Patient Patterns and Perspectives on Using Opioid Regimens for Chronic Cancer Pain

A Conceptual Analysis of Opioid Use Disorder in Chronic Noncancer Pain Using Rodger's Evolutionary Approach

OBJECTIVE

This study aims to examine the complex nature of opioid use disorder (OUD) in chronic noncancer pain (CNCP) by exploring its antecedents, attributes, consequences, and interrelated concepts.

DESIGN

A systematic literature review was conducted to gather relevant studies published between 2015 and 2022, utilizing the CINAHL, MEDLINE, PsycINFO, and PubMed databases.

DATA SOURCES

The selected databases provided a comprehensive range of articles related to OUD in CNCP, ensuring a comprehensive topic analysis.

METHODS

Twenty-two articles meeting the inclusion criteria were included in the analysis. These articles were critically reviewed and analyzed to identify key themes and concepts related to OUD in CNCP.

RESULTS

The findings of this study shed light on the multifaceted aspects of OUD in CNCP, including its antecedents, such as goals of physical function improvement, prescription of opioids for CNCP, social influences, and mental health dynamics. The attributes of OUD in CNCP were identified as chronic pain, noncancer pain, opioid use, misuse, and abuse. OUD's consequences in CNCP include impaired functioning, increased health risks, psychological distress, social challenges, and economic burden.

CONCLUSION

Understanding the complexity of OUD in CNCP is crucial for improving patient outcomes. Collaborative efforts among healthcare systems, regulatory bodies, and professional organizations are needed to develop policies promoting safe and effective pain management while mitigating risks associated with opioid use in CNCP.

IMPLICATIONS FOR PRACTICE

Implementing policy recommendations derived from this study enhances care and outcomes for individuals with CNCP. By addressing complex issues of OUD in CNCP and adopting evidence-based practices, healthcare providers can optimize pain management and promote well-being in CNCP patients.

Perceptions of prescription opioids among marginalized patients with hematologic malignancies in the context of the opioid epidemic: a qualitative study

PURPOSE

Opioids are essential for treating pain in hematologic malignancies (HM), yet are heavily stigmatized in the era of the opioid epidemic. Stigma and negative attitudes towards opioids may contribute to poorly managed cancer pain. We aimed to understand patient attitudes towards opioids for HM pain management, particularly among historically marginalized populations.

METHODS

We interviewed a convenience sample of 20 adult patients with HM during outpatient visits at an urban academic medical center. Semi-structured interviews were audio-recorded, transcribed, and qualitatively analyzed using the framework method.

RESULTS

Among 20 participants, 12 were female and half were Black. Median age was 62 (interquartile range = 54-68). HM diagnoses included multiple myeloma (n = 10), leukemia (n = 5), lymphoma (n = 4), and myelofibrosis (n = 1). Eight themes emerged from interviews that seemed to influence HM-related pain self-management, including (1) fear of opioid-related harms, (2) opioid side effects and harms to health, (3) fatalism and stoicism, (4) perceived value of opioids for HM-related pain, (5) low perceived susceptibility to opioid-related harms and externalizing blame, (6) preferences for non-opioid pain management approaches, (7) trust in providers and opioid accessibility, and (8) external sources of pain management support and information.

CONCLUSIONS

This qualitative study demonstrates that fears and stigmatized views of opioids can conflict with marginalized patients' needs to manage debilitating HM-related pain. Negative attitudes towards opioids were shaped by the opioid epidemic and reduced willingness to seek out or use analgesics.

IMPLICATIONS FOR CANCER SURVIVORS

These findings help expose patient-level barriers to optimal HM pain management, revealing attitudes, and knowledge to be targeted by future pain management interventions in HM.

Patient beliefs associated with medication hesitancy in palliative care: A systematic review using the theory of planned behavior

CONTEXT

The demand of palliative care is increasing due to the aging population and treatment hesitancy or intentional avoidance compromises symptom management.

OBJECTIVES

To identify patient beliefs associated with medication hesitancy by using the theory of planned behavior (TPB) namely, attitudes, subjective norms, behavioral intention, and perceived behavioral control associated with medication hesitancy or intentional noncompliance by avoidance.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analysis guideline was followed to conduct a systematic literature search involving the CINAHL, Embase, MEDLINE, and PsycINFO databases from inception until March 2022. Hand-searched articles from reference lists and gray literature were included. Thematic analysis was conducted on qualitative data and triangulated with quantitative data.

RESULTS

About 554 articles were retrieved from the literature search and 17 articles were included based on the eligibility criteria. Three subthemes that were identified under TPB constructs were attitude: negative attitude toward medications, passive attitude toward illness and inaccurate information about disease or medication; one subtheme was identified under subjective norms: perceived negative opinions from others; and one subtheme was identified under perceived behavioral control: perception of manageable symptoms. Quantitative data provided triangulation of qualitative findings related to fear of addiction and side effects, feelings of hopelessness, unclear direction and information, social stigma, endurable symptoms, and illness as determinants for medication avoidance.

SIGNIFICANCE OF RESULTS

This systematic review highlighted some patient beliefs related to medication hesitancy or avoidance. Clinicians should take patient beliefs and concerns into consideration when creating treatment regimens for people receiving palliative care to optimize medication adherence and the quality of care.

Electronic Real-Time Monitoring Reveals Limited Adherence to Long-Term Opioid Prescriptions in Pain Patients

Background

Pain management physicians are increasingly focused on limiting prescription opioid abuse, yet existing tools for monitoring adherence have limited accuracy. Medication event monitoring system (MEMS) is an emerging technology for tracking medication usage in real-time but has not been tested in chronic pain patients on long-term opioid regimens.

Objective

We conducted a pilot clinical trial to investigate the utility of MEMS for monitoring opioid adherence and compared to traditional methods including self-report diaries, urine drug screen (UDS), and physicians' opinions.

Methods

Opioid-maintained chronic pain patients were recruited from a pain management clinic. Participants (n=28) were randomly assigned to either receive MEMS bottles containing their opioid medication for a 90-day period or to continue using standard medication bottles. MEMS bottles were configured to record and timestamp all bottle openings and the number of pills that were removed from the bottle (via measurement of weight change).

Results

Participants who received MEMS demonstrated highly heterogenous dosing patterns, with a substantial number of patients rapidly removing excessive amounts of medication and/or "stockpiling" medication. By comparison, physicians rated all participants as either "totally compliant" or "mostly compliant". UDS results did not reveal any illicit drug use, but 25% of participants (n=7) tested negative for their prescribed opioid metabolite. MEMS data did not correlate with physician-rated adherence (P=0.24) and UDS results (P=0.77). MEMS data consistently revealed greater non-adherence than self-report data (P<0.001).

Conclusion

These results highlight the limits in our understanding of naturalistic patterns of daily opioid use in chronic pain patients as well as support the use of MEMS for detecting potential misuse as compared to routine adherence monitoring methods. Future research directions include the need to determine how MEMS could be used to improve patient outcomes, minimize harm, and aid in clinical decision-making.

Trial Registration

This study was preregistered on ClinicalTrials.gov (NCT03752411).

Virtual reality-guided mindfulness for chronic pain in cancer survivors: protocol for the virtual mind study-a single-group feasibility trial

Background

Chronic cancer-related pain (CRP) can have a significant negative impact on quality of life. Mindfulness is hypothesized to mitigate chronic CRP by regulating both physical and emotional resistance to pain. In recent years, there has been interest in the use of virtual reality (VR) to deliver mindfulness meditation. VR provides an immersive and engaging environment, which may enhance one's focused attention to present-moment experiences, potentially making mindfulness less effortful and more efficacious for individuals with chronic pain. There has been little research in this area for people with a history of cancer.

Objective

The aim of this mixed methods study is to evaluate the feasibility of a VR-guided mindfulness (VRGM) intervention offered to adult cancer survivors with chronic CRP.

Methods

This mixed methods feasibility study will employ a single-arm, pretest-posttest design with semistructured interviews. In total, 15 cancer survivors will be enrolled in a 6-week home-based intervention that consists of 10-15 min of daily VRGM practice. The primary outcome is feasibility as assessed by accrual rates, retention in the study, intervention adherence, questionnaire completion, and side effect rates. Participants will be assessed on psychosocial outcome measures (i.e., pain, sleep, depressive and anxiety symptoms, fatigue, quality of life, and mindfulness) before and after the intervention, and 6 weeks post intervention (follow-up). Changes in pain will be described in relation to levels of immersion and presence in the virtual environment, trait mindfulness, and amount of VRGM practice. Qualitative information will provide subjective detail on participants' experience with VRGM to complement quantitative data. This study has been approved by the Health Research Ethics Board of Alberta Cancer Committee (HREBA.CC-20-0411).

Conclusions

This novel intervention provides a potential alternative treatment to pharmacological pain management. Results from this study may inform future larger VGRM trials for chronic CRP to help reduce suffering in people with cancer. Study findings will be disseminated through open access publications, traditional conference presentations, professional cancer organizations, and social media platforms.

Pain coping, multidisciplinary care, and mHealth: Patients' views on managing advanced cancer pain

OBJECTIVE

Pain is common among people with advanced cancer. While opioids provide significant relief, incorporating psycho-behavioral treatments may improve pain outcomes. We examined patients' experiences with pain self-management and how their self-management of chronic, cancer-related pain may be complemented by behavioral mobile health (mHealth) interventions.

METHODS

We conducted semi-structured qualitative interviews with patients with advanced cancer and pain. Each participant reviewed content from our behavioral mHealth application for cancer pain management and early images of its interface. Participants reflected on their experiences self-managing cancer pain and on app content. Interviews were transcribed verbatim and analyzed using a combination of inductive and deductive thematic analysis.

RESULTS

Patients (n = 28; 54% female; mean age = 53) across two geographic regions reported using psychological strategies (e.g., reframing negative thoughts, distraction, pain acceptance, social support) to manage chronic cancer-related pain. Patients shared their perspectives on the integration of psycho-behavioral pain treatments into their existing medical care and their experiences with opioid hesitancy. Patient recommendations for how mHealth interventions could best support them coalesced around two topics: 1.) convenience in accessing integrated pharmacological and psycho-behavioral pain education and communication tools and 2.) relevance of the specific content to their clinical situation.

CONCLUSIONS

Integrated pharmacological and psycho-behavioral pain treatments were important to participants. This underscores a need to coordinate complimentary approaches when developing cancer pain management interventions. Participant feedback suggests that an mHealth intervention that integrates pain treatments may have the capacity to increase advanced cancer patients' access to destigmatizing, accessible care while improving pain self-management.

Development and pre-pilot testing of STAMP + CBT: an mHealth app combining pain cognitive behavioral therapy and opioid support for patients with advanced cancer and pain

PURPOSE

We developed and piloted a mobile health app to deliver cognitive behavioral therapy for pain (pain-CBT), remote symptom monitoring, and pharmacologic support for patients with pain from advanced cancer.

METHODS

Using an iterative process of patient review and feedback, we developed the STAMP + CBT app. The app delivers brief daily lessons from pain-CBT and pain psychoeducation, adapted for advanced cancer. Daily surveys assess physical symptoms, psychological symptoms, opioid utilization and relief. Just-in-time adaptive interventions generate tailored psychoeducation in response. We then conducted a single-arm pilot feasibility study at two cancer centers. Patients with advanced cancer and chronic pain used the app for 2 or 4 weeks, rated its acceptability and provided feedback in semi-structured interviews. Feasibility and acceptability were defined as ≥ 70% of participants completing ≥ 50% of daily surveys, and ≥ 80% of acceptability items rated ≥ 4/5.

RESULTS

Fifteen participants (female = 9; mean age = 50.3) tested the app. We exceeded our feasibility and accessibility benchmarks: 73% of patients completed ≥ 50% of daily surveys; 87% of acceptability items were rated ≥ 4/5. Participants valued the app's brevity, clarity, and salience, and found education on stress and pain to be most helpful. The app helped participants learn pain management strategies and decrease maladaptive thoughts. However, participants disliked the notification structure (single prompt with one snooze), which led to missed content.

CONCLUSION

The STAMP + CBT app was an acceptable and feasible method to deliver psychological/behavioral treatment with pharmacologic support for cancer pain. The app is being refined and will be tested in a larger randomized pilot study. TRN: NCT05403801 (05/06/2022).

Fentanyl in cancer pain management: avoiding hasty judgments and discerning its potential benefits

Cancer pain is an important challenge in treatment and requires a rapid onset of action for its control. In particular, breakthrough cancer pain (BTcP) should be adequately controlled with a stable dose of a short-acting oral opioid. Fentanyl is a synthetic, highly selective opioid with many advantageous chemical properties, including high lipophilicity and distinct pharmacokinetic properties. It is recommended for pain management in a variety of settings, including acute pain, chronic pain and BTcP. To date, its variously designed formulations allow non-invasive administration; amongst others, sublingual fentanyl has proven useful in the management of BTcP and in improving the quality of life of patients with cancer. This review provides an update on the management of BTcP with fentanyl, with consideration of safety, as it remains an important tool in the treatment of cancer pain.

[Factors influencing analgesic use patterns in patients with chronic tumor-associated pain. : A qualitative pilot study considering different groups of medications]

BACKGROUND

Patients are surviving tumor diseases longer and longer due to the improvement of tumor-specific therapy and pain is a common symptom. The gold standard for tumor-associated chronic pain is multimodal therapy. Non-adherence causes high costs and may put patients at risk. The aim of this study was to investigate the adherence behavior and subjective treatment compliance of patients with tumor-associated chronic pain. The focus was on the patients' perspective. Different groups of medications, such as NOPA, opioids, co-analgesics and cannabinoids, as well as non-drug treatments were included.

METHODS

Semistructured guided interviews with 10 patients with chronic tumor pain were conducted within a qualitative research approach. The interviews were recorded and transcribed. The evaluation was using a focused content structuring interview analysis according to Kuckartz and Rädiker.

RESULTS

Five main categories were defined. The central category based on the research question was "Adherence behavior from the patient's perspective." The category "Medication therapy" formed the framework of the study. Other main categories were "History of illness", "Relationship with treatment providers" and "Attitudes and beliefs". A total of 77 additional subcategories were formed and interpreted. Adherence behavior from the patients' perspective differed between the different medication groups. A palliative setting influenced treatment decisions and adherence. The medication regimens used were complex and dynamic, especially when there were multiple practitioners involved. Furthermore, there was ambiguity in the use of cannabinoids. Non-drug therapies were marginalized by patients. From the point of view of the patients interviewed, it was not so much the treatment providers who influenced their adherence behavior, but rather their own experiences, attitudes, and convictions.

DISCUSSION

The study included all medication groups and non-drug therapies equally, complementing previous literature in a qualitative setting. Adherence factors known from previous research were reflected in the subjective perception of the group of patients with chronic pain after tumor diseases. Marginalization of non-medication methods could be explained by the fact that multimodal therapy approaches were too rarely constantly used and controlled in the phase of chronification. Therefore, drug and non-drug therapies should be applied even more consistently to patients with tumor-associated pain.

Top Ten Tips Palliative Care Clinicians Should Know About Behavioral Pain Management for Persistent Pain

Seriously ill patients often experience persistent pain. As a part of a comprehensive repertoire of pain interventions, palliative care clinicians can help by using behavioral pain management. Behavioral pain management refers to evidence-based psychosocial interventions to reduce pain intensity and enhance functional outcomes and quality of life. Conceptualized using the biopsychosocial model, techniques involve promoting helpful behaviors (e.g., activity pacing, stretching, and relaxation exercises) and modifying underlying patterns of thinking, feeling, and communicating that can exacerbate pain. The authors have expertise in pain management, clinical health psychology, geropsychology, behavioral science, and palliative medicine. The article reviews the current evidence for behavioral interventions for persistent pain and provides 10 recommendations for behavioral pain management.

When can cancer patient treatment nonadherence be considered intentional or unintentional? A scoping review

BACKGROUND

Treatment nonadherence in cancer patients remains high with most interventions having had limited success. Most studies omit the multi-factorial aspects of treatment adherence and refer to medication adherence. The behaviour is rarely defined as intentional or unintentional.

AIM

The aim of this Scoping Review is to increase understanding of modifiable factors in treatment nonadherence through the relationships that physicians have with their patients. This knowledge can help define when treatment nonadherence is intentional or unintentional and can assist in predicting cancer patients at risk of nonadherence and in intervention design. The scoping review provides the basis for method triangulation in two subsequent qualitative studies: 1. Sentiment analysis of online cancer support groups in relation to treatment nonadherence; 2. A qualitative validation survey to refute / or validate claims from this scoping review. Thereafter, framework development for a future (cancer patient) online peer support intervention.

METHODS

A Scoping Review was performed to identify peer reviewed studies that concern treatment / medication nonadherence in cancer patients-published between 2000 to 2021 (and partial 2022). The review was registered in the Prospero database CRD42020210340 and follows the PRISMA-S: an extension to the PRISMA Statement for Reporting Literature Searches in Systematic Searches. The principles of meta-ethnography are used in a synthesis of qualitative findings that preserve the context of primary data. An aim of meta-ethnography is to identify common and refuted themes across studies. This is not a mixed methods study, but due to a limited qualitativevidence base and to broaden findings, the qualitative elements (author interpretations) found within relevant quantitative studies have been included.

RESULTS

Of 7510 articles identified, 240 full texts were reviewed with 35 included. These comprise 15 qualitative and 20 quantitative studies. One major theme, that embraces 6 sub themes has emerged: 'Physician factors can influence patient factors in treatment nonadherence'. The six (6) subthemes are: 1. Suboptimal Communication; 2. The concept of Information differs between Patient and Physician; 3.Inadequate time. 4. The need for Treatment Concordance is vague or missing from concepts; 5. The importance of Trust in the physician / patient relationship is understated in papers; 6. Treatment concordance as a concept is rarely defined and largely missing from studies.

LINE OF ARGUMENT WAS DRAWN

Treatment (or medication) nonadherence that is intentional or unintentional is often attributed to patient factors-with far less attention to the potential influence of physician communication factors. The differentation between intentional or unintentional nonadherence is missing from most qualitative and quantitative studies. The holistic inter-dimensional / multi-factorial concept of 'treatment adherence' receives scant attention. The main focus is on medication adherence / nonadherence in the singular context. Nonadherence that is unintentional is not necessarily passive behaviour and may overlap with intentional nonadherence. The absence of treatment concordance is a barrier to treatment adherence and is rarely articulated or defined in studies.

CONCLUSION

This review demonstrates how cancer patient treatment nonadherence is often a shared outcome. An equal focus on physican and patient factors can increase understanding of the two main types of nonadherence (intentional or unintentional). This differentation should help improve the fundamentals of intervention design.

"Fortunately I felt pain, or I would have thought I was on my way out": experiencing pain and negotiating analgesic treatment in the context of cancer

OBJECTIVES

To explore cancer patients' experience of pain and coping strategies as well as beliefs and representations associated with pain, pain management and treatments.

METHOD AND PARTICIPANTS

A qualitative study based on semi-structured interviews was conducted among 16 patients with cancer. The inductive research strategy adopted derived from the Grounded Theory approach and the data transcribed verbatim were gradually analyzed involving researcher triangulation.

FINDINGS

The experience of pain and the coping strategies developed by patients to deal with it are shaped by the experience and representations of cancer associated with death and suffering. Pain acts both as an indication to the patients that they are still alive and as an indicator of the progression of the disease. Cancer also models patients' relationships to analgesic treatments and health care providers, since pain is an area in which patients can take back control of what is happening to them. Patients' expression of reluctance to accept analgesic treatments is also influenced by the significance of opioid treatments in this context, which are perceived as an indication that the end of life is close.

CONCLUSIONS

The contextualization of pain through the particularities of cancer is critical in order to understand cancer patients' experience of pain.

IMPLICATIONS FOR PSYCHOSOCIAL PROVIDERS

Not only patients' knowledge but also the meaning-making of pain should be incorporated in interventions targeting pain management.

Use of Opioids for Adults With Pain From Cancer or Cancer Treatment: ASCO Guideline

PURPOSE

To provide guidance on the use of opioids to manage pain from cancer or cancer treatment in adults.

METHODS

A systematic review of the literature identified systematic reviews and randomized controlled trials of the efficacy and safety of opioid analgesics in people with cancer, approaches to opioid initiation and titration, and the prevention and management of opioid adverse events. PubMed and the Cochrane Library were searched from January 1, 2010, to February 17, 2022. American Society of Clinical Oncology convened an Expert Panel to review the evidence and formulate recommendations.

RESULTS

The evidence base consisted of 31 systematic reviews and 16 randomized controlled trials. Opioids have primarily been evaluated in patients with moderate-to-severe cancer pain, and they effectively reduce pain in this population, with well-characterized adverse effects. Evidence was limited for several of the questions of interest, and the Expert Panel relied on consensus for these recommendations or noted that no recommendation could be made at this time.

RECOMMENDATIONS

Opioids should be offered to patients with moderate-to-severe pain related to cancer or active cancer treatment unless contraindicated. Opioids should be initiated PRN (as needed) at the lowest possible dose to achieve acceptable analgesia and patient goals, with early assessment and frequent titration. For patients with a substance use disorder, clinicians should collaborate with a palliative care, pain, and/or substance use disorder specialist to determine the optimal approach to pain management. Opioid adverse effects should be monitored, and strategies are provided for prevention and management.Additional information is available at www.asco.org/supportive-care-guidelines.

Unacceptable pain in oncology: The patients' perspective on reasons for absence of pain interventions

Objective

Around 40% of oncology patients receive inadequate pain treatment. A previous study reported pain interventions for only 70% of patients who reported unacceptable pain at the self‐service registration desk. The aim of this study is to gain insight in reasons for the absence of pain intervention among oncology patients who reported unacceptable pain.

Methods

In this mixed methods study, 20 patients visiting the oncology outpatient clinic were selected via patient record assessment and interviewed about their perceived reasons for absence of pain intervention.

Results

The reasons mentioned by the patients for absence of pain intervention included reluctance of the patient to discuss pain, no treatment preferred by the patient, focus of the physician on treatment of the disease, pain treatment difficult or impossible, and the perception that pain is an inevitable consequence of the cancer treatment. Almost 50% of the patients considered the physician responsible for the absence of pain intervention.

Conclusion

In conclusion, a variety of reasons for absence of pain intervention are reported by patients, including patient‐related and health professional‐related reasons. Improvements can be made by promoting regular discussion of pain during hospital visits and empowerment of patients.

Cancer pain during an epidemic and a pandemic

PURPOSE OF REVIEW

As our global population ages, cancer has become more prevalent. Thankfully, oncologic treatments are highly effective, leading to significantly improved rates of long-term survival. However, many of these therapies are associated with persistent pain syndromes. Clinicians caring for people with cancer must understand how the influence of the current epidemic of opioid misuse and the coronavirus disease 2019 (COVID-19) pandemic have complicated cancer pain management. Creative solutions can emerge from this knowledge.

RECENT FINDINGS

Persistent pain due to cancer and its treatment can be managed through multimodal care, although efforts to mitigate the opioid misuse epidemic have created challenges in access to appropriate treatment. Isolation measures associated with the COVID-19 pandemic have limited access to nonpharmacologic therapies, such as physical therapy, and have exacerbated mental health disorders, including anxiety and depression.

SUMMARY

Cancer pain treatment requires more nuanced assessment and treatment decisions as patients live longer. Societal factors multiply existing challenges to cancer pain relief. Research is needed to support safe and effective therapies.

Opioid Prescribing and Use Among Cancer Survivors: A Mapping Review of Observational and Intervention Studies

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.

Opioid Use at End-Of-Life Among Nova Scotia Patients With Cancer

Purpose: To determine the factors associated with opioid analgesic prescriptions as measured by community pharmacy dispensations to all Nova Scotia (NS) patients with cancer at end-of-life from 2005 to 2009.

Methods: The NS Cancer Registry and the NS Prescription Monitoring Program (NSPMP) were used to link Nova Scotians who had a cancer diagnosis and received a prescription for opioids in their last year of life (n = 6,186) from 2005 to 2009. The association of factors with opioid dispensations at end-of-life were determined (e.g., patient demographics, type of prescriber, type of cancer, and opioid type, formulation, and dose).

Results: Almost 54% (n = 6,186) of the end-of-life study population with cancer (n = 11,498) was linked to the NSPMP and therefore dispensed opioids. Most prescriptions were written by general practitioners (89%) and were for strong opioids (81%). Immediate-release formulations were more common than modified-release formulations. Although the annual average parenteral morphine equivalents (MEQ) did not change during the study period, the number of opioid prescriptions per patient per year increased from 5.9 in 2006 to 7.0 in 2009 (p < 0.0001). Patients age 80 and over received the fewest prescriptions (mean 3.9/year) and the lowest opioid doses (17.0 MEQ) while patients aged 40–49 received the most prescriptions (mean 14.5/year) and the highest doses of opioid (80.2 MEQ).

Conclusion: Our study examined opioid analgesic use at end-of-life in patients with cancer for a large real-world population and determined factors, trends and patterns associated with type and dose of opioid dispensed. We provide information regarding how general practitioners prescribe opioid therapy to patients at end-of-life. Our data suggest that at the time of this study, there may have been under-prescribing of opioids to patients with cancer at end-of-life. This information can be used to increase awareness among general practitioners, and to inform recommendations from professional regulatory bodies, to aid in managing pain for cancer patients at end-of-life. Future work could address how opioid prescribing has changed over time, and whether efforts to reduce opioid prescribing in response to the opioid crisis have affected patients with cancer at end-of-life in Nova Scotia.

Leveraging mobile health technology and research methodology to optimize patient education and self-management support for advanced cancer pain

PURPOSE

Patient education is critical for management of advanced cancer pain, yet the benefits of psychoeducational interventions have been modest. We used mobile health (mHealth) technology to better meet patients' needs.

METHODS

Using the Agile and mHealth Development and Evaluation Frameworks, a multidisciplinary team of clinicians, researchers, patients, and design specialists followed a four-phase iterative process to develop comprehensive, tailored, multimedia cancer pain education for a patient-facing smartphone application. The target population reviewed the content and provided feedback.

RESULTS

The resulting application provides comprehensive cancer pain education spanning pharmacologic and behavioral aspects of self-management. Custom graphics, animated videos, quizzes, and audio-recorded relaxations complemented written content. Computable algorithms based upon daily symptom surveys were used to deliver brief, tailored motivational messages that linked to more comprehensive teaching. Patients found the combination of pharmacologic and behavioral support to be engaging and helpful.

CONCLUSION

Digital technology can be used to provide cancer pain education that is engaging and tailored to individual needs. A replicable interdisciplinary and patient-centered approach to intervention development was advantageous. mHealth interventions may be a scalable approach to improve cancer pain. Frameworks that merge software and research methodology can be useful in developing interventions.

Healthcare professionals' perceptions of dignity-preserving care for older home-dwelling women with incurable cancer in Norway

Municipal end-of-life care for older home-dwelling patients with cancer is a complex matter requiring healthcare professionals (HCPs) to recognize gender differences in a social, historical and organizational context. A qualitative approach was chosen to explore and identify HCPs value-based principles and organizational conditions promoting dignity-preserving care practice for these women. HCPs recognized the importance of sheltering the women's identity, their sense of being home and acknowledged their personal preferences as value-based principles, whereas creating a flexible culture of care, establishing a functional professional collaboration and developing individualized plans of care, were crucial organizational conditions influencing the practice of dignity-preserving care.

Endogenous opiates and behavior: 2019

This paper is the forty-second consecutive installment of the annual anthological review of research concerning the endogenous opioid system, summarizing articles published during 2019 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides and receptors as well as effects of opioid/opiate agonists and antagonists. The review is subdivided into the following specific topics: molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors (1), the roles of these opioid peptides and receptors in pain and analgesia in animals (2) and humans (3), opioid-sensitive and opioid-insensitive effects of nonopioid analgesics (4), opioid peptide and receptor involvement in tolerance and dependence (5), stress and social status (6), learning and memory (7), eating and drinking (8), drug abuse and alcohol (9), sexual activity and hormones, pregnancy, development and endocrinology (10), mental illness and mood (11), seizures and neurologic disorders (12), electrical-related activity and neurophysiology (13), general activity and locomotion (14), gastrointestinal, renal and hepatic functions (15), cardiovascular responses (16), respiration and thermoregulation (17), and immunological responses (18).

Gaps in the Use of Long-Acting Opioids Within Intervals of Consecutive Days Among Cancer Outpatients Using Electronic Pill Caps

OBJECTIVE

This study describes individual cancer patients' nonuse of extended-release or long-acting (ER/LA) opioids, including periods of gap between opioid doses taken.

DESIGN

Secondary analysis of a three-month observational study of prescribed ER/LA opioids monitored using electronic pill caps.

SETTING

Two outpatient oncology clinics of a large health system in the Mid-Atlantic region.

PARTICIPANTS

Inclusion was based on self-identified African Americans and whites, at least 18 years old, diagnosed with solid tumors or multiple myeloma. For the current analysis, the additional inclusion criterion was prescription of an oral ER/LA opioid for cancer pain to be taken around the clock.

METHODS

The electronic monitoring period for each study participant was partitioned into intervals of days between days with one or more openings (using medication event monitoring systems) representing rates of ER/LA opioid nonuse over consecutive days and over time.

RESULTS

Of the sample (N = 109), two-thirds of the cancer patients had some nonuse of prescribed ER/LA opioids, with one in four having nonuse during 31.5-87.5% of their electronic-monitoring periods. Nonuse over periods of five or more, six or more, and seven or more consecutive days occurred for 37.6%, 34.9%, and 30.3% of the participants, respectively.

CONCLUSIONS

About one in three ambulatory cancer patients in this study had substantial gaps between days of ER/LA opioid use, potentially resulting in risk of overdose depending upon the prescribed ER/LA opioid type, dose, and length of the time the opioid was stopped and resumed at the previous dose. This phenomenon has received little to no attention in the opioid safety discourse.

Attitudes and appropriateness of pain management in cancer patients using pain management index

Objectives

Inadequate management of cancer pain (CP) remains a global medical problem. In this study, the aim was to assess attitudes of cancer patients towards their CP treatment and to evaluate effectiveness of pain management.

Methods

A sample of 300 adult cancer patients admitted to a single hospital were face-to-face interviewed in a cross-sectional study design using a structured questionnaire. The short form of the Brief Pain Inventory was used to collect data on pain, and Pain Management Index (PMI) was calculated to assess adequacy of pain management.

Key findings

Median age of patients was 53 years (interquartile range, 43–63). Half of patients (50.5%) believed their pain therapy needs improvement. Almost half patients had severe pain at interview (49.8%). Pain interfered most with patient enjoyment of life with a mean interference score 6.13 ± 2.37. Majority of cancer patients (84.3%) received a non-opioid analgesic while a minority (15.7%) received opioid analgesic in which morphine was the most common drug. The use of non-opioid adjuvants was minimal. Mean PMI for patients was −1.15 ± 0.75 (range −2 to +1), and most patients (80.3%) had inadequate pain treatment. Gender and smoking status of patients were significantly associated with adequacy of pain management (P = 0.009 and P = 0.004, respectively). There were no associations between patient age, educational level or tumour characteristics and adequacy of pain management.

Conclusions

Cancer patients in this study present with severe pain and the rates of undertreatment are high. There is an urgent need to improve management plans to assure appropriate use of therapeutic modalities for treatment of cancer-related pain.

When Patients Take Charge of Opioids: Self-Management Concerns and Practices Among Cancer Outpatients in the Context of Opioid Crisis

CONTEXT

With concerns about opioid prescribing practices prominent in the professional and lay literature, there is less focus on patients' self-management of opioids for cancer pain and potential safety risks.

OBJECTIVES

To investigate reports of opioid self-management practices and concerns among patients undergoing active cancer treatments-a group excluded from the scope of most policy initiatives on prescription opioids.

METHODS

This sequential multimethod study used freelisting (n = 65) and open-ended semistructured interviews with a racially diverse subgroup (n = 32). Adult ambulatory patients with solid malignancies or multiple myeloma and pain (≥4 on a scale of 0-10) were recruited from an urban National Cancer Institute-designated cancer center in Philadelphia. Freelists were analyzed using consensus analysis and semistructured interview data were analyzed using thematic analysis.

RESULTS

In freelisting, "pain relief" emerged as the primary term in relation to taking pain medications preceding "addiction" concerns. In interviews, patients described several heuristics and some potentially unsafe practices to minimize opioid use to a self-defined "normal." These included reducing opioid dose by cutting pills; self-tapering off opioids; using extended-release/long-acting opioids on an as-needed basis; mixing over-the-counter, nonopioid analgesics; and using illicit drugs to avoid "harder medicines" (opioids). Many patients preferred nonopioid treatments for pain but invariably faced access barriers. Some described assuming stewardship of their prescribed opioids and felt that oncology clinicians are quick to prescribe opioids without providing workable alternatives.

CONCLUSIONS

Risks related to self-management of opioids among cancer outpatients, including potential overdose risks, need urgent attention. Interventions are needed for improving clinician-patient communication, patient education, safety, and access to effective nonopioid alternatives.