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Mercadante S, Adamoli L, Bellavia G, Castellana L, Favara T, Insalaco L, Mauceri M, Scibilia C, Lo Mauro M, Lo Cascio A, Casuccio A. Opioids in advanced cancer: use, storage and disposal in the home. BMJ Support Palliat Care 2024; 13:e855-e858. [PMID: 36175123 DOI: 10.1136/spcare-2022-003964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 09/15/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To determine the patterns of storing, using and disposing of opioids among patients with advanced cancer followed at home. METHODS Patients who were prescribed opioids were selected. Prescribed opioids and their doses used for background pain and breakthrough pain were collected, as well as CAGE (cut down, annoyed, guilty and eye opener) for alcohol and drugs, smoking and history of illicit substance use. Questions regarding the opioid use, storage and disposal were posed. RESULTS 100 patients were surveyed. Fifty-one patients had unused opioids at home, 25 patients did not throw away the drugs, 40 patients saved opioids for future use and 35 patients were unaware of proper opioid disposal methods. A total of 28 patients reported unsafe use by sharing or losing their opioids; 12 patients were unaware that their opioid could be fatal when taken by others. Most patients acknowledged that pain medications could be dangerous when taken by others. Patients with a partner and who were married were more likely to keep their opioids locked (p=0.028 and p=0.025, respectively). CONCLUSION A large number of patients with advanced cancer followed at home do not store, use and dispose of opioids safely. Patient education programmes should be incorporated to decrease the availability of opioids at home for abuse, diversion, and accidental poisoning.
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Affiliation(s)
| | - Lucia Adamoli
- Società Assistenza Malato Oncologico Terminale, Palermo, Italy
| | | | | | - Tommaso Favara
- Società Assistenza Malato Oncologico Terminale, Palermo, Italy
| | | | - Marco Mauceri
- Società Assistenza Malato Oncologico Terminale, Palermo, Italy
| | - Carla Scibilia
- Società Assistenza Malato Oncologico Terminale, Palermo, Italy
| | - Mario Lo Mauro
- Società Assistenza Malato Oncologico Terminale, Palermo, Italy
| | | | - Alessandra Casuccio
- Università degli Studi di Palermo Scuola di Medicina e Chirurgia, Palermo, Italy
- Hygiene, Università degli Studi di Palermo Facoltà di Medicina e Chirurgia, Palermo, Italy
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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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Yusufov M, Pirl WF, Braun I, Sannes T, McHugh RK. Toward a Psychological Model of Chemical Coping with Opioids in Cancer Care. Harv Rev Psychiatry 2023; 31:259-266. [PMID: 37948154 PMCID: PMC11060627 DOI: 10.1097/hrp.0000000000000384] [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: 11/12/2023]
Abstract
LEARNING OBJECTIVES AFTER PARTICIPATING IN THIS CME ACTIVITY, THE PSYCHIATRIST SHOULD BE BETTER ABLE TO • Outline the risk factors involved with opioid accessibility in patients receiving treatment for cancer.• Identify factors to address in order to mitigate risk for opioid misuse during cancer care. ABSTRACT Most patients with advanced cancer receive treatment for related pain. Opioid accessibility, however, is a risk factor for misuse, which can present care challenges and quality-of-life concerns. There is a lack of consistent universal screening prior to initiation of opioid prescribing. One crucial issue in treating this population is adequately identifying and mitigating risk factors driving opioid misuse. Drawing on theory and research from addiction science, psychology, palliative care, and oncology, the presented conceptual framework suggests that risk factors for opioid misuse during cancer care can be stratified into historical, current, malleable, and unmalleable factors. The framework identifies necessary factors to address in order to mitigate risk for opioid misuse during cancer care, and offers key directions for future research.
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Affiliation(s)
- Miryam Yusufov
- Dana-Farber Cancer Institute, Department of Psychosocial Oncology & Palliative Care, 450 Brookline Avenue, Boston, MA 02215
- Harvard Medical School, Boston, MA 02115
| | - William F. Pirl
- Dana-Farber Cancer Institute, Department of Psychosocial Oncology & Palliative Care, 450 Brookline Avenue, Boston, MA 02215
- Harvard Medical School, Boston, MA 02115
| | - Ilana Braun
- Dana-Farber Cancer Institute, Department of Psychosocial Oncology & Palliative Care, 450 Brookline Avenue, Boston, MA 02215
- Harvard Medical School, Boston, MA 02115
| | - Timothy Sannes
- Dana-Farber Cancer Institute, Department of Psychosocial Oncology & Palliative Care, 450 Brookline Avenue, Boston, MA 02215
- Harvard Medical School, Boston, MA 02115
| | - R. Kathryn McHugh
- McLean Hospital, Center of Excellence in Alcohol, Drugs, and Addiction, 115 Mill Street, Belmont, MA 02478
- Harvard Medical School, Boston, MA 02115
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Lee CY, Good P, Huggett G, Greer R, Hardy J. Drug dependence epidemiology in palliative care medicinal cannabis trials. BMJ Support Palliat Care 2023:spcare-2023-004583. [PMID: 37748856 DOI: 10.1136/spcare-2023-004583] [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: 09/01/2023] [Accepted: 09/06/2023] [Indexed: 09/27/2023]
Abstract
OBJECTIVES Drug dependence is becoming increasingly common and meeting palliative care patients with substance use disorders is inevitable. However, data on substance use in these patients are lacking. This study aims to evaluate the prevalence of drug dependence in palliative care patients with advanced cancer and correlate with symptom distress and opioid use. METHODS Palliative care patients with advanced cancer interested in participation in a medicinal cannabis trial were required to complete Alcohol, Smoking and Substance Involvement Screening Test (ASSIST), Edmonton Symptom Assessment Scale (ESAS) and record of concomitant medications including baseline opioid use as part of the eligibility screen. RESULTS Of the 182 participants, 167 (92%) reported lifetime alcohol and 132/182 (73%) lifetime tobacco use. No participant reached the threshold criteria for high risk of drug dependence with majority being low risk. There was no correlation between ASSIST score, ESAS and oral morphine equivalent. CONCLUSION This study identified alcohol and tobacco as the main substances used in this group of patients and that most were of very low risk for drug dependence. This suggests routine drug screening for palliative care patient may not be justified, but the high possibility of questionnaire bias is acknowledged.
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Affiliation(s)
- Chee Yen Lee
- Palliative Medicine, Ipswich Hospital, Ipswich, Queensland, Australia
- Palliative Medicine, Mater Misericordiae Ltd Brisbane, South Brisbane, Queensland, Australia
| | - Phillip Good
- UQ, Saint Lucia, Queensland, Australia
- Supportive and Palliative Care, Mater Health Services, Brisbane, Queensland, Australia
- Mater Research Institute The University of Queensland, South Brisbane, Queensland, Australia
| | - Georgie Huggett
- Mater Research Institute The University of Queensland, South Brisbane, Queensland, Australia
| | | | - Janet Hardy
- Supportive and Palliative Care, Mater Health Services, Brisbane, Queensland, Australia
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Edwards T, Arthur J, Joy M, Lu Z, Dibaj S, Bruera E, Zhukovsky D. Assessing risk for nonmedical opioid use among patients with cancer: Stability of the CAGE-AID questionnaire across clinical care settings. Palliat Support Care 2023:1-5. [PMID: 37439217 PMCID: PMC10787045 DOI: 10.1017/s1478951523000871] [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] [Indexed: 07/14/2023]
Abstract
OBJECTIVES The Cut down, Annoyed, Guilty, and Eye opener- Adapted to Include Drugs (CAGE-AID) questionnaire (CA) is a validated screening tool used to assess risk for nonmedical opioid use (NMOU) in patients receiving opioids for cancer pain. Data on consistencies and variations in responses to the CA between different clinical settings are lacking. We evaluated the frequency and consistency in scoring of the CA among patients seen between the first inpatient consult (T1) and the first outpatient follow-up (T2) visits. METHODS A retrospective chart review of 333 consecutive patients seen at both T1 and T2 within 3 months between August 2016 and March 2017 was reviewed. RESULTS Median age was 58 years (range, 18-87 years); 53% were female. CA was completed for 88% of patients at T1 and 94% at T2. Of these, 10% and 13% were CAGE-AID positive, respectively. CA score changed from negative to positive in 4% and from positive to negative in 1% of patients between T1 and T2. Kappa coefficient for agreement of CA between T1 and T2 was 0.74 (95% CI: 0.62-0.86, p = 0.02). SIGNIFICANT OF RESULTS Completion rate and consistency of patient responses to the CA were high irrespective of clinical setting. Of these patients, 10% and 13% were CA positive which is suggestive of high risk for NMOU. Further studies are needed to evaluate ways to ensure more consistency in the completion of the CA and enhance its utilization in routine clinical practice.
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Affiliation(s)
- Tonya Edwards
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer, Houston, TX, USA
| | - Joseph Arthur
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer, Houston, TX, USA
| | - Manju Joy
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer, Houston, TX, USA
| | - Zhanni Lu
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer, Houston, TX, USA
| | - Seyedeh Dibaj
- Department of Biostatistics, The University of Texas MD Anderson Cancer, Houston, TX, USA
| | - Eduardo Bruera
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer, Houston, TX, USA
| | - Donna Zhukovsky
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer, Houston, TX, USA
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Tahabi FM, Storey S, Luo X. SymptomGraph: Identifying Symptom Clusters from Narrative Clinical Notes using Graph Clustering. PROCEEDINGS OF THE ... SYMPOSIUM ON APPLIED COMPUTING. SYMPOSIUM ON APPLIED COMPUTING 2023; 2023:518-527. [PMID: 37720922 PMCID: PMC10504685 DOI: 10.1145/3555776.3577685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
Patients with cancer or other chronic diseases often experience different symptoms before or after treatments. The symptoms could be physical, gastrointestinal, psychological, or cognitive (memory loss), or other types. Previous research focuses on understanding the individual symptoms or symptom correlations by collecting data through symptom surveys and using traditional statistical methods to analyze the symptoms, such as principal component analysis or factor analysis. This research proposes a computational system, SymptomGraph, to identify the symptom clusters in the narrative text of written clinical notes in electronic health records (EHR). SymptomGraph is developed to use a set of natural language processing (NLP) and artificial intelligence (AI) methods to first extract the clinician-documented symptoms from clinical notes. Then, a semantic symptom expression clustering method is used to discover a set of typical symptoms. A symptom graph is built based on the co-occurrences of the symptoms. Finally, a graph clustering algorithm is developed to discover the symptom clusters. Although SymptomGraph is applied to the narrative clinical notes, it can be adapted to analyze symptom survey data. We applied Symptom-Graph on a colorectal cancer patient with and without diabetes (Type 2) data set to detect the patient symptom clusters one year after the chemotherapy. Our results show that SymptomGraph can identify the typical symptom clusters of colorectal cancer patients' post-chemotherapy. The results also show that colorectal cancer patients with diabetes often show more symptoms of peripheral neuropathy, younger patients have mental dysfunctions of alcohol or tobacco abuse, and patients at later cancer stages show more memory loss symptoms. Our system can be generalized to extract and analyze symptom clusters of other chronic diseases or acute diseases like COVID-19.
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Arthur JA, Edwards T, Lu Z, Tang M, Amaram-Davila J, Reddy A, Hui D, Yennurajalingam S, Anderson AE, Jennings K, Reddy S, Bruera E. Interdisciplinary intervention for the management of nonmedical opioid use among patients with cancer pain. Cancer 2022; 128:3718-3726. [PMID: 35997289 PMCID: PMC10304363 DOI: 10.1002/cncr.34392] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 06/06/2022] [Accepted: 06/15/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Few studies have assessed interventions aimed at managing nonmedical opioid use (NMOU) behavior among patients with cancer. The authors developed the Compassionate High-Alert Team (CHAT) intervention to manage patients receiving opioids for cancer pain who demonstrate NMOU behavior. The objective of this study was to determine the change in frequency of NMOU behaviors, pain intensity, and opioid requirements among those who received the intervention. METHODS A total of 130 patients receiving opioids for cancer pain that had documented evidence of NMOU and received the CHAT intervention were reviewed. Demographic and clinical information such as NMOU behaviors, pain scores, and morphine equivalent daily dose at baseline, 3, and 6 months post-intervention was obtained. RESULTS NMOU behaviors significantly decreased from a median (interquartile range) of 2 (1-3) at baseline to 0 (0-1) at both 3 and 6 months post-intervention (p < .001). A total of 45 of 75 (60%) and 31 of 50 (62%) of CHAT recipients achieved complete response to the intervention at 3 and 6 months, respectively. Higher baseline number of NMOU behaviors was independently associated with patient response to the intervention (odds ratio [OR], 1.97; 95% confidence interval [CI],1.09-4.28, p = .049 at 3 months; OR, 2.5; 95% CI, 1.20-6.47, p = .03 at 6 months). The median pain score decreased from 7 at baseline to 6 at both 3 and 6 months (p = .01). Morphine equivalent daily dose did not significantly change during that same period (143 mg/day vs. 139 mg/day, p = .13). CONCLUSIONS Most patients who received the CHAT intervention improved in their NMOU behaviors and pain intensity scores 3 and 6 months post-intervention. These preliminary findings support the efficacy of CHAT in managing patients receiving opioids for cancer pain who demonstrate NMOU behavior.
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Affiliation(s)
- Joseph A. Arthur
- Department of Palliative, Rehabilitation, and Integrative
Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas,
USA
| | - Tonya Edwards
- Department of Palliative, Rehabilitation, and Integrative
Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas,
USA
| | - Zhanni Lu
- Department of Palliative, Rehabilitation, and Integrative
Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas,
USA
| | - Michael Tang
- Department of Palliative, Rehabilitation, and Integrative
Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas,
USA
| | - Jaya Amaram-Davila
- Department of Palliative, Rehabilitation, and Integrative
Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas,
USA
| | - Akhila Reddy
- Department of Palliative, Rehabilitation, and Integrative
Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas,
USA
| | - David Hui
- Department of Palliative, Rehabilitation, and Integrative
Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas,
USA
| | - Sriram Yennurajalingam
- Department of Palliative, Rehabilitation, and Integrative
Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas,
USA
| | - Aimee E. Anderson
- Department of Palliative, Rehabilitation, and Integrative
Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas,
USA
| | - Kristofer Jennings
- Department of Biostatistics, The University of Texas MD
Anderson Cancer Center, Houston, Texas, USA
| | - Suresh Reddy
- Department of Palliative, Rehabilitation, and Integrative
Medicine, 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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Taniguchi C, Narisada A, Tanaka H, Iida H, Iida M, Mori R, Nakayama A, Suzuki K. Smoking cessation after cancer diagnosis reduces the risk of severe cancer pain: A longitudinal cohort study. PLoS One 2022; 17:e0272779. [PMID: 35944029 PMCID: PMC9362951 DOI: 10.1371/journal.pone.0272779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 07/26/2022] [Indexed: 11/18/2022] Open
Abstract
Background Whether abstinence from smoking among cancer patients reduces cancer pain is still unclear. Opioids can act as a surrogate index for evaluating the incidence of severe cancer pain in countries where opioid abuse is infrequent. This study aimed to investigate whether changed smoking behavior after cancer diagnosis influences the incidence of severe cancer pain as determined by strong opioid use. Methods Using a large Japanese insurance claims database (n = 4,797,329), we selected 794,702 insured employees whose annual health checkup data could be confirmed ≥6 times between January 2009 and December 2018. We selected 591 study subjects from 3,256 employees who were diagnosed with cancer pain and had health checkup data at the year of cancer pain diagnosis. Results A significantly greater proportion of patients who continued smoking after cancer diagnosis (“current smoker”, n = 133) received strong opioids (36.8%) compared with patients who had never smoked or had stopped before cancer diagnosis (“non-smoker”, n = 383, 20.6%; p<0.05) but also compared with patients who had quit smoking after cancer diagnosis (“abstainer:”, n = 75, 24.0%; p<0.05). In multivariable Cox proportional hazards regression analysis, abstainers had a significantly lower risk of receiving strong opioids than current smokers (hazard ratio: 0.57, 95% CI: 0.328 to 0.997). These findings were consistent across multiple sensitivity analyses. Conclusion Our study demonstrated that patients who quit smoking after cancer diagnosis have a lower risk of severe cancer pain. This information adds clinical incentives for improving quality of life among those who smoked at the time of cancer diagnosis.
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Affiliation(s)
- Chie Taniguchi
- College of Nursing, Aichi Medical University, Nagakute, Aichi, Japan
- * E-mail:
| | - Akihiko Narisada
- Institute for Occupational Health Science, Aichi Medical University, Nagakute, Aichi, Japan
| | - Hideo Tanaka
- Public Health Center of Neyagawa City, Neyagawa, Osaka, Japan
- Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Hiroki Iida
- Department of Anesthesiology and Pain Medicine, Central Japan International Medical Center, Minokamo, Gifu, Japan
| | - Mami Iida
- Department of Internal Medicine and Cardiology, Gifu Prefectural General Medical Center, Gifu, Gifu, Japan
| | - Rina Mori
- College of Nursing, Aichi Medical University, Nagakute, Aichi, Japan
| | - Ayako Nakayama
- College of Nursing, Aichi Medical University, Nagakute, Aichi, Japan
| | - Kohta Suzuki
- Institute for Occupational Health Science, Aichi Medical University, Nagakute, Aichi, Japan
- Department of Health and Psychosocial Medicine, Aichi Medical University School of Medicine, Nagakute, Aichi, Japan
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Azhar A, Hui D. Management of Physical Symptoms in Patients with Advanced Cancer During the Last Weeks and Days of Life. Cancer Res Treat 2022; 54:661-670. [PMID: 35790195 PMCID: PMC9296923 DOI: 10.4143/crt.2022.143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 06/27/2022] [Indexed: 11/21/2022] Open
Abstract
Patients with advanced cancer are faced with many devastating symptoms in the last weeks and days of life, such as pain, delirium, dyspnea, bronchial hypersecretions (death rattle), and intractable seizures. Symptom management in the last weeks of life can be particularly challenging because of the high prevalence of delirium complicating symptom assessment, high symptom expression secondary to psychosocial and spiritual factors, limited life-expectancy requiring special considerations for prognosis-based decision-making, and distressed caregivers. There is a paucity of research involving patients in the last weeks of life, contributing to substantial variations in clinical practice. In this narrative review, we shall review the existing literature and provide a practical approach to in-patient management of several of the most distressing physical symptoms in the last weeks to days of life.
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Fitzgerald Jones K, Khodyakov D, Arnold R, Bulls H, Dao E, Kapo J, Meier D, Paice J, Liebschutz J, Ritchie C, Merlin J. Consensus-Based Guidance on Opioid Management in Individuals With Advanced Cancer-Related Pain and Opioid Misuse or Use Disorder. JAMA Oncol 2022; 8:1107-1114. [PMID: 35771550 DOI: 10.1001/jamaoncol.2022.2191] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Importance Opioid misuse and opioid use disorder (OUD) are important comorbidities in people with advanced cancer and cancer-related pain, but there is a lack of consensus on treatment. Objective To develop consensus among palliative care and addiction specialists on the appropriateness of various opioid management strategies in individuals with advanced cancer-related pain and opioid misuse or OUD. Design, Setting, and Participants For this qualitative study, using ExpertLens, an online platform and methodology for conducting modified Delphi panels, between August and October 2020, we conducted 2 modified Delphi panels to understand the perspectives of palliative and addiction clinicians on 3 common clinical scenarios varying by prognosis (weeks to months vs months to years). Of the 129 invited palliative or addiction medicine specialists, 120 participated in at least 1 round. A total of 84 participated in all 3 rounds. Main Outcomes and Measures Consensus was investigated for 3 clinical scenarios: (1) a patient with a history of an untreated opioid use disorder, (2) a patient taking more opioid than prescribed, and (3) a patient using nonprescribed benzodiazepines. Results Participants were mostly women (47 [62%]), White (94 (78 [65%]), and held MD/DO degrees (115 [96%]). For a patient with untreated OUD, regardless of prognosis, it was deemed appropriate to begin treatment with buprenorphine/naloxone and inappropriate to refer to a methadone clinic. Beginning split-dose methadone was deemed appropriate for patients with shorter prognoses and of uncertain appropriateness for those with longer prognoses. Beginning a full opioid agonist was deemed of uncertain appropriateness for those with a short prognosis and inappropriate for those with a longer prognosis. Regardless of prognosis, for a patient with no medical history of OUD taking more opioids than prescribed, it was deemed appropriate to increase monitoring, inappropriate to taper opioids, and of uncertain appropriateness to increase the patient's opioids or transition to buprenorphine/naloxone. For a patient with a urine drug test positive for non-prescribed benzodiazepines, regardless of prognosis, it was deemed appropriate to increase monitoring, inappropriate to taper opioids and prescribe buprenorphine/naloxone. Conclusions and Relevance The findings of this qualitative study provide urgently needed consensus-based guidance for clinicians and highlight critical research and policy gaps.
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Affiliation(s)
- Katie Fitzgerald Jones
- William F. Connell School of Nursing, Boston College, Chestnut Hill, Massachusetts.,VA Boston Healthcare System, Boston, Massachusetts
| | | | - Robert Arnold
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Hailey Bulls
- CHAllenges in Managing and Preventing Pain (CHAMPP) Clinical Research Center, Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Emily Dao
- RAND Corporation, Santa Monica, California
| | - Jennifer Kapo
- MSCE Palliative Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Diane Meier
- Department of Geriatrics and Palliative Medicine, Center to Advance Palliative Care, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Judith Paice
- RN Feinberg School of Medicine, Division of Hematology-Oncology, Northwestern University, Chicago, Illinois
| | - Jane Liebschutz
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Christine Ritchie
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston
| | - Jessica Merlin
- CHAllenges in Managing and Preventing Pain (CHAMPP) Clinical Research Center, Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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Arya R, Hong D, Schultz O, Jutzy JM, Cotangco K, Peters P, Daily EW, McCall AR, Howard AR, Hasan Y, Kothari R, Son CH. Opioid Use in Patients With Cervical Cancer at Two Urban Medical Centers. Adv Radiat Oncol 2022; 7:100833. [PMID: 35387422 PMCID: PMC8977857 DOI: 10.1016/j.adro.2021.100833] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 10/06/2021] [Indexed: 12/15/2022] Open
Abstract
Purpose Patients with cervical cancer are at high risk for opioid use. This study aimed to characterize opioid prescribing patterns at 2 urban hospitals. Methods and Materials Data from patients with cervical cancer treated with curative intent from 2011 to 2018 were retrospectively collected. Women with unrelated chronic opioid use before diagnosis, persistent/recurrent disease at 3 months after initiation of treatment, or initiation of opioids >6 months after treatment were excluded. Demographics, disease characteristics, treatment, and outpatient prescription practices were collected. Endpoints included duration of opioid use ≥6 and ≥12 months. Results There were 106 women included, of whom 83% received definitive radiation. Most patients (n = 91, 85.8%) received outpatient opioids. Most common timing of prescriptions were before cancer therapy (35.9%), postprocedure (26.4%), and during radiation therapy (17.0%). Median duration was 3 (interquartile range, 1-11) months; 35.2% of these patients received opioids ≥6 months and 22% received opioids ≥12 months. Greater International Federation of Gynaecology and Obstetrics (FIGO) stage, recurrent/residual disease, initiation of opioids before treatment, history of depression or anxiety, and use of gabapentin or steroids were associated with long-term opioid use. Conclusions Most patients were prescribed outpatient opioids, many of whom used opioids for 12 months. Improvement in provider communication and education, increased posttreatment monitoring, and further evaluation of nonopioid therapies are needed in this patient population to reduce long-term opioid use.
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A systematic review of assessment approaches to predict opioid misuse in people with cancer. Support Care Cancer 2022; 30:5645-5658. [PMID: 35166898 PMCID: PMC9135805 DOI: 10.1007/s00520-022-06895-w] [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: 08/13/2021] [Accepted: 02/02/2022] [Indexed: 11/11/2022]
Abstract
Context Cancer prevalence is increasing, with many patients requiring opioid analgesia. Clinicians need to ensure patients receive adequate pain relief. However, opioid misuse is widespread, and cancer patients are at risk. Objectives This study aims (1) to identify screening approaches that have been used to assess and monitor risk of opioid misuse in patients with cancer; (2) to compare the prevalence of risk estimated by each of these screening approaches; and (3) to compare risk factors among demographic and clinical variables associated with a positive screen on each of the approaches. Methods Medline, Cochrane Controlled Trial Register, PubMed, PsycINFO, and Embase databases were searched for articles reporting opioid misuse screening in cancer patients, along with handsearching the reference list of included articles. Bias was assessed using tools from the Joanna Briggs Suite. Results Eighteen studies met the eligibility criteria, evaluating seven approaches: Urine Drug Test (UDT) (n = 8); the Screener and Opioid Assessment for Patients with Pain (SOAPP) and two variants, Revised and Short Form (n = 6); the Cut-down, Annoyed, Guilty, Eye-opener (CAGE) tool and one variant, Adapted to Include Drugs (n = 6); the Opioid Risk Tool (ORT) (n = 4); Prescription Monitoring Program (PMP) (n = 3); the Screen for Opioid-Associated Aberrant Behavior Risk (SOABR) (n = 1); and structured/specialist interviews (n = 1). Eight studies compared two or more approaches. The rates of risk of opioid misuse in the studied populations ranged from 6 to 65%, acknowledging that estimates are likely to have varied partly because of how specific to opioids the screening approaches were and whether a single or multi-step approach was used. UDT prompted by an intervention or observation of aberrant opioid behaviors (AOB) were conclusive of actual opioid misuse found to be 6.5–24%. Younger age, found in 8/10 studies; personal or family history of anxiety or other mental ill health, found in 6/8 studies; and history of illicit drug use, found in 4/6 studies, showed an increased risk of misuse. Conclusions Younger age, personal or familial mental health history, and history of illicit drug use consistently showed an increased risk of opioid misuse. Clinical suspicion of opioid misuse may be raised by data from PMP or any of the standardized list of AOBs. Clinicians may use SOAPP-R, CAGE-AID, or ORT to screen for increased risk and may use UDT to confirm suspicion of opioid misuse or monitor adherence. More research into this important area is required. Significance of results This systematic review summarized the literature on the use of opioid misuse risk approaches in people with cancer. The rates of reported risk range from 6 to 65%; however, true rate may be closer to 6.5–24%. Younger age, personal or familial mental health history, and history of illicit drug use consistently showed an increased risk of opioid misuse. Clinicians may choose from several approaches. Limited data are available on feasibility and patient experience. PROSPERO registration number. CRD42020163385.
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13
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Cook O, Doran J, Crosbie K, Sweeney P, Millard I, O'Connor M. Palliative care needs and models of care for people who use drugs and/or alcohol: A mixed methods systematic review. Palliat Med 2022; 36:292-304. [PMID: 35184626 DOI: 10.1177/02692163211061994] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Providing palliative care for individuals who use alcohol and/or drugs poses a multi-faceted challenge. In addition to clinical and social needs, individuals may endure mental health problems, co-morbidities and homelessness, thus requiring a multi-disciplinary, flexible approach to care. AIM To identify the palliative care needs and models of care for people who use drugs and/or alcohol. DESIGN A mixed-methods systematic review was conducted using the JBI Manual for Evidence Synthesis. DATA SOURCES Six databases were searched to identify relevant studies. Full text review and quality appraisal were completed independently and in-duplicate by two reviewers with conflicts resolved by a third reviewer. Qualitative and quantitative data were tabulated together using narrative synthesis, then categorised according to outcomes of interest, with similar and divergent findings reported accordingly. RESULTS Thirteen studies were included, nine qualitative and four quantitative, using a range of data collection methods, across various settings. The difficulties for individuals who use alcohol and/or drugs as well as their formal and informal carers, in relation to end-of-life care were examined, revealing access, care and skills issues. Three themes emerged which could underpin the development of a model of care: interpersonal/organisational relationships; holistic care; and collaborating with other services and training. CONCLUSION Despite end-of-life needs of this population being different to others, challenges include creating inclusive policies, sensitising staff to distinctive individual needs and training exchanges for staff working in both drug and alcohol services and palliative care.
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Affiliation(s)
- Olivia Cook
- Nursing & Midwifery, Monash University, Clayton, VIC, Australia
| | - John Doran
- Palliative Care, Melbourne City Mission, Melbourne, VIC, Australia
| | - Kate Crosbie
- Palliative Care, Melbourne City Mission, Melbourne, VIC, Australia
| | - Phillipa Sweeney
- Palliative Care, Melbourne City Mission, Melbourne, VIC, Australia
| | - Ian Millard
- Palliative Care, Melbourne City Mission, Melbourne, VIC, Australia
| | - Margaret O'Connor
- Nursing & Midwifery, Monash University, Clayton, VIC, Australia.,Palliative Care, Melbourne City Mission, Melbourne, VIC, Australia
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14
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Lau J, Mazzotta P, Fazelzad R, Ryan S, Tedesco A, Smith AJ, Sud A, Furlan AD, Zimmermann C. Assessment tools for problematic opioid use in palliative care: A scoping review. Palliat Med 2021; 35:1295-1322. [PMID: 34000897 PMCID: PMC8267087 DOI: 10.1177/02692163211015567] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Screening for problematic opioid use is increasingly recommended in patients receiving palliative care. AIM To identify tools used to assess for the presence or risk of problematic opioid use in palliative care. DESIGN Scoping review. DATA SOURCES Bibliographic databases (inception to January 31, 2020), reference lists, and grey literature were searched to find primary studies reporting on adults receiving palliative care and prescription opioids to manage symptoms from advanced cancer, neurodegenerative diseases, or end-stage organ diseases; and included tools to assess for problematic opioid use. There were no restrictions based on study design, location, or language. RESULTS We identified 42 observational studies (total 14,431 participants) published between 2009 and 2020 that used questionnaires (n = 32) and urine drug tests (n = 21) to assess for problematic opioid use in palliative care, primarily in US (n = 38) and outpatient palliative care settings (n = 36). The questionnaires were Cut down, Annoyed, Guilty, and Eye-opener (CAGE, n = 8), CAGE-Adapted to Include Drugs (CAGE-AID, n = 6), Opioid Risk Tool (n = 9), Screener and Opioid Assessment for Patients with Pain (SOAPP; n = 3), SOAPP-Revised (n = 2), and SOAPP-Short Form (n = 5). Only two studies' primary objectives were to evaluate a questionnaire's psychometric properties in patients receiving palliative care. There was wide variation in how urine drug tests were incorporated into palliative care; frequency of abnormal urine drug test results ranged from 8.6% to 70%. CONCLUSION Given the dearth of studies using tools developed or validated specifically for patients receiving palliative care, further research is needed to inform clinical practice and policy regarding problematic opioid use in palliative care.
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Affiliation(s)
- Jenny Lau
- Division of Palliative Care, University of Toronto, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.,Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Paolo Mazzotta
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.,Temmy Latner Centre for Palliative Care, Sinai Health System, Toronto, ON, Canada
| | - Rouhi Fazelzad
- UHN Library and Information Services, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Suzanne Ryan
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.,Division of Palliative Medicine, University of Toronto, Toronto, ON, Canada
| | - Alissa Tedesco
- Temmy Latner Centre for Palliative Care, Sinai Health System, Toronto, ON, Canada
| | - Andrew J Smith
- Addictions Division, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Abhimanyu Sud
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.,Medical Psychiatry Alliance, Toronto, ON, Canada
| | - Andrea D Furlan
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of Toronto, Toronto, ON, Canada.,Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada.,Institute for Work and Health, Toronto, ON, Canada
| | - Camilla Zimmermann
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.,Division of Palliative Medicine, University of Toronto, Toronto, ON, Canada.,Division of Medical Oncology, University of Toronto, Toronto, ON, Canada
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15
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Arthur JA, Tang M, Lu Z, Hui D, Nguyen K, Rodriguez EM, Edwards T, Yennurajalingam S, Dalal S, Dev R, Reddy A, Tanco K, Haider A, Liu DD, Bruera E. Random urine drug testing among patients receiving opioid therapy for cancer pain. Cancer 2021; 127:968-975. [PMID: 33231885 PMCID: PMC10015495 DOI: 10.1002/cncr.33326] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 08/24/2020] [Accepted: 10/06/2020] [Indexed: 11/06/2022]
Abstract
BACKGROUND There is limited information regarding the true frequency of nonmedical opioid use (NMOU) among patients receiving opioid therapy for cancer pain. Data to guide patient selection for urine drug testing (UDT) as well as the timing and frequency of ordering UDT are insufficient. This study examined the frequency of abnormal UDT among patients with cancer who underwent random UDT and their characteristics. METHODS Demographic and clinical information for patients with cancer who underwent random UDT were retrospectively reviewed and compared with a historical cohort that underwent targeted UDT. Random UDT was ordered regardless of a patient's risk potential for NMOU. Targeted UDT was ordered on the basis of a physician's estimation of a patient's risk for NMOU. RESULTS In all, 552 of 573 eligible patients (96%) underwent random UDT. Among these patients, 130 (24%) had 1 or more abnormal results; 38 of the 88 patients (43%) who underwent targeted UDT had 1 or more abnormal results. When marijuana was excluded, 15% of the random group and 37% of the targeted group had abnormal UDT findings (P < .001). It took a shorter time from the initial consultation to detect 1 or more abnormalities with the random test than the targeted test (median, 130 vs 274 days; P = .02). Abnormal random UDT was independently associated with younger age (P < .0001), male sex (P = .03), Cut Down, Annoyed, Guilty, and Eye Opener-Adapted to Include Drugs positivity (P = .001), and higher Edmonton Symptom Assessment System anxiety (P = .01). CONCLUSIONS Approximately 1 in 4 patients receiving opioids for cancer pain at a supportive care clinic who underwent random UDT had 1 or more abnormalities. Random UDT detected abnormalities earlier than the targeted test. These findings suggest that random UDT is justified among patients with cancer pain.
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Affiliation(s)
- Joseph A Arthur
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Michael Tang
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Zhanni Lu
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - David Hui
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Kristy Nguyen
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Eden Mae Rodriguez
- Pharmacy Services, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Tonya Edwards
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sriram Yennurajalingam
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Shalini Dalal
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Rony Dev
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Akhila Reddy
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Kimberson Tanco
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ali Haider
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Diane D Liu
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Eduardo Bruera
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
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16
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Al-Ansari AM, Abd-El-Gawad WM, AboSerea SM, ElShereafy EES, Ali FAS, ElSayed MAE. The pattern of change in opioid and adjuvant prescriptions for cancer pain before and after referral to a comprehensive program in the Palliative Care Center in Kuwait. BMC Palliat Care 2021; 20:25. [PMID: 33536013 PMCID: PMC7860188 DOI: 10.1186/s12904-021-00717-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 01/17/2021] [Indexed: 11/25/2022] Open
Abstract
Background Cancer-related pain is a complicated symptom that often coincides with fatigue, depression, and anxiety. Although many safe treatments are available, inadequate control of Cancer-related pain continues to lead to suffering in cancer patients. This study’s aim is to describe pain control, and the pattern of change in opioid and adjuvant medication prescriptions, before and after referral to the Palliative Care Center. Methods We conducted a prospective cohort study in adult cancer patients the Palliative Care Center between January 1, 2016 and December 30, 2017. We measured pain intensity and other associated symptoms via the Revised Edmonton Symptom Assessment System (ESAS-r) and documented detailed analgesics and adjuvant medication history before starting any palliative care and on days 0, 3, 6, and 14. Results The analysis included 240 patients whose cancer-related pain, anxiety, and depression scores meaningfully improved by day 6. The changes in the median (interquartile ranges) of Cancer-related pain, anxiety, and depression scores from day 0 to day 6 were: 6 (4–8) to 3 (1–4); 6 (4–9) to 2 (1–4); and 3 (2–6) to 2 (1–4), respectively, with p < 0.001 for all. Morphine was the most common opioid administered; the percentage using it increased from 20.4% (n = 49) before referral to 49.6% (n = 119) on day 6 (p < 0.001). The median morphine equivalent daily dose decreased from a median (interquartile ranges) of 60(31–93) mg/day before referral to 34(22–66) mg/day on day 6 (p < 0.001). There was also a statistically significant increase in the percentage of patients taking adjuvant medications, from 38.8% before referral to 84.2% on day 6 (p < 0.001). Comparing D0 to D6, the number of patients using Gabapentinoids significantly increased from 57(23.75%) to 79(32.9%) (p < 0.001), amitriptyline dramatically increased from 14 (5.8%) to 44 (18.3%) (p < 0.001), and other antidepressant drugs increased from 15 (6.2%) to 34 (14.1%) (p < 0.001). Conclusion After referral to the Palliative Care Center, patients’ pain and other symptoms scores decreased significantly, even with lower median morphine equivalent daily doses, arguably through more appropriately directed opioid use. This is evidence for the effectiveness of the comprehensive program at the Palliative Care Center in Kuwait. Supplementary Information The online version contains supplementary material available at 10.1186/s12904-021-00717-2.
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Affiliation(s)
| | - Wafaa Mostafa Abd-El-Gawad
- Geriatrics and Gerontology Department, Faculty of Medicine, Ain Shams University, Al- Abbaseya, Cairo, Egypt.
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17
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Alcohol, Tobacco, and Substance Use and Association with Opioid Use Disorder in Patients with Non-malignant and Cancer Pain: a Review. CURRENT ANESTHESIOLOGY REPORTS 2020. [DOI: 10.1007/s40140-020-00415-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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18
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MacDonald M, Shah S, Swanson J, Song E, Ahsan T, Pabbathi S, Mhaskar R, Mirza AS. Substance Use in Uninsured Cancer Survivors: A Multicenter Cross-Sectional Study of Free Clinics. Cureus 2020; 12:e10083. [PMID: 33005507 PMCID: PMC7522175 DOI: 10.7759/cureus.10083] [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] [Indexed: 11/10/2022] Open
Abstract
Introduction Substance use disorders occur in about 5% of the cancer population and can decrease treatment adherence, impede pain management, and undermine a cancer survivor’s network of social support. Although current literature demonstrates substance use is associated with socioeconomic disparity, there is limited research on the prevalence of alcohol, tobacco, and illicit drug use among uninsured cancer survivors in the United States. Our multicenter cross-sectional study describes the prevalence of substance use in uninsured cancer survivors in the Tampa Bay Area. Methods A comprehensive retrospective chart review of electronic medical records and paper charts was conducted at nine free clinics in the Tampa Bay Area of Florida between January 1, 2016, and December 31, 2017. Substance use prevalence was compared between uninsured cancer survivors and uninsured patients without reported cancer history after adjusting for available demographic risk factors. Results There were 222 patients with a history of cancer and 6,768 patients without a history of cancer included for analysis. Cancer survivors had a median age of 55 years (interquartile range 48-61 years), were mostly female (n = 146, 66.1%), and of Hispanic ethnicity (n = 94, 52.5%). Cancer survivors were more likely to be current smokers (n = 42, 25.1%) compared to patients without a cancer history (n = 759, 16.1%). Patients with a history of cancer were more likely to be current drinkers (n = 34, 26%) compared to non-cancer patients (n = 942, 22.9%). There was no significant difference in illicit drug use history between the two groups. Conclusions Our study demonstrates that uninsured cancer survivors are more likely to be smokers and alcohol consumers than uninsured patients without a history of cancer. There was no significant difference in illicit drug use in cancer survivors and patients without a history of cancer. Future educational interventions should target substance use among uninsured cancer survivors.
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Affiliation(s)
- Madeline MacDonald
- Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, USA
| | - Shreni Shah
- Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, USA
| | - Justin Swanson
- College of Public Health, University of South Florida, Tampa, USA
| | - Ethan Song
- Plastic Surgery, University of South Florida Morsani College of Medicine, Tampa, USA
| | - Tanzila Ahsan
- College of Arts and Sciences, University of South Florida, Tampa, USA
| | - Smitha Pabbathi
- Internal Medicine, Moffitt Cancer Center Department of Internal Medicine, Tampa, USA
| | - Rahul Mhaskar
- Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, USA
| | - Abu-Sayeef Mirza
- Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, USA
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19
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Anandarajah G, Mennillo HA, Rachu G, Harder T, Ghosh J. Lifestyle Medicine Interventions in Patients With Advanced Disease Receiving Palliative or Hospice Care. Am J Lifestyle Med 2020; 14:243-257. [PMID: 32477022 PMCID: PMC7232901 DOI: 10.1177/1559827619830049] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Revised: 01/18/2019] [Accepted: 01/21/2019] [Indexed: 01/01/2023] Open
Abstract
Background: Lifestyle medicine interventions have the potential to improve symptom management, daily function, and quality of life (QOL) in patients with advanced or terminal disease receiving palliative or hospice care. The goal of this review is to summarize the current state of the literature on this subject. Methods: The authors used a broad search strategy to identify relevant studies, reviews, and expert opinions, followed by narrative summary of available information. Results: Four main categories of lifestyle interventions feature prominently in the palliative care literature: exercise, nutrition, stress management, and substance use. High-quality studies in this vulnerable population are relatively sparse. Some interventions show promise. However, most show mixed results or inadequate evidence. For some interventions, risks in this generally frail population outweigh the benefits. Clinical decision making involves balancing research findings, including the risks and benefits of interventions, with a clear understanding of patients' prognosis, goals of care, and current physical, emotional, and spiritual state. Achieving optimum QOL, safety, and ethical care are emphasized. Conclusions: The use of lifestyle interventions in patients receiving palliative or hospice care is a complex undertaking, requiring tailoring recommendations to individual patients. There is potential for considerable benefits; however, more research is needed.
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Affiliation(s)
- Gowri Anandarajah
- Gowri Anandarajah, MD, Office of Medical Education, Warren Alpert Medical School of Brown University, 222 Richmond Street, Providence, RI 02912; e-mail:
| | - Haran Asher Mennillo
- Warren Alpert Medical School of Brown University, Providence, Rhode Island (GA, HAM, JG)
- Hope Hospice and Palliative Care Rhode Island, Providence, Rhode Island (GA, GR)
- Brown University, Providence, Rhode Island (TH)
| | - Gregory Rachu
- Warren Alpert Medical School of Brown University, Providence, Rhode Island (GA, HAM, JG)
- Hope Hospice and Palliative Care Rhode Island, Providence, Rhode Island (GA, GR)
- Brown University, Providence, Rhode Island (TH)
| | - Tyler Harder
- Warren Alpert Medical School of Brown University, Providence, Rhode Island (GA, HAM, JG)
- Hope Hospice and Palliative Care Rhode Island, Providence, Rhode Island (GA, GR)
- Brown University, Providence, Rhode Island (TH)
| | - Jyotsna Ghosh
- Warren Alpert Medical School of Brown University, Providence, Rhode Island (GA, HAM, JG)
- Hope Hospice and Palliative Care Rhode Island, Providence, Rhode Island (GA, GR)
- Brown University, Providence, Rhode Island (TH)
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20
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Haider A, Azhar A, Nguyen K, Dev R, Naqvi SMA, Naqvi SMA, Edwards T, Reddy A, Dalal S, Tanco KC, Arthur J, Williams JL, Park M, Liu DD, Dibaj SS, Bruera E. Concurrent use of opioids with benzodiazepines or nonbenzodiazepine sedatives among patients with cancer referred to an outpatient palliative care clinic. Cancer 2019; 125:4525-4531. [PMID: 31460669 DOI: 10.1002/cncr.32484] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 07/10/2019] [Accepted: 08/02/2019] [Indexed: 11/10/2022]
Abstract
BACKGROUND The concurrent use of opioids with benzodiazepines (BZD) or nonbenzodiazepine sedatives (S) recently was found to be associated with an increased risk of overdose death compared with the use of opioids alone. In the current study, the authors examined the frequency and trend of concurrent opioid/BZD-S use and its associated risk factors among patients with cancer. METHODS Data regarding the frequency and trend of concurrent opioid/BZD-S use were extracted for 1500 randomly selected patients referred to the outpatient palliative care clinic at The University of Texas MD Anderson Cancer Center between the calendar years of 2011 and 2016. To explore associated risk factors, the authors compared the demographic and clinical predictors of 418 patients each in the concurrent opioid/BZD-S group and opioids-only group. RESULTS In 2011, at the time of referral to the palliative care clinic, 96 of 221 patients with cancer (43%) were prescribed concurrent opioids/BZD-S. This rate progressively declined to 67 of 217 patients (31%) by 2016 (P = .0008). Patients in the concurrent opioid/BZD-S group had a higher percentage of females (233 individuals; 55% [P = .007]) and whites (323 individuals; 77% [P = .002]), and patients reported higher scores regarding depression (P = .0001), anxiety (P ≤ .0001), drowsiness (P = .048), and worst feeling of well-being (P = .001). The morphine equivalent daily dose was significantly higher in concurrent opioid/BZD-S group (median of 67.5 mg/day [interquartile range (IQR), 30-135 mg/day] vs 60 mg/day [IQR, 30-105 mg/day]; P = .034). Multivariate analysis demonstrated that anxiety (P ≤ .0001), white race (P = .0092), and poor Eastern Cooperative Oncology Group performance status (P = .0017) were significantly associated with concurrent use. CONCLUSIONS The concurrent use of opioids with BZD-S has declined but continues to be frequent among patients with cancer. Anxiety, white race, and poor Eastern Cooperative Oncology Group performance status were associated with its use. More research is needed to explore which medications can replace these agents.
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Affiliation(s)
- Ali Haider
- Department of Palliative Care, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ahsan Azhar
- Department of Palliative Care, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Kristy Nguyen
- Department of Palliative Care, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Rony Dev
- Department of Palliative Care, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Syed Mujtaba Ali Naqvi
- Department of Palliative Care, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Syed Mussadiq Ali Naqvi
- Department of Palliative Care, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Tonya Edwards
- Department of Palliative Care, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Akhila Reddy
- Department of Palliative Care, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Shalini Dalal
- Department of Palliative Care, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Kimberson C Tanco
- Department of Palliative Care, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Joseph Arthur
- Department of Palliative Care, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Janet L Williams
- Department of Palliative Care, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Minjeong Park
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Diane D Liu
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Seyedeh S Dibaj
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Eduardo Bruera
- Department of Palliative Care, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
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21
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Mercadante S, Adile C, Ferrera P, Casuccio A. Association between alcoholism and symptom expression, patient symptom goals, and clinical response in advanced cancer patients. Support Care Cancer 2019; 28:3361-3369. [PMID: 31760520 DOI: 10.1007/s00520-019-05152-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 10/24/2019] [Indexed: 12/21/2022]
Abstract
AIM The aim of this study was to determine the influence of alcoholism on symptom expression, personalized symptom goal (PSG) and patient goal response (PGR), and patient global impression (PGI) in advanced cancer patients. METHODS This was a secondary analysis of an international multicenter study. Advanced cancer patients who had a history of alcohol dependence positive, according to CAGE (cut down, annoy, guilt, eye-opener), were selected. Thirty patients (3.45%) were CAGE-positive. This sample was matched with 30 patients with similar characteristics who were CAGE-negative. Patients rated symptom intensity by using the Edmonton Symptom Assessment Score (ESAS) at admission (T0) and then after 1 week. For each symptom, patients reported their PSG. After a week of comprehensive palliative care, PSG was measured again (T7), as well as the achievement of PGR, and PGI. Minimal clinically important difference (MCID) was calculated by PGI of improvement or deterioration at T7 (bit better or a little worse, respectively). RESULTS A significant decrease in intensity was found for most symptoms in both groups. In CAGE-negative and CAGE-positive patients, most patients had a PSG of ≤ 3 for all ESAS items as a target at T0. All PSG targets did not changed significantly after 1 week of palliative care in both groups. Although CAGE-positive basically had unfavorable PGI and PGR, a statistical significance was achieved only for appetite (P = 0.037; ANOVA test). In CAGE-negative patients, Karnofsky was the only factor independently associated with PGI for pain and dyspnea. Factors independently associated with PGI for nausea were symptom intensity at T0 and home situation. In CAGE-positive patients, Karnofsky was independently associated with PGI for pain, nausea, and well-being. Symptom intensity at T0 was independently associated with PGI for weakness. CONCLUSION CAGE-positive advanced cancer patients favorably responded to a palliative care intervention. No greater differences have been found in comparison with CAGE-negative patients for PSG, PGR, and PGI, except for appetite. Further studies with large number of patients could confirm some trends observed in this study.
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Affiliation(s)
- Sebastiano Mercadante
- Main Regional Center for Pain Relief and Supportive-Palliative Care Unit, La Maddalena Cancer Center, Palermo, Italy. .,Anesthesia and Intensive Care Unit & Pain Relief and Palliative Care Unit, La Maddalena Cancer Center, Via san Lorenzo 312, 90145, Palermo, Italy.
| | - Claudio Adile
- Main Regional Center for Pain Relief and Supportive-Palliative Care Unit, La Maddalena Cancer Center, Palermo, Italy
| | - Patrizia Ferrera
- Main Regional Center for Pain Relief and Supportive-Palliative Care Unit, La Maddalena Cancer Center, Palermo, Italy
| | - Alessandra Casuccio
- Department of Sciences for Health Promotion and Mother Child Care, University of Palermo, Palermo, Italy
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22
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Beard E, Brown J, West R, Drummond C, Kaner E, Michie S. Predictive Validity, Diagnostic Accuracy and Test-Retest Reliability of the Strength of Urges to Drink (SUTD) Scale. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:E3714. [PMID: 31581626 PMCID: PMC6801575 DOI: 10.3390/ijerph16193714] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 09/22/2019] [Accepted: 09/27/2019] [Indexed: 01/26/2023]
Abstract
This study compared the 1-item Strength of Urges to Drink (SUTD) scale with the 10-item Alcohol Use Disorders Identification Test (AUDIT) on (i) test-retest reliability, (ii) predictive validity, and (iii) diagnostic accuracy. Data come from 2960 participants taking part in the Alcohol Toolkit Study (ATS), a monthly population survey of adults in England. The long-term test-retest reliability of the SUTD was 'fair', but lower than that for the AUDIT (Kappaweighted 0.24 versus 0.49). Individuals with "slight/moderate" urges to drink had higher odds of reporting an attempt to cut down relative to those not experiencing urges (adjusted odds ratios (AdjORs) 1.78 95% confidence interval (CI) 1.43-2.22 and 1.54 95% CI 1.20-1.96). Drinkers reporting "moderate/slight/strong" urges to drink had mean change in consumption scores which were 0.16 (95% CI -0.31 to -0.02), 0.40 (95% CI -0.56 to -0.24) and 0.37 (95% CI -0.69 to -0.05) units lower than those reporting no urges. For all outcomes, strong associations were found with AUDIT scores. The accuracy of the SUTD for discriminating between drinkers who did and did not reduce their consumption was 'acceptable', and similar to that for the AUDIT (ROCAUC 0.6). The AUDIT had better diagnostic accuracy in predicting change in alcohol consumption. The SUTD may be an efficient dynamic measure of urges to drink for population surveys and studies assessing the impact of alcohol-reduction interventions.
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Affiliation(s)
- Emma Beard
- Department of Behavioural Science and Health, University College London, London WC1E 7HB, UK.
- Department of Clinical, Educational and Health Psychology, University College London, London WC1E 7HB, UK.
| | - Jamie Brown
- Department of Behavioural Science and Health, University College London, London WC1E 7HB, UK.
- Department of Clinical, Educational and Health Psychology, University College London, London WC1E 7HB, UK.
| | - Robert West
- Department of Behavioural Science and Health, University College London, London WC1E 7HB, UK.
| | - Colin Drummond
- National Addiction Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London SE5 8BB, UK.
| | - Eileen Kaner
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne NE2 4AX, UK.
| | - Susan Michie
- Department of Clinical, Educational and Health Psychology, University College London, London WC1E 7HB, UK.
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23
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Galindo-Aldana GM, Murillo-Macías C, Cedano-Gasca A, Padilla-López A, García-León IA. Drug Trend Study in Mexican Population: Consumption and Cognitive Dysfunction Correlates. REVISTA DE LA FACULTAD DE MEDICINA 2019. [DOI: 10.15446/revfacmed.v67n4.64157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Introduction: Drug abuse screening tests (DAST) are a useful tool in decision making regarding the planning and implementation of drug-related public health policies. In addition, they constitute a rapid way to obtain data on the effects of drug consumption in specific populations.Objective: To describe the correlation between drug abuse (per type of drug) and cognitive dysfunction prevalence based on the information reported in a DAST.Materials and methods: A DAST was administered to 1299 individuals from 5 cities in Baja California, Mexico. In addition, an internal consistency reliability test was conducted to determine the internal consistency level of the instrument.Results: Several correlations between the consumption of different drugs were found. The main associations were found between methamphetamine and marijuana consumption. In addition, a positive correlation between the age at first drug use and cognitive impairment was found.Conclusions: DAST are brief administration instruments that allow obtaining data on drug abuse and drug addiction patterns. In addition, they can be used to identify the interaction between the consumption patterns of different drugs and the possible association between age at first drug use and cognitive dysfunction.
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24
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Yusufov M, Braun IM, Pirl WF. A systematic review of substance use and substance use disorders in patients with cancer. Gen Hosp Psychiatry 2019; 60:128-136. [PMID: 31104826 DOI: 10.1016/j.genhosppsych.2019.04.016] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Revised: 04/23/2019] [Accepted: 04/25/2019] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Few studies examined substance use in cancer patients. The aims of this systematic review were to summarize this evidence, identify methodological limitations, and provide future research directions. METHOD Articles on substance use in cancer (focused on illicit substance, opioid, and alcohol use) were searched in Medline, PsycINFO, and PsycARTICLES. RESULTS On the basis of inclusion criteria, 28 studies were reviewed. Twenty-one contained empiric data from 500,123 participants; seven were review or conceptual papers. All studies were published between 1995 and 2018. Quality assessment revealed relatively low risk of bias and high methodological quality. Five studies examined substance use or substance use disorder (SUD) broadly. Mean ages ranged from 17.6 to 74.7 years. Substance use rates ranged from 2% to 35%, with a median opioid rate of 18% and 25.5% for alcohol. Nine of the studies had samples comprised either mostly or exclusively of advanced cancer patients. Disease groups included breast, head & neck, and gastric cancer. None of the studies used a theoretical framework or model. CONCLUSIONS Given the prevalence of substance use in cancer patients, interventions are needed. Further theory-grounded studies are warranted to foster the translation of research into clinical practice and elucidate substance use management recommendations.
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Affiliation(s)
- Miryam Yusufov
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA 02215, United States; Harvard Medical School, Department of Psychiatry, Boston, MA 02115, United States.
| | - Ilana M Braun
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA 02215, United States; Harvard Medical School, Department of Psychiatry, Boston, MA 02115, United States
| | - William F Pirl
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA 02215, United States; Harvard Medical School, Department of Psychiatry, Boston, MA 02115, United States
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25
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Tanco K, Dumlao D, Kreis R, Nguyen K, Dibaj S, Liu D, Marupakula V, Shaikh A, Baile W, Bruera E. Attitudes and Beliefs About Medical Usefulness and Legalization of Marijuana among Cancer Patients in a Legalized and a Nonlegalized State. J Palliat Med 2019; 22:1213-1220. [PMID: 31386595 DOI: 10.1089/jpm.2019.0218] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background: There is a growing preference for the use of marijuana for medical purposes, despite limited evidence regarding its benefits and potential safety risks. Legalization status may play a role in the attitudes and preferences toward medical marijuana (MM). Objectives: The attitudes and beliefs of cancer patients in a legalized (Arizona) versus nonlegalized state (Texas) regarding medical and recreational legalization and medical usefulness of marijuana were compared. Settings/Subjects: Two hundred adult cancer patients were enrolled from outpatient Palliative Care centers at Banner MD Anderson Cancer Center in Gilbert, AZ (n = 100) and The University of Texas MD Anderson Cancer Center in Houston, TX (n = 100). Design and Measurements: Adult cancer patients seen by the Palliative Care teams in the outpatient centers were evaluated. Various physical and psychosocial assessments were conducted, including a survey of attitudes and beliefs toward marijuana. Results: The majority of individuals support legalization of marijuana for medical use (Arizona 92% [85-97%] vs. Texas 90% [82-95%]; p = 0.81) and belief in its medical usefulness (Arizona 97% [92-99%] vs. Texas 93% [86-97%]; p = 0.33) in both states. Overall, 181 (91%) patients supported legalization for medical purposes whereas 80 (40%) supported it for recreational purposes (p < 0.0001). Patients preferred marijuana over current standard treatments for anxiety (60% [51-68%]; p = 0.003). Patients found to favor legalizing MM were younger (p = 0.027), had worse fatigue (p = 0.015), appetite (p = 0.004), anxiety (p = 0.017), and were Cut Down, Annoyed, Guilty, and Eye Opener-Adapted to Include Drugs (CAGE-AID) positive for alcohol/drugs (p < 0.0001). Conclusion: Cancer patients from both legalized and nonlegalized states supported legalization of marijuana for medical purposes and believed in its medical use. The support for legalization for medical use was significantly higher than for recreational use in both states.
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Affiliation(s)
- Kimberson Tanco
- Department of Palliative, Rehabilitation, and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Donato Dumlao
- Subspecialty Palliative Care in Medical Oncology, Banner MD Anderson Cancer Center, Gilbert, Arizona
| | - Rebecca Kreis
- Subspecialty Palliative Care in Medical Oncology, Banner MD Anderson Cancer Center, Gilbert, Arizona
| | - Kristy Nguyen
- Department of Pharmacy, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Seyedeh Dibaj
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Diane Liu
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Ayesha Shaikh
- Subspecialty Palliative Care in Medical Oncology, Banner MD Anderson Cancer Center, Gilbert, Arizona
| | - Walter Baile
- Department of Behavioral Science, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Eduardo Bruera
- Department of Palliative, Rehabilitation, and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas
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26
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Koyyalagunta D, Bruera E, Engle MP, Driver L, Dong W, Demaree C, Novy DM. Compliance with Opioid Therapy: Distinguishing Clinical Characteristics and Demographics Among Patients with Cancer Pain. PAIN MEDICINE 2019; 19:1469-1477. [PMID: 29016951 DOI: 10.1093/pm/pnx178] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Background Because an increase of patients who misuse opioids has been identified in our cancer clinical setting through urine drug testing (UDT) and the Screener and Opioid Assessment for Patient's with Pain-Short Form (SOAPP-SF), we conducted this retrospective cohort study to identify patient characteristics that are associated with UDT that indicates noncompliance. Methods Over a two-year period, 167 of 8,727 patients (2.4%) seen in the pain clinic and who underwent UDT were evaluated to determine compliance with prescribed opioid regimens. Descriptive clinical and demographic data were collected, and group differences based on compliance with opioid therapy were evaluated. Results Fifty-eight percent of the patients were noncompliant with their prescribed opioid therapy. Noncompliant patients were younger than compliant patients, with a median age of 46 vs 49 years (P = 0.0408). Noncompliant patients were more likely to have higher morphine equivalent daily doses; however, the difference was not statistically significant. Patients with a history of alcohol (ETOH) (P = 0.0332), illicit drug use (P = 0.1014), and smoking (P = 0.4184) were more likely noncompliant. Univariate regression analysis showed that a history of ETOH use (P = 0.034), a history of anxiety (P = 0.027), younger age (P = 0.07), and a SOAPP-SF score of 4 or higher (P = 0.05) were associated with an abnormal UDT. Conclusions History of ETOH use, anxiety, high SOAPP-SF score, and younger age were associated with UDT that indicates noncompliance. Given the very small percentage of UDT testing, it is quite likely that a significant number of patients who did not undergo UDT were also nonadherent with treatment recommendations.
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Affiliation(s)
| | | | | | | | - Wenli Dong
- Statistics, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Chris Demaree
- Tulane University School of Medicine, New Orleans, Louisiana, USA
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27
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Reddy A, de la Cruz M. Safe Opioid Use, Storage, and Disposal Strategies in Cancer Pain Management. Oncologist 2019; 24:1410-1415. [PMID: 31097618 DOI: 10.1634/theoncologist.2019-0242] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 04/17/2019] [Indexed: 11/17/2022] Open
Abstract
Opioids are required by a majority of patients with advanced cancer. Oncologists and palliative care clinicians are faced with the challenge of safely prescribing opioids in the current environment of an opioid crisis. Many patients with cancer use opioids unsafely, store them in unsecure locations, and do not dispose of unused opioids, leading to increased availability of these opioids for others to misuse. More than 50% of people who misuse opioids obtain the drugs from a friend or relative with or without their consent. Patient and provider education has been shown to improve safe opioid use, promote secure storage, and also increase disposal of unused opioids safely in drug take-back programs that are now widely available. This article highlights the importance of patient education and cautious opioid prescribing in patients with cancer. IMPLICATIONS FOR PRACTICE: The current opioid crisis makes it challenging to effectively manage cancer pain. Providers play a prominent role in minimizing opioid misuse. Cautious prescribing with limits enforced on the quantity of opioids prescribed, close follow-up, and consistent and frequent provision of opioid education are a must. Evidence points to the impact of patient education in promoting safety around opioid use. Most people who misuse prescription opioids obtain them from family or friends. Storing opioids in the open or not disposing of unused opioids increases the availability of these opioids for misuse by others. The importance of not sharing, always locking up, and disposing of unused and expired opioids must be highlighted as part of the opioid education that must be delivered every time that opioids are prescribed. Information about local drug take-back programs may also help increase disposal of unused opioids.
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Affiliation(s)
- Akhila Reddy
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Maxine de la Cruz
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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28
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The Patient with Difficult Cancer Pain. Cancers (Basel) 2019; 11:cancers11040565. [PMID: 31010249 PMCID: PMC6521083 DOI: 10.3390/cancers11040565] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 04/17/2019] [Accepted: 04/18/2019] [Indexed: 11/17/2022] Open
Abstract
Most patients with cancer pain can be managed with relatively simple methods using oral analgesics at relatively low doses, even for prolonged periods of time. However, in some clinical conditions pain may be more difficult to manage. Various factors can interfere with a desirable and favorable analgesic response. Data from several studies assessing factors of negative pain prognosis have indicated that neuropathic pain, incident pain, psychological distress, opioid addiction, and baseline pain intensity were associated with more difficult pain control. In this narrative review, the main factors that make the therapeutic response to opioids difficult are examined.
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29
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Abstract
CONTEXT Severity of alcohol dependence is related to the high-risk behavior of alcohol dependents. AIM To assess the high-risk behavior in patients with alcohol dependence and study the association between them. SETTINGS AND DESIGN This is a descriptive study of high-risk behavior in patients with alcohol dependence, conducted over a period of 15-month duration that is from January 2011 to April 2012 on 200 alcohol-dependent patients (178 men and 22 women) in the Department of Psychiatry, Mamata Medical College and General Hospital, Khammam (TS), India. MATERIALS AND METHODS Patients and their caregivers fulfilling the selection criteria were included in the study, and informed consent was obtained. Interview was carried out after 2 weeks to rule out the possibility of the presence of withdrawal symptoms in alcohol-dependent patients. Tools used for data collection include Sociodemographic and Clinical Profile Schedule, Clinical Institute of Withdrawal Assessment for Alcohol, Mini-Mental Status Examination, Severity of Alcohol Dependence Questionnaire, and High Risk Behavior Questionnaire. STATISTICAL ANALYSIS Descriptive statistics, Chi-square test, and logistic regression test were used. RESULTS The occurrence of high-risk behavior was substantial among patients with alcohol dependence syndrome. Event analysis method indicated that road traffic accidents associated with prior heavy drinking was the most frequently observed high-risk behavior. CONCLUSIONS The study reiterates the relationship between alcohol and sexual behavior and also highlights that individuals dependent on alcohol are a specifically vulnerable group.
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Affiliation(s)
- Anupama Korlakunta
- Department of Psychiatry, Kamineni Institute of Medical Sciences, Nalgonda, Andhra Pradesh, India
| | - C M Pavankumar Reddy
- Department of Psychiatry, Shadan Medical College, Hyderabad, India.,Department of Psychiatry, Mamata Medical College and Hospital, Khammam, Telengana, India
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30
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Bruera E. Patient Evaluation and delivery of Care at the Bedside: Increasing Well-Being. J Palliat Care 2018. [DOI: 10.1177/082585971403000413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Eduardo Bruera
- Department of Palliative Care and Rehabilitation Medicine, University of Texas, MD Anderson Cancer Center, Unit 1414, 1515 Holcombe Boulevard, Houston, Texas, USA 77030
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31
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Bruera E, Del Fabbro E. Pain Management in the Era of the Opioid Crisis. Am Soc Clin Oncol Educ Book 2018; 38:807-812. [PMID: 30231341 DOI: 10.1200/edbk_208563] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PRACTICAL APPLICATIONS Recognize patients at higher risk for nonmedical opioid use. Learn about screening for chemical coping risk. Diagnose nonmedical opioid use. Manage nonmedical opioid use in the clinical oncology setting. Understand clinical criteria for referral to supportive and palliative care teams.
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Affiliation(s)
- Eduardo Bruera
- From The University of Texas MD Anderson Cancer Center, Houston, TX; Virginia Commonwealth University, Massey Cancer Center, Richmond, VA
| | - Egidio Del Fabbro
- From The University of Texas MD Anderson Cancer Center, Houston, TX; Virginia Commonwealth University, Massey Cancer Center, Richmond, VA
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32
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Henry M, Alias A, Frenkiel S, Richardson K, Hier M, Zeitouni A, Kost K, Mlynarek A, Black M, MacDonald C, Chartier G, Rosberger Z. Contribution of psychiatric diagnoses to extent of opioid prescription in the first year post-head and neck cancer diagnosis: A longitudinal study. Psychooncology 2018; 28:107-115. [PMID: 30308695 DOI: 10.1002/pon.4917] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 08/31/2018] [Accepted: 10/06/2018] [Indexed: 11/12/2022]
Abstract
PURPOSE The purpose of this study was to determine, within the first-year post-head and neck cancer (HNC) diagnosis, the contribution of past and upon HNC psychiatric diagnoses (ie, substance use disorder, major depressive disorder, and anxiety disorder) to the extent (ie, cumulated dose) of opioid prescription. METHODS Prospective longitudinal study of 223 consecutive adults (on 313 approached; 72% participation) newly diagnosed (<2 weeks) with a first occurrence of primary HNC, including Structured Clinical Interviews for DSM-IV disorders, validated psychometric measures, and medical chart reviews. Opioid doses were translated into standardized morphine milligram equivalents (MME) using CDC guidelines. A model of variables was tested using multiple linear regression. RESULTS Fifty-five percent (123/223) of patients received opioids at some point during the first 12 months post-HNC diagnosis, 37.7% (84/223) upon HNC diagnosis (pre-treatment), 40.8% (91/223) during treatments, and 31.4% (70/223) post-treatment. The multiple linear regression indicated that an AD (P = 0.04) upon HNC diagnosis in early stage contributes to cumulated MME dose in the first year post-HNC diagnosis. CONCLUSION This study underlines how anxiety has important repercussions on the management of pain and illustrates the importance of screening for AD upon HNC diagnosis to allow for early prophylactic treatment and support.
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Affiliation(s)
- Melissa Henry
- McGill University, Montreal, Canada.,Jewish General Hospital, Montreal, Canada
| | | | - Saul Frenkiel
- McGill University, Montreal, Canada.,Jewish General Hospital, Montreal, Canada.,McGill University Health Centre, Montreal, Canada
| | - Keith Richardson
- McGill University, Montreal, Canada.,McGill University Health Centre, Montreal, Canada
| | - Michael Hier
- McGill University, Montreal, Canada.,Jewish General Hospital, Montreal, Canada
| | - Anthony Zeitouni
- McGill University, Montreal, Canada.,McGill University Health Centre, Montreal, Canada
| | - Karen Kost
- McGill University, Montreal, Canada.,McGill University Health Centre, Montreal, Canada
| | - Alex Mlynarek
- McGill University, Montreal, Canada.,Jewish General Hospital, Montreal, Canada.,McGill University Health Centre, Montreal, Canada
| | - Martin Black
- McGill University, Montreal, Canada.,Jewish General Hospital, Montreal, Canada
| | | | | | - Zeev Rosberger
- McGill University, Montreal, Canada.,Jewish General Hospital, Montreal, Canada
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33
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Dev R, Kim YJ, Reddy A, Hui D, Tanco K, Liu D, Park M, Williams J, Carmack C, Bruera E. Association between tobacco use, pain expression, and coping strategies among patients with advanced cancer. Cancer 2018; 125:153-160. [PMID: 30351502 DOI: 10.1002/cncr.31783] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 07/06/2018] [Accepted: 08/29/2018] [Indexed: 11/06/2022]
Abstract
BACKGROUND The objective of the current study was to evaluate the association between tobacco use, symptom expression, and coping strategies in patients with advanced cancer. METHODS The authors prospectively enrolled patients with advanced cancer and collected data regarding patient demographics, cancer diagnosis, morphine equivalent daily dose, cigarette smoking status using the Behavioral Risk Factor Surveillance System, symptom expression as measured by the Edmonton Symptom Assessment System, the Cut down/Annoyed/Guilty/Eye opener alcoholism questionnaire, the Screener and Opioid Assessment for Patients with Pain-short form survey, and the Brief COPE Questionnaire. RESULTS Among 399 patients, 195 (49%) were never-smokers, 158 (40%) were former smokers, and 46 (11%) were current smokers. The most common malignancies were gastrointestinal (21%) and breast (19%). Current smokers demonstrated significantly higher pain scores at the time of consultation compared with former or never-smokers (mean 6.4 vs 5.9 vs 5.1, respectively; P = .015), demonstrated increased morphine equivalent daily dose (median 90 mg/day vs 60 mg/day vs 50 mg/day, respectively; P = .002), were more likely to screen as positive on the Cut down/Annoyed/Guilty/Eye opener questionnaire (33% vs 24% vs 8.7%, respectively; P < .0001) and were more likely to screen as positive (≥4) on the Screener and Opioid Assessment for Patients with Pain-short form survey (74% vs 13% vs 9.3%, respectively; P < .0001). Compared with former and never-smokers, current smokers were significantly more likely to cope maladaptively with substance use (P = .02), denial (P = .007), and self-blame (P < .0001). CONCLUSIONS Among patients with advanced cancer, current and former smokers appear to be significantly more likely to have higher pain expression and thus require higher opioid doses, and to have more risk factors for using opioids in a nonprescribed manner. The results of the current study highlight the need to provide closer monitoring and increased psychosocial support for patients with cancer who smoke while receiving chronic opioid therapy.
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Affiliation(s)
- Rony Dev
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Yu Jung Kim
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Akhila Reddy
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - David Hui
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Kimberson Tanco
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Diane Liu
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Minjeong Park
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Janet Williams
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Cindy Carmack
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Eduardo Bruera
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
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34
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Smith ME, Lee JS, Bonham A, Varban OA, Finks JF, Carlin AM, Ghaferi AA. Effect of new persistent opioid use on physiologic and psychologic outcomes following bariatric surgery. Surg Endosc 2018; 33:2649-2656. [PMID: 30353238 DOI: 10.1007/s00464-018-6542-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2018] [Accepted: 10/15/2018] [Indexed: 11/24/2022]
Abstract
INTRODUCTION New persistent opioid use following surgery is a common iatrogenic complication, developing in roughly 6% of patients after elective surgery. Despite increased awareness of misuse and associated morbidity, opioids remain the cornerstone of pain management in bariatric surgery. The potential impact of new persistent opioid use on long-term postoperative outcomes is unknown. We sought to determine the relationship between new persistent opioid use and 1-year postoperative outcomes for patients undergoing bariatric surgery. METHODS Using data from the MBSC registry, we identified patients undergoing primary bariatric surgery between 2006 and 2016. Using previously validated patient-reported survey methodology, we evaluated patient opioid use preoperatively and at 1 year following surgery. New persistent use was defined as a previously opioid-naïve patient who self-reported opioid use 1 year after surgery. We used multivariable logistic regression models to evaluate the association between new persistent opioid use, risk-adjusted weight loss, and psychologic outcomes (psychological wellbeing, body image, and depression). RESULTS 27,799 patients underwent primary bariatric surgery between 2006 and 2016. Among opioid-naïve patients, the rate of new persistent opioid use was 6.3%. At 1-year after surgery, patients with new persistent opioid user lost significantly less excess body weight compared to those without new persistent use (57.6% vs. 60.3%; p < 0.0001). Patients with new persistent opioid use had significantly worse psychological wellbeing (35.0 vs. 33.1; p < 0.0001), body image (19.9 vs. 18.0; p < 0.0001), and depression scores (2.4 vs. 5.0; p < 0.0001). New persistent opioid users also reported less overall satisfaction with their bariatric surgery (75.1% vs. 85.7%; p < 0.0001). CONCLUSIONS New persistent opioid use is common following bariatric surgery and associated with significantly worse physiologic and psychologic outcomes. More effective screening and postoperative surveillance tools are needed to identify these patients, who likely require more aggressive counseling and treatment to maximize the benefits of bariatric surgery.
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Affiliation(s)
- Margaret E Smith
- Department of General Surgery, University of Michigan, Ann Arbor, MI, USA. .,University of Michigan Health System, 1500 E. Medical Center Drive, TC 2110, Ann Arbor, MI, 48109-5346, USA.
| | - Jay S Lee
- Department of General Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Aaron Bonham
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Oliver A Varban
- Department of General Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Jonathan F Finks
- Department of General Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Arthur M Carlin
- Department of Surgery, Henry Ford Health System, Detroit, MI, USA
| | - Amir A Ghaferi
- Department of General Surgery, University of Michigan, Ann Arbor, MI, USA
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Gómez-del Valle MC, Zertuche-Maldonado T, Bruera E. Compensación química y adicción a opioides: evidencia, valoración de riesgo y manejo en pacientes con cuidados paliativos. ACTA ACUST UNITED AC 2018. [DOI: 10.1016/j.medipa.2016.12.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Yennurajalingam S, Edwards T, Arthur JA, Lu Z, Najera J, Nguyen K, Manju J, Kuriakose L, Wu J, Liu D, Williams JL, Reddy SK, Bruera E. Predicting the risk for aberrant opioid use behavior in patients receiving outpatient supportive care consultation at a comprehensive cancer center. Cancer 2018; 124:3942-3949. [DOI: 10.1002/cncr.31670] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 04/04/2018] [Accepted: 06/11/2018] [Indexed: 01/18/2023]
Affiliation(s)
- Sriram Yennurajalingam
- Department of Palliative Care, Rehabilitation, and Integrative Medicine; The University of Texas MD Anderson Cancer Center; Houston Texas
| | - Tonya Edwards
- Department of Palliative Care, Rehabilitation, and Integrative Medicine; The University of Texas MD Anderson Cancer Center; Houston Texas
| | - Joseph A. Arthur
- Department of Palliative Care, Rehabilitation, and Integrative Medicine; The University of Texas MD Anderson Cancer Center; Houston Texas
| | - Zhanni Lu
- Department of Palliative Care, Rehabilitation, and Integrative Medicine; The University of Texas MD Anderson Cancer Center; Houston Texas
| | - John Najera
- Department of Palliative Care, Rehabilitation, and Integrative Medicine; The University of Texas MD Anderson Cancer Center; Houston Texas
| | - Kristy Nguyen
- Department of Palliative Care, Rehabilitation, and Integrative Medicine; The University of Texas MD Anderson Cancer Center; Houston Texas
| | - Joy Manju
- Department of Palliative Care, Rehabilitation, and Integrative Medicine; The University of Texas MD Anderson Cancer Center; Houston Texas
| | - Leela Kuriakose
- Department of Palliative Care, Rehabilitation, and Integrative Medicine; The University of Texas MD Anderson Cancer Center; Houston Texas
| | - Jimin Wu
- Department of Quantitative Sciences; The University of Texas MD Anderson Cancer Center; Houston Texas
| | - Diane Liu
- Department of Biostatistics; The University of Texas MD Anderson Cancer Center; Houston Texas
| | - Janet L. Williams
- Department of Palliative Care, Rehabilitation, and Integrative Medicine; The University of Texas MD Anderson Cancer Center; Houston Texas
| | - Suresh K. Reddy
- Department of Palliative Care, Rehabilitation, and Integrative Medicine; The University of Texas MD Anderson Cancer Center; Houston Texas
| | - Eduardo Bruera
- Department of Palliative Care, Rehabilitation, and Integrative Medicine; The University of Texas MD Anderson Cancer Center; Houston Texas
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Ebenau A, Dijkstra B, Stal-Klapwijk M, ter Huurne C, Blom A, Vissers K, Groot M. Palliative care for patients with a substance use disorder and multiple problems: a study protocol. BMC Palliat Care 2018; 17:97. [PMID: 30075776 PMCID: PMC6091086 DOI: 10.1186/s12904-018-0351-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 07/18/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The specific palliative care needs and problems of patients with a substance use disorder and multiple problems, and those of their proxies, are under recognized Besides, the organization of palliative care, including the division of health care professionals' responsibilities, is often unclear. Perspectives of patients and proxies are hardly known. We describe the outline of a study designed to explore how palliative care for patients with a substance use disorder is organized in the Netherlands and to explore problems and needs, as well as possible improvements from the healthcare professionals', patients' and proxies' perspective. The aim of this protocol paper is to provide insights in ways to conduct research with vulnerable research participants and to offer a detailed description of the study design. The broader study aims to gain insight in and formulate recommendations on how to improve palliative care for patients with a substance use disorder. METHODS A qualitative study with patients, proxies and healthcare professionals. Semi-structured interviews will be held with 10-15 patients who suffer from a severe substance use disorder. They are in a palliative care trajectory and either diagnosed with a chronic or life-threatening disease or, as a result of addictive behavior, a physical deterioration without the prospect of cure. Semi-structured interviews will also be held with 5-10 proxies. Healthcare professionals, volunteers and/or 'experts-by-experience' (n = 24-40) will be participating in semi-structured group interviews. All (group) interviews will be thematically analyzed. Additionally, a strengths, weaknesses, opportunities and threats (SWOT) analysis will be applied to the group interview data with the aim to summarize and concretize the findings. DISCUSSION Everyone has a right to an optimal end-of-life phase of life and a dignified dying process. This study will provide valuable knowledge about palliative care for patients with a substance use disorder and explicitly bring to light the needs and problems of the patients and their proxies and healthcare professionals in a palliative care phase.
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Affiliation(s)
- Anne Ebenau
- Salvation Army, Central Netherlands, Zandvoortweg 211; 3741 BE, Baarn, the Netherlands
| | - Boukje Dijkstra
- Nijmegen Institute for Scientist-Practitioners in Addiction (NISPA), P.O. Box 6909, 6503 GK Nijmegen, the Netherlands
| | | | - Chantal ter Huurne
- Tactus Addiction care, Lokatie Ripperdastraat, Ripperdastraat 8, 7511 JR Enschede, The Netherlands
| | - Ans Blom
- Network Palliative Care region Arnhem and de Liemers, Hospice Rozenheuvel, Rosendaalselaan 20, 6891 DD Rozendaal, the Netherlands
| | - Kris Vissers
- Department of Anesthesiology, Radboud University Medical Center, Pain and Palliative Care, Expertise Center for Palliative Care, Internal Post 549, P.O. Box 9101, 6500 HB Nijmegen, the Netherlands
| | - Marieke Groot
- Salvation Army, Central Netherlands, Zandvoortweg 211; 3741 BE, Baarn, the Netherlands
- Department of Anesthesiology, Radboud University Medical Center, Pain and Palliative Care, Expertise Center for Palliative Care, Internal Post 549, P.O. Box 9101, 6500 HB Nijmegen, the Netherlands
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Go SI, Song HN, Lee SJ, Bruera E, Kang JH. Craving Behavior from Opioid Addiction Controlled with Olanzapine in an Advanced Cancer Patient: A Case Report. J Palliat Med 2018; 21:1367-1370. [PMID: 30070936 DOI: 10.1089/jpm.2017.0636] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Opioid addiction, although uncommon in cancer patients, can be a significant challenge for optimal pain management in certain patients. We present a case of a 59-year-old man with advanced colon cancer whose compulsive craving for the buccal tablet of fentanyl citrate (BTFC) was improved with the use of olanzapine. He was hospitalized for abdominal pain caused by disease progression. He had visited several times at outpatient follow-up to obtain a prescription for BTFC because he took all medications before the appointed times. After admission, intravenous infusion of oxycodone and opioid rotation were applied to the patient to control his pain. However, he complained that the pain was not relieved at all and persistently asked for only BTFC 7 to 15 times per day. With the diagnosis of opioid addiction, the transdermal buprenorphine patch was applied, but was ineffective for controlling the addictive behaviors. Finally, olanzapine (10 mg/day per os), a dopamine receptor antagonist, was given to control the craving behavior because psychological dependence is mediated by the dopaminergic system. Three days later, opioid craving was reduced from five to one on a 5-point Likert scale. The pain was well controlled to numeric rating scale 1 or 2 without cravings for BTFC. Craving behavior as a result of opioid addiction may be controlled with olanzapine. Further prospective studies on this issue are warranted.
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Affiliation(s)
- Se-Il Go
- 1 Division of Hematology-Oncology, Department of Internal Medicine, Gyeongsang National University Changwon Hospital, College of Medicine, Gyeongsang National University , Changwon, South Korea
| | - Haa-Na Song
- 2 Department of Internal Medicine, College of Medicine, Gyeongsang National University , Jinju, South Korea
| | - So-Jin Lee
- 3 Department of Psychiatry, College of Medicine, Gyeongsang National University , Jinju, South Korea
| | - Eduardo Bruera
- 4 Department of Palliative Care and Rehabilitation Medicine, MD Anderson Cancer Center , Houston, Texas
| | - Jung Hun Kang
- 2 Department of Internal Medicine, College of Medicine, Gyeongsang National University , Jinju, South Korea
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Arthur J, Tanco K, Park M, Haider A, Maligi C, Dalal S, Naqvi SMA, Liu D, Bruera E. Personalized Pain Goal as an Outcome Measure in Routine Cancer Pain Assessment. J Pain Symptom Manage 2018. [PMID: 29526610 DOI: 10.1016/j.jpainsymman.2018.03.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND There is currently no universally accepted outcome measure in cancer pain management. The personalized pain goal (PPG) has been shown to be a relevant outcome measure. We examined its use in routine outpatient practice and compared it with the clinically important difference (CID, ≥2 points or 30%), a pain outcome measure frequently used in several clinical studies. MEASURES Initial and follow-up clinical information of outpatients with advanced cancer pain were retrospectively reviewed. PPG response was defined as pain ≤ PPG and CID response as ≥30% or ≥2-point decrease in pain intensity at follow-up. OUTCOMES PPG was successfully completed in 375 of 387 eligible patients (97%) with cancer pain. The median baseline PPG was three for all patients and remained unchanged at follow-up. One hundred thirty-two of 375 (35%) had a PPG response and 243 of 375 (65%) were non-responders. The odds ratio for PPG non-response was 1.01 for each milligram increase in morphine equivalent daily dose (P = 0.001), 1.46 for each point increase in the number of adjuvant analgesics (P = 0.006), 2.63 for severe pain (P = 0.002), and 2.55 for moderate depression (P = 0.006). Using PPG response as the gold standard for pain relief, the overall sensitivity and specificity of CID response were 83% and 77%, respectively. CONCLUSION PPG was successfully completed in the vast majority of patients, suggesting its feasibility as a pain outcome measure in routine clinical practice. Higher baseline pain intensity, depression, opioid dose, and number of adjuvant analgesics were independent predictors of poor pain relief. Further research is needed to further evaluate its clinical importance in cancer pain management.
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Affiliation(s)
- Joseph Arthur
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.
| | - Kimberson Tanco
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Minjeong Park
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ali Haider
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Courtney Maligi
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Shalini Dalal
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Syed M A Naqvi
- Department of Palliative, Rehabilitation, and Integrative Medicine, 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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Canal-Sotelo J, Trujillano-Cabello J, Larkin P, Arraràs-Torrelles N, González-Rubió R, Rocaspana-Garcia M, Barallat-Gimeno E. Prevalence and characteristics of breakthrough cancer pain in an outpatient clinic in a Catalan teaching hospital: incorporation of the Edmonton Classification System for Cancer pain into the diagnostic algorithm. BMC Palliat Care 2018; 17:81. [PMID: 29807537 PMCID: PMC5971419 DOI: 10.1186/s12904-018-0336-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 05/23/2018] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Breakthrough cancer pain (BTcP) is defined according to its principal characteristics: high intensity, short time interval between onset and peak intensity, short duration, potential recurrence over 24 h and non-responsiveness to standard analgesic regimes. The Edmonton Classification System for Cancer Pain (ECS-CP) is a classification tool that evaluates different dimensions of pain. The aim of this study was to measure prevalence and the main characteristics of BTcP in a sample of advanced cancer patients and to explore the complexity observed when ECS-CP is incorporated into BTcP diagnostics algorithm. METHODS Descriptive prevalence study (Retrospective chart review). Davies' algorithm was used to identify BTcP and ECS-CP was used to recognize appropriate dimensions of pain. The study was conducted in a sample of advanced cancer patients attending hospital outpatient clinic in Lleida, Spain. 277 patients were included from 01/01/2014 to 31/12/2015. No direct contact was made with participants. The following information was extracted from the palliative care outpatient clinic database: age, gender, civil status, cognitive impairment status, functional performance status and variables related to tumour. Only BTcP cases were included. RESULTS Prevalence of BTcP was 39.34% (63.9% men). Mean of age was 68.2 years. Main diagnosis was lung cancer (n = 154; 31.6%). Metastases were diagnosed in 83% of the sample. 138 patients (49.8%) were diagnosed with 1 type of BTcP and 139 (50.2%) were diagnosed with more than one type of BTcP. In total, 488 different types of BTcP were recorded (mean 1.75 ± 0, 9), 244 of these types (50%) presented a component of neuropathic pain. Addictive behaviour, measured through CAGE test, was present in 29.2% (N = 81) of the patients and psychological distress was present in 40.8% (n = 113). CONCLUSIONS Prevalence of BTcP (39.34%) is similar to the one reflected in the existing literature. Study results indicate that the routine use of ECS-CP in a clinical setting allows us to detect more than one type of BTcP as well as additional complexity associated with pain (neuropathic, addictive behavior and psychological distress).
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Affiliation(s)
- Jaume Canal-Sotelo
- Hospital Universitari Arnau de Vilanova, UFISS GSS, Alcalde Rovira Roure, 80, 25198 Lleida, Spain
| | | | - Philip Larkin
- University College Dublin, School of Nursing and Midwifery and health Systems Health Sciences, Belfield, Dublin, Ireland
| | | | | | - Mariona Rocaspana-Garcia
- Faculty of Nursing and Phisiotherapy, Universitat de Lleida, Montserrat Roig 2, 25198 Lleida, Spain
| | - Eva Barallat-Gimeno
- Faculty of Nursing and Phisiotherapy, Universitat de Lleida, Montserrat Roig 2, 25198 Lleida, Spain
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Ho P, Rosenheck R. Substance Use Disorder Among Current Cancer Patients: Rates and Correlates Nationally in the Department of Veterans Affairs. PSYCHOSOMATICS 2018; 59:267-276. [DOI: 10.1016/j.psym.2018.01.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/09/2017] [Revised: 01/07/2018] [Accepted: 01/08/2018] [Indexed: 11/29/2022]
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Lawlor PG, Lawlor NA, Reis-Pina P. The Edmonton Classification System for Cancer Pain: a tool with potential for an evolving role in cancer pain assessment and management. ACTA ACUST UNITED AC 2018. [DOI: 10.1080/23809000.2018.1467211] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Peter G Lawlor
- Bruyère Research Institute, Bruyère Continuing Care, Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Canada
| | - Niamh A Lawlor
- Ottawa Hospital Cancer Program, The Ottawa Hospital (NAL), Ottawa, Canada
| | - Paulo Reis-Pina
- Palliative Care Unit, Casa de Saúde da Idanha, Sintra, Portugal
- Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
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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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Abstract
PURPOSE Alcohol misuse affects up to 28% of palliative care inpatients. This article aims to summarize the existing literature on the care of palliative patients with alcohol dependence. METHODS The author searched CINAHL, Scopus, MEDLINE, and PubMed from inception until July 2017 using search terms including "alcohol*," "dependence," and "palliative." The results were reported in a narrative manner. RESULTS Identification of alcohol-dependent patients can be improved through the use of validated tools such as "Cut Down, Annoyed, Guilty, Eye Opener" (CAGE) and "Alcohol Use Disorders Identification Test" (AUDIT). These patients may have specific palliative care needs such as increased susceptibility to terminal agitation, high prevalence of comorbidities, and poor social support networks. Management may involve detoxification, controlled usage of alcohol, or treatment of alcohol withdrawal. CONCLUSIONS Patients may derive clinical benefit when alcohol dependence is identified by health-care professionals. Routine screening should be considered. Further research is needed to directly compare treatments for alcohol dependence in palliative care.
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Affiliation(s)
- Aisling MacCormac
- 1 Riverside GP Training Scheme, Health Education North West London, United Kingdom
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Alcohol Abuse Decreases Pelvic Control and Survival in Cervical Cancer: An Opportunity of Lifestyle Intervention for Outcome Improvement. Am J Clin Oncol 2017; 40:451-457. [PMID: 25784565 DOI: 10.1097/coc.0000000000000187] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE We examined the incidence and the effect of alcohol abuse on pelvic control (PC), disease-free survival (DFS), and overall survival (OS) in locally advanced cervical cancer patients undergoing definitive radiation therapy (RT). METHODS Between 2007 and 2013, 95 patients treated with RT were reviewed, and the tumor characteristics, the RT dose, the treatment time, chemotherapy, and the number of cycles were recorded. The association between alcohol abuse and DFS, OS, and the duration of PC was analyzed using multivariable Cox proportional hazards models. RESULTS Of the 95 patients with an average age of 54.8 years (range, 27 to 91 y), 30% were FIGO stage 1B1, 1B2, 2A, 52% stage 2B, 3A; and 18% stage 3B; 86% of the patients were treated with weekly cisplatin chemotherapy. Alcohol history showed that 10 (10.5%) patients met the CDC criteria for heavy alcohol use. With a mean follow-up time of 2 years, 85 patients (88.5%) achieved PC and 86 patients (90.5%) were free of distant metastasis. A total of 82 patients (86.3%) were alive at the last follow-up. When controlling for the total treatment time, excessive alcohol abuse was significantly associated with a decrease in DFS (P=0.005; hazard ratio [HR], 6.19; 95% confidence interval [CI]: 1.73, 22.18), OS (P=0.001; HR, 6.68; 95% CI: 2.10, 21.26), and PC (P=0.029; HR, 3.10; 95% CI: 1.13, 8.56) on univariable analysis. On multivariable analysis, excessive alcohol abuse was significantly associated with a decrease in DFS (P=0.005; HR, 10.57; 95% CI: 2.07, 53.93) and OS (P=0.001; HR, 10.80; 95% CI: 2.57, 45.40). CONCLUSIONS In this small hypothesis-generating series of patients with heavy alcohol use, the data support the association that heavy alcohol use increases the risk of cancer recurrence and mortality. Additional research is required to better define the patient- and treatment-related factors that may be targeted for intervention.
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Lee JSJ, Hu HM, Edelman AL, Brummett CM, Englesbe MJ, Waljee JF, Smerage JB, Griggs JJ, Nathan H, Jeruss JS, Dossett LA. New Persistent Opioid Use Among Patients With Cancer After Curative-Intent Surgery. J Clin Oncol 2017; 35:4042-4049. [PMID: 29048972 DOI: 10.1200/jco.2017.74.1363] [Citation(s) in RCA: 259] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose The current epidemic of prescription opioid misuse has increased scrutiny of postoperative opioid prescribing. Some 6% to 8% of opioid-naïve patients undergoing noncancer procedures develop new persistent opioid use; however, it is unknown if a similar risk applies to patients with cancer. We sought to define the risk of new persistent opioid use after curative-intent surgery, identify risk factors, and describe changes in daily opioid dose over time after surgery. Methods Using a national data set of insurance claims, we identified patients with cancer undergoing curative-intent surgery from 2010 to 2014. We included melanoma, breast, colorectal, lung, esophageal, and hepato-pancreato-biliary/gastric cancer. Primary outcomes were new persistent opioid use (opioid-naïve patients who continued filling opioid prescriptions 90 to 180 days after surgery) and daily opioid dose (evaluated monthly during the year after surgery). Logistic regression was used to identify risk factors for new persistent opioid use. Results A total of 68,463 eligible patients underwent curative-intent surgery and filled opioid prescriptions. Among opioid-naïve patients, the risk of new persistent opioid use was 10.4% (95% CI, 10.1% to 10.7%). One year after surgery, these patients continued filling prescriptions with daily doses similar to chronic opioid users ( P = .05), equivalent to six tablets per day of 5-mg hydrocodone. Those receiving adjuvant chemotherapy had modestly higher doses ( P = .002), but patients with no chemotherapy still had doses equivalent to five tablets per day of 5-mg hydrocodone. Across different procedures, the covariate-adjusted risk of new persistent opioid use in patients receiving adjuvant chemotherapy was 15% to 21%, compared with 7% to 11% for those with no chemotherapy. Conclusion New persistent opioid use is a common iatrogenic complication in patients with cancer undergoing curative-intent surgery. This problem requires changes to prescribing guidelines and patient counseling during the surveillance and survivorship phases of care.
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Affiliation(s)
| | - Hsou Mei Hu
- All authors: University of Michigan, Ann Arbor, MI
| | | | | | | | | | | | | | - Hari Nathan
- All authors: University of Michigan, Ann Arbor, MI
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Haider A, Zhukovsky DS, Meng YC, Baidoo J, Tanco KC, Stewart HA, Edwards T, Joy MP, Kuriakose L, Lu Z, Williams JL, Liu DD, Bruera E. Opioid Prescription Trends Among Patients With Cancer Referred to Outpatient Palliative Care Over a 6-Year Period. J Oncol Pract 2017; 13:e972-e981. [PMID: 29028417 DOI: 10.1200/jop.2017.024901] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION In the United States, opioid regulations have become increasingly stringent in recent years. Increased regulatory scrutiny, in part, is related to heightened awareness through literature and a recent media blitz on the opioid prescription epidemic. These regulations have the potential to impact prescription trends by health care providers. Our objective was to evaluate changes in the type and dose of opioid prescriptions among patients who are referred by oncologists to an outpatient palliative care clinic. MATERIALS AND METHODS We reviewed the electronic health records of 750 patients who were seen as new consultations at MD Anderson Cancer Center's outpatient palliative care clinic between January 1 and April 30 each year from 2010 through 2015. Data collected included demographics, cancer type and stage, symptom assessment, performance status, opioid type, and opioid dose defined as the morphine equivalent daily dose (MEDD). RESULTS Median age was 59 years (interquartile range [IQR], 51 to 67), 383 (51%) were female, 529 (70%) were white, and 654 (87%)of patients had advanced cancer. In 2010, median MEDD before referral was 78 mg/d (IQR, 30 to 150); however, by 2015, the MEDD had progressively decreased to 40 mg/d (IQR, 19 to 80; P = .001). Hydrocodone was the most common opioid prescribed between 2010 and 2015; however, after its reclassification as a schedule II opioid in October 2014, the use of tramadol, a schedule IV opioid, increased ( P < .001). CONCLUSION During the past several years, the MEDD prescribed by referring oncologists has decreased. After hydrocodone reclassification, the use of tramadol with less stringent prescription limits has increased.
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Affiliation(s)
- Ali Haider
- The University of Texas MD Anderson Cancer Center, Houston TX; and Tan Tock Seng Hospital, Singapore
| | - Donna S Zhukovsky
- The University of Texas MD Anderson Cancer Center, Houston TX; and Tan Tock Seng Hospital, Singapore
| | - Yee Choon Meng
- The University of Texas MD Anderson Cancer Center, Houston TX; and Tan Tock Seng Hospital, Singapore
| | - Joseph Baidoo
- The University of Texas MD Anderson Cancer Center, Houston TX; and Tan Tock Seng Hospital, Singapore
| | - Kimberson C Tanco
- The University of Texas MD Anderson Cancer Center, Houston TX; and Tan Tock Seng Hospital, Singapore
| | - Holly A Stewart
- The University of Texas MD Anderson Cancer Center, Houston TX; and Tan Tock Seng Hospital, Singapore
| | - Tonya Edwards
- The University of Texas MD Anderson Cancer Center, Houston TX; and Tan Tock Seng Hospital, Singapore
| | - Manju P Joy
- The University of Texas MD Anderson Cancer Center, Houston TX; and Tan Tock Seng Hospital, Singapore
| | - Leela Kuriakose
- The University of Texas MD Anderson Cancer Center, Houston TX; and Tan Tock Seng Hospital, Singapore
| | - Zhanni Lu
- The University of Texas MD Anderson Cancer Center, Houston TX; and Tan Tock Seng Hospital, Singapore
| | - Janet L Williams
- The University of Texas MD Anderson Cancer Center, Houston TX; and Tan Tock Seng Hospital, Singapore
| | - Diane D Liu
- The University of Texas MD Anderson Cancer Center, Houston TX; and Tan Tock Seng Hospital, Singapore
| | - Eduardo Bruera
- The University of Texas MD Anderson Cancer Center, Houston TX; and Tan Tock Seng Hospital, Singapore
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Arthur J, Edwards T, Reddy S, Nguyen K, Hui D, Yennu S, Park M, Liu D, Bruera E. Outcomes of a Specialized Interdisciplinary Approach for Patients with Cancer with Aberrant Opioid-Related Behavior. Oncologist 2017; 23:263-270. [PMID: 29021378 DOI: 10.1634/theoncologist.2017-0248] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Accepted: 09/06/2017] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Data on the development and outcomes of effective interventions to address aberrant opioid-related behavior (AB) in patients with cancer are lacking. Our outpatient supportive care clinic developed and implemented a specialized interdisciplinary team approach to manage patients with AB. The purpose of this study was to report clinical outcomes of this novel intervention. MATERIALS AND METHODS The medical records of 30 consecutive patients with evidence of AB who received the intervention and a random control group of 70 patients without evidence of AB between January 1, 2015, and August 31, 2016, were reviewed. RESULTS At baseline, pain intensity (p = .002) and opioid dose (p = .001) were significantly higher among patients with AB. During the course of the study, the median number of ABs per month significantly decreased from three preintervention to 0.4 postintervention (p < .0001). The median morphine equivalent daily dose decreased from 165 mg/day at the first intervention visit to 112 mg/day at the last follow-up (p = .018), although pain intensity did not significantly change (p = .984). "Request for opioid medication refills in the clinic earlier than the expected time" was the AB with the highest frequency prior to the intervention and the greatest improvement during the study period. Younger age (p < .0001) and higher Edmonton Symptom Assessment System anxiety score (p = .005) were independent predictors of the presence of AB. CONCLUSION The intervention was associated with a reduction in the frequency of AB and opioid utilization among patients with cancer receiving chronic opioid therapy. More research is needed to further characterize the clinical effectiveness of this intervention. IMPLICATIONS FOR PRACTICE There are currently no well-defined and evidence-based strategies to manage cancer patients on chronic opioid therapy who demonstrate aberrant opioid-related behavior. The findings of this study offer a promising starting point for the creation of a standardized strategy for clinicians and provides valuable information to guide their practice regarding these patients. The study results will also help clinicians to better understand the types and frequencies of the most common aberrant behaviors observed among patients with cancer who are receiving chronic opioid therapy. This will enhance the process of timely patient identification, management, or referral to the appropriate specialist teams.
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Affiliation(s)
- Joseph Arthur
- Department of Palliative Care and Rehabilitation Medicine, Houston, Texas, USA
| | - Tonya Edwards
- Department of Palliative Care and Rehabilitation Medicine, Houston, Texas, USA
| | - Suresh Reddy
- Department of Palliative Care and Rehabilitation Medicine, Houston, Texas, USA
| | - Kristy Nguyen
- Department of Palliative Care and Rehabilitation Medicine, Houston, Texas, USA
| | - David Hui
- Department of Palliative Care and Rehabilitation Medicine, Houston, Texas, USA
| | - Sriram Yennu
- Department of Palliative Care and Rehabilitation Medicine, Houston, Texas, USA
| | - Minjeong Park
- Department of Biostatistics, University of Texas MD Anderson Cancer, Houston, Texas, USA
| | - Diane Liu
- Department of Biostatistics, University of Texas MD Anderson Cancer, Houston, Texas, USA
| | - Eduardo Bruera
- Department of Palliative Care and Rehabilitation Medicine, Houston, Texas, USA
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49
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Reddy A, Vidal M, Stephen S, Baumgartner K, Dost S, Nguyen A, Heung Y, Kwan S, Wong A, Pangemanan I, Azhar A, Tayjasanant S, Rodriguez E, Waletich J, Lim KH, Wu J, Liu D, Williams J, Yennurajalingam S, Bruera E. The Conversion Ratio From Intravenous Hydromorphone to Oral Opioids in Cancer Patients. J Pain Symptom Manage 2017; 54:280-288. [PMID: 28711751 DOI: 10.1016/j.jpainsymman.2017.07.001] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 06/14/2017] [Accepted: 07/07/2017] [Indexed: 01/21/2023]
Abstract
CONTEXT The lack of knowledge of the accurate conversion ratio (CR) between intravenous (IV) and oral hydromorphone and opioid rotation ratio (ORR) between IV hydromorphone and oral morphine equivalent daily dose (MEDD) may lead to poorly controlled pain or overdosing in cancer inpatients. OBJECTIVES We aimed to determine the CR and ORR from IV hydromorphone to oral hydromorphone and MEDD (obtained from oral morphine and oxycodone). METHODS A total of 4745 consecutive inpatient palliative care consults during 2010-14 were reviewed for conversions from IV hydromorphone to oral hydromorphone, morphine or oxycodone. Patient characteristics, symptoms, and opioid doses were determined in patients successfully discharged on oral opioids without readmission within one week. Linear regression analysis was used to estimate the CR or ORR between the 24 hour IV hydromorphone mg dose before conversion and the oral opioid mg dose used before discharge. RESULTS Among 394 patients on IV hydromorphone, 147 underwent conversion to oral hydromorphone and 247 underwent rotation to oral morphine (163) or oxycodone (84). The median (interquartile range) CR from IV to PO hydromorphone was 2.5 (2.14-2.75) with correlation of 0.95 (P < 0.0001). The median ORR (interquartile range) from IV hydromorphone to MEDD was 11.46 (9.84-13.00) with correlation of 0.93(P < 0.0001). The median ORR was 11.54 in patients receiving <30 mg of IV hydromorphone/day and 9.86 in patients receiving ≥30 mg (P = 0.0004). CONCLUSION Our study found that 1 mg of IV hydromorphone is equivalent to 2.5 mg of oral hydromorphone and 11.46 mg of MEDD. Hydromorphone at doses ≥30 mg/day may require a lower ORR to other opioids.
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Affiliation(s)
- Akhila Reddy
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.
| | - Marieberta Vidal
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Saneese Stephen
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Karen Baumgartner
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sara Dost
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ann Nguyen
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Yvonne Heung
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Simeon Kwan
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Angelique Wong
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Imelda Pangemanan
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ahsan Azhar
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Supakarn Tayjasanant
- Siriraj Palliative Care Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Edenmae Rodriguez
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jessica Waletich
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Kyu-Hyoung Lim
- Department of Internal Medicine, Kangwon National University School of Medicine, South Korea
| | - Jimin Wu
- 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
| | - Janet Williams
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sriram Yennurajalingam
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Eduardo Bruera
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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50
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Sacco P, Cagle JG, Moreland ML, Camlin EA. Screening and Assessment of Substance Use in Hospice Care: Examining Content from a National Sample of Psychosocial Assessments. J Palliat Med 2017; 20:850-856. [DOI: 10.1089/jpm.2016.0538] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Affiliation(s)
- Paul Sacco
- School of Social Work, University of Maryland-Baltimore, Baltimore, Maryland
| | - John G. Cagle
- School of Social Work, University of Maryland-Baltimore, Baltimore, Maryland
| | - Melissa L. Moreland
- School of Social Work, University of Maryland-Baltimore, Baltimore, Maryland
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