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Jones KF, White G, Bennett A, Bulls H, Escott P, Orris S, Escott E, Fischer S, Hamm M, Krishnamurti T, Wong R, LeBlanc TW, Liebschutz J, Meghani S, Smith C, Temel J, Ritchie C, Merlin JS. Benefits, Harms, and Stakeholder Perspectives Regarding Opioid Therapy for Pain in Individuals With Metastatic Cancer: Protocol for a Descriptive Cohort Study. JMIR Res Protoc 2024; 13:e54953. [PMID: 38478905 PMCID: PMC10973954 DOI: 10.2196/54953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 01/31/2024] [Accepted: 02/01/2024] [Indexed: 04/01/2024] Open
Abstract
BACKGROUND Opioids are a key component of pain management among patients with metastatic cancer pain. However, the evidence base available to guide opioid-related decision-making in individuals with advanced cancer is limited. Patients with advanced cancer or cancer that is unlikely to be cured frequently experience pain. Opioids are a key component of pain management among patients with metastatic cancer pain. Many individuals with advanced cancer are now living long enough to experience opioid-related harm. Emerging evidence from chronic noncancer pain literature suggests that longer-term opioid therapy may have limited benefits for pain and function, and opioid-related harms are also a major concern. However, whether these benefits and harms of opioids apply to patients with cancer-related pain is unknown. OBJECTIVE This manuscript outlines the protocol for the "Opioid Therapy for Pain in Individuals With Metastatic Cancer: The Benefits, Harms, and Stakeholder Perspectives (BEST) Study." The study aims to better understand opioid decision-making in patients with advanced cancer, along with opioid benefits and harms, through prospective examination of patients' pain experiences and opioid side effects and understanding the decision-making by patients, care partners, and clinicians. METHODS This is a multicenter, prospective cohort study that aims to enroll 630 patients with advanced cancer, 20 care partners, and 20 clinicians (670 total participants). Patient participants must have an advanced solid cancer diagnosis, defined by the American Cancer Society as cancer that is unlikely to be cured. We will recruit patient participants within 12 weeks after diagnosis so that we can understand opioid benefits, harms, and perspectives on opioid decision-making throughout the course of their advanced cancer (up to 2 years). We will also specifically elicit information regarding long-term opioid use (ie, opioids for ≥90 consecutive days) and exclude patients on long-term opioid therapy before an advanced cancer diagnosis. Lived-experience perspectives related to opioid use in those with advanced cancer will be captured by qualitative interviews with a subset of patients, clinicians, and care partners. Our data collection will be grounded in a behavioral decision research approach that will allow us to develop future interventions to inform opioid-related decision-making for patients with metastatic cancer. RESULTS Data collection began in October 2022 and is anticipated to end by November 2024. CONCLUSIONS Upon successful execution of our study protocol, we anticipate the development of a comprehensive evidence base on opioid therapy in individuals with advanced cancer guided by the behavioral decision research framework. The information gained from this study will be used to guide interventions to facilitate opioid decisions among patients, clinicians, and care partners. Given the limited evidence base about opioid therapy in people with cancer, we envision this study will have significant real-world implications for cancer-related pain management and opioid-related clinical decision-making. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/54953.
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Affiliation(s)
- Katie Fitzgerald Jones
- New England Geriatrics Research, Education, and Clinical Center (GRECC), Jamaica Plain, MA, United States
| | | | - Antonia Bennett
- University of North Carolina, Chapel Hill, NC, United States
| | - Hailey Bulls
- University of Pittsburgh, Pittsburgh, PA, United States
| | - Paula Escott
- University of Pittsburgh, Pittsburgh, PA, United States
| | - Sarah Orris
- University of Pittsburgh, Pittsburgh, PA, United States
| | | | | | - Megan Hamm
- University of Pittsburgh, Pittsburgh, PA, United States
| | | | - Risa Wong
- University of Pittsburgh, Pittsburgh, PA, United States
| | | | | | | | - Cardinale Smith
- Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Jennifer Temel
- Division of Hematology/Oncology, Massachusetts General Hospital, Boston, MA, United States
| | - Christine Ritchie
- Center for Aging and Serious Illness, Massachusetts General Hospital, Boston, MA, United States
- Department of Medicine, Harvard Medical School, Boston, MA, United States
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Han J, Rolles M, Torabi F, Griffiths R, Bedston S, Akbari A, Burnett B, Lyons J, Greene G, Thomas R, Long T, Arnold C, Huws DW, Lawler M, Lyons RA. The impact of the COVID-19 pandemic on community prescription of opioid and antineuropathic analgesics for cancer patients in Wales, UK. Support Care Cancer 2023; 31:531. [PMID: 37606853 PMCID: PMC10444652 DOI: 10.1007/s00520-023-07944-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 07/12/2023] [Indexed: 08/23/2023]
Abstract
PURPOSE Public health measures instituted at the onset of the COVID-19 pandemic in the UK in 2020 had profound effects on the cancer patient pathway. We hypothesise that this may have affected analgesic prescriptions for cancer patients in primary care. METHODS A whole-nation retrospective, observational study of opioid and antineuropathic analgesics prescribed in primary care for two cohorts of cancer patients in Wales, using linked anonymised data to evaluate the impact of the pandemic and variation between different demographic backgrounds. RESULTS We found a significant increase in strong opioid prescriptions during the pandemic for patients within their first 12 months of diagnosis with a common cancer (incidence rate ratio (IRR) 1.15, 95% CI: 1.12-1.18, p < 0.001 for strong opioids) and significant increases in strong opioid and antineuropathic prescriptions for patients in the last 3 months prior to a cancer-related death (IRR = 1.06, 95% CI: 1.04-1.07, p < 0.001 for strong opioids; IRR = 1.11, 95% CI: 1.08-1.14, p < 0.001 for antineuropathics). A spike in opioid prescriptions for patients diagnosed in Q2 2020 and those who died in Q2 2020 was observed and interpreted as stockpiling. More analgesics were prescribed in more deprived quintiles. This differential was less pronounced in patients towards the end of life, which we attribute to closer professional supervision. CONCLUSIONS We demonstrate significant changes to community analgesic prescriptions for cancer patients related to the UK pandemic and illustrate prescription patterns linked to patients' demographic background.
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Affiliation(s)
- Jun Han
- Population Data Science, Swansea University Medical School, Swansea, UK
- DATA-CAN, the UK's Health Data Research Hub for Cancer, London, UK
| | - Martin Rolles
- Population Data Science, Swansea University Medical School, Swansea, UK.
- South West Wales Cancer Centre, Swansea Bay University Health Board, Swansea, UK.
| | - Fatemeh Torabi
- Population Data Science, Swansea University Medical School, Swansea, UK
| | - Rowena Griffiths
- Population Data Science, Swansea University Medical School, Swansea, UK
| | - Stuart Bedston
- Population Data Science, Swansea University Medical School, Swansea, UK
| | - Ashley Akbari
- Population Data Science, Swansea University Medical School, Swansea, UK
- DATA-CAN, the UK's Health Data Research Hub for Cancer, London, UK
| | - Bruce Burnett
- Population Data Science, Swansea University Medical School, Swansea, UK
| | - Jane Lyons
- Population Data Science, Swansea University Medical School, Swansea, UK
| | - Giles Greene
- Welsh Cancer Intelligence and Surveillance Unit, Public Health Wales, Cardiff, UK
| | - Rebecca Thomas
- Observatory and Cancer Analysis Team, Public Health Wales, Cardiff, UK
| | - Tamsin Long
- Observatory and Cancer Analysis Team, Public Health Wales, Cardiff, UK
| | - Cathy Arnold
- DATA-CAN, the UK's Health Data Research Hub for Cancer, London, UK
- Data Services, University of Leeds, Leeds, UK
| | - Dyfed Wyn Huws
- Welsh Cancer Intelligence and Surveillance Unit, Public Health Wales, Cardiff, UK
| | - Mark Lawler
- DATA-CAN, the UK's Health Data Research Hub for Cancer, London, UK
- Patrick G Johnston Centre for Cancer Research, Queens University Belfast, Belfast, UK
| | - Ronan A Lyons
- Population Data Science, Swansea University Medical School, Swansea, UK
- DATA-CAN, the UK's Health Data Research Hub for Cancer, London, UK
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Check DK, Avecilla RAV, Mills C, Dinan MA, Kamal AH, Murphy B, Rezk S, Winn A, Oeffinger KC. Opioid Prescribing and Use Among Cancer Survivors: A Mapping Review of Observational and Intervention Studies. J Pain Symptom Manage 2022; 63:e397-e417. [PMID: 34748896 DOI: 10.1016/j.jpainsymman.2021.10.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 10/22/2021] [Accepted: 10/23/2021] [Indexed: 12/12/2022]
Abstract
CONTEXT Recent years show a sharp increase in research on opioid use among cancer survivors, but evidence syntheses are lacking, leaving knowledge gaps. Corresponding research needs are unclear. OBJECTIVES To provide an evidence synthesis. METHODS We searched PubMed and Embase, identifying articles related to cancer, and opioid prescribing/use published through September 2020. We screened resulting titles/abstracts. Relevant studies underwent full-text review. Inclusion criteria were quantitative examination of and primary focus on opioid prescribing or use, and explicit inclusion of cancer survivors. Exclusion criteria included end-of-life opioid use and opioid use as a secondary or downstream outcome (for intervention studies). We extracted information on the opioid-related outcome(s) examined (including definitions and terminology used), study design, and methods. RESULTS Research returned 16,591 articles; 296 were included. Only 22 of 296 studies evaluated an intervention. There were 105 studies evaluating outcomes indicative of potentially high-risk, nonrecommended, or avoidable opioid use, e.g., continuous use-described as chronic use, prolonged use, and persistent use (n = 17); use after completion of curative-intent treatment-described as chronic opioid use, long-term opioid use, persistent opioid use, prolonged opioid use, continued opioid use, late opioid use, post-treatment opioid use (n = 27); use of opioids concurrent with other potentially high-risk medications (n = 13), and opioid misuse (n = 14). CONCLUSIONS We found lack of consistency in the measurement of and terms used to describe similar opioid use outcomes, and a lack of interventional research targeting well-documented patterns of potentially nonrecommended, potentially avoidable, or potentially high-risk opioid prescribing or use.
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Affiliation(s)
- Devon K Check
- Department of Population Health Sciences, Duke University School of Medicine (D.K.C.), Durham, North Carolina; Duke Cancer Institute, Duke University Medical Cente (D.K.C., R.A.A., C.M., A.H.K., K.C.O.), Durham, North Carolina.
| | - Renee A V Avecilla
- Duke Cancer Institute, Duke University Medical Cente (D.K.C., R.A.A., C.M., A.H.K., K.C.O.), Durham, North Carolina
| | - Coleman Mills
- Duke Cancer Institute, Duke University Medical Cente (D.K.C., R.A.A., C.M., A.H.K., K.C.O.), Durham, North Carolina
| | - Michaela A Dinan
- Department of Chronic Disease Epidemiology, Yale School of Public Health (M.A.D.), New Haven, Connecticut; Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale Cancer Center (M.A.D.), New Haven, Connecticut
| | - Arif H Kamal
- Duke Cancer Institute, Duke University Medical Cente (D.K.C., R.A.A., C.M., A.H.K., K.C.O.), Durham, North Carolina; Department of Medicine, Duke University Medical Center (A.H.K.), Durham, North Carolina
| | - Beverly Murphy
- Duke University Medical Center Library & Archives, Duke University School of Medicine (B.M.), Durham, North Carolina
| | - Salma Rezk
- Division of Pharmaceutical Outcomes and Policy, UNC Eshelman School of Pharmacy (S.R.), Chapel Hill, North Carolina
| | - Aaron Winn
- School of Pharmacy, Medical College of Wisconsin (A.W.), Milwaukee, Wisconsin
| | - Kevin C Oeffinger
- Duke Cancer Institute, Duke University Medical Cente (D.K.C., R.A.A., C.M., A.H.K., K.C.O.), Durham, North Carolina; Department of Medicine, Duke University School of Medicine (K.C.O.), Durham, North Carolina
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Sabik LM, Eom KY, Sun Z, Merlin JS, Bulls HW, Moyo P, Pruskowski JA, van Londen G, Rosenzweig M, Schenker Y. Patterns and Trends in Receipt of Opioids Among Patients Receiving Treatment for Cancer in a Large Health System. J Natl Compr Canc Netw 2022; 20:460-467.e1. [PMID: 35231900 PMCID: PMC10463265 DOI: 10.6004/jnccn.2021.7104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 10/18/2021] [Indexed: 01/21/2023]
Abstract
BACKGROUND Given limited evidence on opioid prescribing among patients receiving treatment for cancer during the ongoing opioid epidemic, our objective was to assess predictors of and trends in opioid receipt during cancer treatment, including how patterns differ by type of cancer. METHODS Using cancer registry data, we identified patients with a first lifetime primary diagnosis of breast, colorectal, or lung cancer from 2013 to 2017 who underwent treatment within a large cancer center network. Cancer registry data were linked to electronic health record information on opioid prescriptions. We examined predictors of and trends in receipt of any opioid prescription within 12 months of cancer diagnosis. RESULTS The percentage of patients receiving opioids varied by cancer type: breast cancer, 35% (1,996/5,649); colorectal, 37% (776/2,083); lung, 47% (1,259/2,654). In multivariable analysis, opioid use in the year before cancer diagnosis was the factor most strongly associated with receipt of opioids after cancer diagnosis, with 4.90 (95% CI, 4.10-5.86), 5.09 (95% CI, 3.88-6.69), and 3.31 (95% CI, 2.68-4.10) higher odds for breast, colorectal, and lung cancers, respectively. We did not observe a consistent decline in opioid prescribing over time, and trends differed by cancer type. CONCLUSIONS Our findings suggest that prescription of opioids to patients with cancer varies by cancer type and other factors. In particular, patients are more likely to receive opioids after cancer diagnosis if they were previously exposed before diagnosis, suggesting that pain among patients with cancer may commonly include non-cancer-related pain. Heterogeneity and complexity among patients with cancer must be accounted for in developing policies and guidelines aimed at addressing pain management while minimizing the risk of opioid misuse.
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Affiliation(s)
- Lindsay M. Sabik
- University of Pittsburgh Graduate School of Public Health, Department of Health Policy and Management
| | - Kirsten Y. Eom
- University of Pittsburgh Graduate School of Public Health, Department of Health Policy and Management
| | - Zhaojun Sun
- University of Pittsburgh Graduate School of Public Health, Department of Health Policy and Management
| | - Jessica S. Merlin
- University of Pittsburgh School of Medicine, Palliative Research Center (PaRC) and Section of Palliative Care and Medical Ethics, Division of General Internal Medicine
| | - Hailey W. Bulls
- University of Pittsburgh School of Medicine, Palliative Research Center (PaRC) and Section of Palliative Care and Medical Ethics, Division of General Internal Medicine
| | - Patience Moyo
- Brown University School of Public Health, Department of Health Services, Policy, and Practice
| | | | - G.J. van Londen
- University of Pittsburgh School of Medicine, Department of Medicine, Divisions of Hematology-Oncology and Geriatric Medicine
| | - Margaret Rosenzweig
- University of Pittsburgh School of Nursing, Department of Acute & Tertiary Care
| | - Yael Schenker
- University of Pittsburgh School of Medicine, Palliative Research Center (PaRC) and Section of Palliative Care and Medical Ethics, Division of General Internal Medicine
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Delcher C, Harris DR, Park C, Strickler G, Talbert J, Freeman PR. "Doctor and pharmacy shopping": A fading signal for prescription opioid use monitoring? Drug Alcohol Depend 2021; 221:108618. [PMID: 33677354 PMCID: PMC8026641 DOI: 10.1016/j.drugalcdep.2021.108618] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 01/26/2021] [Accepted: 01/26/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND The term "doctor and pharmacy shopping" colloquially describes patients with high multiple provider episodes (MPEs)-a threshold count of distinct prescribers and/or pharmacies involved in prescription fulfillment. Opioid-related MPEs are implicated in the global opioid crisis and heavily monitored by government databases such as U.S. state prescription drug monitoring programs (PDMPs). We applied a widely-used MPE definition to examine U.S. trends from a large, commercially-insured population from 2010 to 2017. Further, we examined the proportion of enrollees identified as "doctor shoppers" with evidence of a cancer diagnosis to examine the risk of false positives. METHODS Using a large, commercially-insured population, we identified patients with opioid-related MPEs: opioid prescriptions (Schedule II-V, no buprenorphine) filled from ≥5 prescribers AND ≥ 5 pharmacies within the past 90 days ("5x5x90d"). Quarterly rates per 100,000 enrollees (two specifications) were calculated between 2010 and 2017. We examined the trend in a recently published all-payer, 7 state cohort from the U.S. Centers for Disease Control and Prevention for comparison. Cancer-related ICD-9/10-CM codes were used. RESULTS Quarterly MPE rates declined by approximately 73 % from 18.2-4.9 per 100,000 enrollee population with controlled substance prescriptions. In 2017, nearly one fifth of these commercially-insured enrollees identified by the 5x5x90d algorithm were diagnosed with cancer. Approximately 8% of this sample included patients with ≥ 1 buprenorphine prescriptions. CONCLUSIONS Opioid "shopping" flags are a long-standing but rapidly fading PDMP signal. To avoid unintended consequences, such as identifying legitimate medical encounters requiring high healthcare utilization or opioid treatment, while maintaining vigilance, more nuanced and sophisticated approaches are needed.
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Affiliation(s)
- Chris Delcher
- Institute for Pharmaceutical Outcomes and Policy, University of Kentucky, 760 Press Avenue, Research Building 2, Ste 260, Lexington, KY, 40536-0679, United States; Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, 760 Press Avenue, Research Building 2, Ste 260, Lexington, KY, 40536-0679, United States.
| | - Daniel R. Harris
- Institute for Pharmaceutical Outcomes and Policy, University of Kentucky, 760 Press Avenue, Research Building 2, Ste 260 Lexington, KY 40536-0679,Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, 760 Press Avenue, Research Building 2, Ste 260 Lexington, KY 40536-0679
| | - Changwe Park
- Institute for Pharmaceutical Outcomes and Policy, University of Kentucky, 760 Press Avenue, Research Building 2, Ste 260 Lexington, KY 40536-0679,Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, 760 Press Avenue, Research Building 2, Ste 260 Lexington, KY 40536-0679
| | - Gail Strickler
- Schneider Institutes for Health Policy, Brandeis University, 415 South Street Waltham, MA 02454-9110
| | - Jeffery Talbert
- Institute for Biomedical Informatics, College of Medicine, University of Kentucky, 267 Healthy Kentucky Research Building 760 Press Ave Lexington, KY 40536
| | - Patricia R. Freeman
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, 760 Press Avenue, Research Building 2, Ste 260 Lexington, KY 40536-0679
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Risk of Chronic Opioid Use After Radiation for Head and Neck Cancer: A Systematic Review and Meta-Analysis. Adv Radiat Oncol 2020; 6:100583. [PMID: 33728386 PMCID: PMC7935701 DOI: 10.1016/j.adro.2020.09.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 09/15/2020] [Accepted: 09/23/2020] [Indexed: 12/16/2022] Open
Abstract
Purpose Opioid addiction is a major public health concern. Chronic opioid use (COU) patterns after radiation for head and neck cancer (HNC) remain poorly understood. The aim of this study was to estimate the prevalence of COU and to identify its risk factors in patients with HNC undergoing curative-intent radiation therapy (RT) or chemoradiotherapy (CRT). Methods and Materials We performed a systematic review and meta-analysis using the PubMed (Medline), EMBASE, and Cochrane Library databases, queried from dates of inception until January 2020. COU was defined as persistent use of opioids ≥ 3 months after treatment completion. Meta-analyses were performed using random effects models. Heterogeneity was assessed using the I2 value. Results Seven retrospective studies, reporting on 1841 patients, met the inclusion criteria. Median age was 59.4 (range: 56.0-62.0) years with 1343 (72.9%) men and 498 (27.1%) women. Primary tumor locations included oropharynx (n = 891, 48.4%), oral cavity (n = 533, 29.0%), larynx (n = 93, 5.1%), hypopharynx (n = 32, 1.7%), and nasopharynx (n = 29, 1.6%). Eight hundred fifty-four (46.0%) patients had stage I/II and 952 (50.3%) had stage III-IV disease. Three hundred one (16.3%) patients had RT alone, 738 (40.1%) received CRT, and 594 (32.3%) underwent surgery followed by adjuvant RT/CRT. The proportion of patients with HNC who developed COU post-RT/CRT was 40.7% at 3 months (95% confidence interval [CI]: 22.6%-61.7%; I2 = 97.1%) and 15.5% at 6 months (95% CI: 7.3%-29.7%; I2 = 94.3%). Oropharyngeal malignancies had the highest rate of COU based on primary tumor location (46.6%; 95% CI: 30.8%-63.1%; P < .0001). High proportions of COU were found in patients with a history of psychiatric disorder(s) (61.7%), former/current alcohol abuse (53.9%), and opioid requirements before radiation treatment (51.6%; P = .035). Conclusions A significant proportion of patients who undergo RT for HNC suffer from COU. High-risk factors for COU include an oropharyngeal primary, history of psychiatric disorder, former/current alcohol abuse, and pre-treatment opioid use. New strategies to mitigate COU are needed.
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