/2018] [Indexed: 12/11/2022]
Abstract
Purpose Adequate cancer pain management (CPM) is challenging in resource-limited settings, where current international guideline recommendations are difficult to implement owing to constraints such as inadequate availability and accessibility of opioids, limited awareness of appropriate opioid use among patients and clinicians, and lack of guidance on how to translate the best evidence into clinical practice. The multinational and multidisciplinary CAncer Pain managEment in Resource-limited settings (CAPER) Working Group proposes a two-step initiative to bridge clinical practice gaps in CPM in resource-limited settings. Methods A thorough review of the literature, a steering committee meeting in February 2017, and post-meeting teleconference discussions contributed to the development of this initiative. As a first step, we developed practical evidence-based CPM algorithms to support healthcare providers (HCPs) in tailoring treatment according to availability of and access to resources. The second part of the initiative proposes a framework to support an effective implementation of the CPM algorithms that includes an educational program, a pilot implementation, and an advocacy plan. Results We developed CPM algorithms for first-line use, breakthrough cancer pain, opioid rotation, and refractory cancer pain based on the National Comprehensive Cancer Network guidelines and expert consensus. Our proposed educational program emphasizes the practical elements and illustrates how HCPs can provide optimal CPM according to evidence-based guidelines despite varied resource limitations. Pilot studies are proposed to demonstrate the effectiveness of the algorithms and the educational program, as well as for providing evidence to support a draft advocacy document, to lobby policymakers to improve availability and accessibility of analgesics in resource-limited settings. Conclusions These practical evidence-informed algorithms and the implementation framework represent the first multinational step towards achieving optimal CPM in resource-limited settings. Electronic supplementary material The online version of this article (10.1007/s00520-018-4471-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sam H Ahmedzai
- National Institute of Health Research Clinical Research Network for Cancer, Leeds, UK
| | | | - Kamel Bouzid
- Medical Oncology Department, Pierre & Marie Curie Center, Algiers, Algeria
| | - Rachel Gibson
- Division of Health Sciences, University of South Australia, Adelaide, Australia
| | - Yuddi Gumara
- National Cancer Center Dharmais Hospital, Jakarta, Indonesia
| | - Azza Adel Ibrahim Hassan
- Supportive & Palliative Care Section, Medical Oncology Department, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar.,Cancer Management & Research, Medical Research Institute, Alexandria University, Alexandria, Egypt
| | - Seiji Hattori
- Department of Cancer Pain Management, The Cancer Institute Hospital of JFCR, Tokyo, Japan
| | - Dorothy Keefe
- Department of Medicine, Faculty of Health Sciences, University of Adelaide, Adelaide, Australia
| | | | - Dae Ho Lee
- Department of Oncology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Kazuo Tamura
- General Medical Research Center, Fukuoka University School of Medicine, Fukuoka, Japan
| | - Jie Jun Wang
- Department of Oncology, Shanghai Changzheng Hospital, Second Military Medical University, No. 64 He Tian Road, Shanghai, 200070, People's Republic of China.
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Mayahara M, Wilbur J, Fogg L, Breitenstein SM. Behavioral Pain Intervention for Hospice and Palliative Care Patients: An Integrative Review. Am J Hosp Palliat Care 2018; 35:1245-1255. [PMID: 29772922 DOI: 10.1177/1049909118775421] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Despite the advances in pain management, achieving optimal pain control in hospice and palliative care is challenging. Patient/caregiver's lack of pain management knowledge, poor pain reporting, and poor adherence to pain management regimens are all associated with inadequate pain control. The purpose of this integrated review is to examine behavioral interventions designed for patients and caregivers to improve pain control in hospice and palliative care settings. Ten studies were identified through a database search. Seven of the 10 studies found significant improvement in at least 1 pain marker. Of the 7 studies that looked at changes in pain knowledge, 5 had significant improvements in at least 1 knowledge subscale. The 2 studies that looked at adherence to pain management found significant improvements. One limitation of the reviewed studies was that the delivery of them would not be efficient across all health-care settings, and, as a consequence, more technologically sophisticated delivery methods are needed. Therefore, while it is clear from the review that effective pain management interventions have been developed for hospice and palliative care patients, it is also clear that future research needs to focus on providing these same interventions through a more technologically sophisticated delivery method.
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Coyne P, Mulvenon C, Paice JA. American Society for Pain Management Nursing and Hospice and Palliative Nurses Association Position Statement: Pain Management at the End of Life. Pain Manag Nurs 2018; 19:3-7. [DOI: 10.1016/j.pmn.2017.10.019] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2017] [Accepted: 10/29/2017] [Indexed: 11/25/2022]
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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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Cancer Pain Management and Pain Interference with Daily Functioning among Cancer Patients in Gondar University Hospital. Pain Res Manag 2017; 2017:5698640. [PMID: 28694715 PMCID: PMC5485331 DOI: 10.1155/2017/5698640] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Revised: 03/15/2017] [Accepted: 04/05/2017] [Indexed: 11/18/2022]
Abstract
Cancer is an increasing public health burden for Ethiopia. Pain is among the most common symptoms in patients with cancer. Hence, we aimed to assess cancer pain prevalence, cancer pain interference, and adequacy of cancer pain treatment in the oncology ward of an Ethiopian teaching hospital. Of 83 patients, total of 76 (91.6%) cancer patients experienced pain with varying degree of severity, and 7 (8.4%) patients experienced severe pain. Of the 76 cancer patients with pain, 68 (89.2%) experienced pain interference with their daily activities. Fifty-four (65%) patients were receiving inadequate cancer pain treatment with negative Pain Management Index. Therefore, it is vital to anticipate and assess pain of the cancer patients as routine clinical practice, to optimize analgesic therapy, and to identify and overcome barriers to adequate pain management.
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Urine drug screen findings among ambulatory oncology patients in a supportive care clinic. Support Care Cancer 2017; 25:1859-1864. [PMID: 28120116 DOI: 10.1007/s00520-017-3575-1] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Accepted: 01/09/2017] [Indexed: 10/20/2022]
Abstract
PURPOSE Professional organizations provide no guidelines regarding assessment and management of opioid abuse risk in cancer. Universal precautions (UP) developed for non-cancer pain, include assessments for aberrant behavior, screening questionnaires, and urine drug screens (UDS). The role of UDS for identifying opioid abuse risk in cancer is uncertain. Our aim is to characterize inappropriate UDS, and identify a potential role for UDS in therapeutic decision-making. METHODS An observational retrospective chart review of 232 consecutive supportive care clinic patients were seen during the study. Twenty-eight of the two hundred thirty-two did not meet inclusion criteria. One hundred fifty of the two hundred four had active cancer, while 54 had no evidence of active disease. Clinicians ordered UDS based on their clinical judgment of patients' substance misuse risk. Edmonton symptom assessment scores, history of substance abuse, alcohol use, tobacco use, aberrant behavior, and morphine equivalent daily dose (MEDD) were obtained. RESULTS Pain scores and MEDD were higher (p = 0.021; p < 0.001) in the UDS group vs non-UDS. Forty percent of the patients (n = 82/204) had at least one UDS and 70% (60/82) had an inappropriate result. Thirty-nine percent (32) were inappropriately negative, showing no prescribed opioids. Forty-nine of the eighty-two were positive for non-prescribed opioids, benzodiazepine, or illicit substance. Eleven of the forty-nine had only cannabis metabolites in their urine. There were no significant differences between appropriate and inappropriate UDS groups regarding pain scores, MEDD or referral to psychology, psychiatry, or substance abuse specialists. CONCLUSIONS UDS on the 82 oncology patients at high risk for substance misuse were frequently positive (46%) for non-prescribed opioids, benzodiazepines or potent illicit drugs such as heroin or cocaine, and 39% had inappropriately negative UDS, raising concerns for diversion.
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Opioid Use in Gynecologic Oncology; Balancing Efficacy, Accessibility and Safety: An SGO Clinical Practice Statement. Gynecol Oncol 2016; 144:232-234. [PMID: 27988048 DOI: 10.1016/j.ygyno.2016.11.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Patel B, Hacker E, Murks C, Ryan C. Interdisciplinary Pain Education: Moving From Discipline-Specific to Collaborative Practice. Clin J Oncol Nurs 2016; 20:636-643. [DOI: 10.1188/16.cjon.636-643] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Choflet A, Narang A, Herald Hoofring L, Bonerigo S, Mian O, Katulis L, Cheng Z, Appling S. Prevalence of Substance Use in Patients With Cancer Receiving Radiation Therapy. Clin J Oncol Nurs 2016; 20:397-402. [DOI: 10.1188/16.cjon.397-402] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Bosnjak SM, Maurer MA, Ryan KM, Popovic I, Husain SA, Cleary JF, Scholten W. A Multifaceted Approach to Improve the Availability and Accessibility of Opioids for the Treatment of Cancer Pain in Serbia: Results From the International Pain Policy Fellowship (2006-2012) and Recommendations for Action. J Pain Symptom Manage 2016; 52:272-83. [PMID: 26988849 DOI: 10.1016/j.jpainsymman.2016.01.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Revised: 01/08/2016] [Accepted: 02/13/2016] [Indexed: 11/19/2022]
Abstract
Cancer is the second leading cause of death in Serbia, and at least 14,000-16,000 patients experience moderate-to-severe cancer pain every year. Cancer pain relief has been impeded by inadequate availability of opioid analgesics and barriers to their accessibility. In 2006, a Serbian oncologist was selected as an International Pain Policy Fellow. The fellow identified barriers to opioid availability in Serbia and implemented an action plan to address the unavailability of oral morphine, attitudinal and knowledge barriers about opioids, and barriers in the national opioid control policy, in collaboration with the government, local partners, and international experts, including those from the World Health Organization. Collaborative efforts resulted in availability of immediate-release oral morphine, registration of controlled-release hydromorphone, and reimbursement of oral methadone for cancer pain; numerous educational activities aimed at changing inadequate knowledge and negative attitudes toward opioids; recognition of opioids as essential medicines for palliative care in a new National Palliative Care Strategy; and recognition of the medical use of opioids as psychoactive-controlled substances for the relief of pain included in a new national law on psychoactive-controlled substances, and the development of recommendations for updating regulations on prescribing and dispensing opioids. An increase in opioid consumption at the institutional and national levels also was observed. This article outlines a multifaceted approach to improving access to strong opioids for cancer pain management and palliative care in a middle-income country and offers a potential road map to success.
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Affiliation(s)
- Snezana M Bosnjak
- Department of Supportive Oncology, Oncology Intensive Care Unit, Institute for Oncology and Radiology of Serbia, Belgrade, Serbia
| | - Martha A Maurer
- Pain & Policy Studies Group, Carbone Cancer Center, University of Wisconsin, Madison, Wisconsin, USA.
| | - Karen M Ryan
- Research and Sponsored Programs, University of Wisconsin, Madison, Wisconsin, USA
| | - Ivana Popovic
- Hospital Pharmacy, Institute for Oncology and Radiology of Serbia, Belgrade, Serbia
| | - S Asra Husain
- Pain & Policy Studies Group, Carbone Cancer Center, University of Wisconsin, Madison, Wisconsin, USA
| | - James F Cleary
- Pain & Policy Studies Group, Carbone Cancer Center, University of Wisconsin, Madison, Wisconsin, USA
| | - Willem Scholten
- Willem Scholten Consultancy, Medicines and Controlled Substances, Lopik, The Netherlands
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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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Abstract
Objective. The increasing incidence of cancer survivorship has shifted treatment of cancer-related pain from short-term analgesia to long-term chronic pain management. As a result, alternatives to oral analgesics, such as intrathecal therapy, may be beneficial for patients with cancer-related pain. The authors review the use of intrathecal therapy in the management of cancer-related pain. Methods. The Medline database was searched for English-language articles that included “ziconotide” or “morphine” AND (“cancer” OR “malignant”) AND “intrathecal” in title or abstract. Available abstracts from scientific congresses in the areas of neuromodulation and oncology were also reviewed. Results. Intrathecal therapy provides pain relief with reduced systemic concerns in patients with cancer-related pain. Patients should undergo multidisciplinary evaluation and, in most cases, drug trialing before intrathecal pump implantation. Morphine, an opioid (µ-opioid receptor antagonist), and ziconotide, a nonopioid (selective N-type calcium channel inhibitor), are both approved for intrathecal analgesia; however, tolerance and safety concerns may deter the use of intrathecal morphine. Ziconotide has also shown efficacy for reduction of cancer-related pain; however, proper dosing and titration must be used to prevent adverse events. There is little information available on use of intrathecal therapies specifically in cancer survivors. Conclusions. Treatment of cancer-related pain has shifted toward chronic pain management strategies, especially among cancer survivors. Intrathecal therapy provides an alternate route of administration of chronic pain medications (e.g., morphine and ziconotide) for cancer patients with and without active disease, although additional research is needed to support effectiveness in cancer survivors.
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Affiliation(s)
- Brian M Bruel
- *University of Texas, MD Anderson Cancer Center, Houston, Texas
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Tamang S, Patel MI, Blayney DW, Kuznetsov J, Finlayson SG, Vetteth Y, Shah N. Detecting unplanned care from clinician notes in electronic health records. J Oncol Pract 2016; 11:e313-9. [PMID: 25980019 DOI: 10.1200/jop.2014.002741] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
PURPOSE Reduction in unplanned episodes of care, such as emergency department visits and unplanned hospitalizations, are important quality outcome measures. However, many events are only documented in free-text clinician notes and are labor intensive to detect by manual medical record review. METHODS We studied 308,096 free-text machine-readable documents linked to individual entries in our electronic health records, representing care for patients with breast, GI, or thoracic cancer, whose treatment was initiated at one academic medical center, Stanford Health Care (SHC). Using a clinical text-mining tool, we detected unplanned episodes documented in clinician notes (for non-SHC visits) or in coded encounter data for SHC-delivered care and the most frequent symptoms documented in emergency department (ED) notes. RESULTS Combined reporting increased the identification of patients with one or more unplanned care visits by 32% (15% using coded data; 20% using all the data) among patients with 3 months of follow-up and by 21% (23% using coded data; 28% using all the data) among those with 1 year of follow-up. Based on the textual analysis of SHC ED notes, pain (75%), followed by nausea (54%), vomiting (47%), infection (36%), fever (28%), and anemia (27%), were the most frequent symptoms mentioned. Pain, nausea, and vomiting co-occur in 35% of all ED encounter notes. CONCLUSION The text-mining methods we describe can be applied to automatically review free-text clinician notes to detect unplanned episodes of care mentioned in these notes. These methods have broad application for quality improvement efforts in which events of interest occur outside of a network that allows for patient data sharing.
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Affiliation(s)
- Suzanne Tamang
- Stanford University School of Medicine; Stanford Health Care, Stanford, CA; and Harvard Medical School, Boston, MA
| | - Manali I Patel
- Stanford University School of Medicine; Stanford Health Care, Stanford, CA; and Harvard Medical School, Boston, MA
| | - Douglas W Blayney
- Stanford University School of Medicine; Stanford Health Care, Stanford, CA; and Harvard Medical School, Boston, MA
| | - Julie Kuznetsov
- Stanford University School of Medicine; Stanford Health Care, Stanford, CA; and Harvard Medical School, Boston, MA
| | - Samuel G Finlayson
- Stanford University School of Medicine; Stanford Health Care, Stanford, CA; and Harvard Medical School, Boston, MA
| | - Yohan Vetteth
- Stanford University School of Medicine; Stanford Health Care, Stanford, CA; and Harvard Medical School, Boston, MA
| | - Nigam Shah
- Stanford University School of Medicine; Stanford Health Care, Stanford, CA; and Harvard Medical School, Boston, MA
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