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Should all patients with cancer undergo an addiction risk assessment prior to receiving opioids?
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Yes.
Risk assessment should be conducted when initiating long-term opioid therapy for cancer pain, followed by incorporation of universal precautions to minimize abuse, addiction and adverse consequences of opioids. The purpose of all of these efforts is safety — keeping our patients safe from misuse and our community free of prescription opioids that might be diverted.
Risk assessment integrates many of the components of a thorough history — including tobacco, alcohol and recreational drug use — already conducted in oncology settings. We also ask about family history of alcohol or drug abuse, whether the patient has a major psychiatric disorder and whether they have experienced sexual abuse. This information is used to guide the oncologist in deciding whether to prescribe opioids. Universal precautions include periodic monitoring using random urine toxicology and review of prescription drug monitoring programs. Other aspects may include controlled substance agreements and pill counts. Specific recommendations regarding risk mitigation and adherence monitoring are defined in “ASCO’s clinical practice guidelines.” Universal precautions can reduce stigma because everyone is assessed, avoiding targeting based upon implicit bias. These practices also improve patient care by treating the entire patient, and addressing and containing risk when it exists.
Many patients fear addiction — often far more than warranted based upon their individual risk factors — particularly given the media attention to the opioid misuse epidemic and resultant deaths. Knowing we are attentive to these risks provides comfort to some. For those with previously undiagnosed substance use disorder, or who are experiencing relapse in the face of a cancer diagnosis, interventions can be employed to address this equally difficult disorder. Even when approaching death, people with addiction can, and often prefer to, work toward sobriety to give meaning to their life and legacy.
Finally, this strategy opens the door to frank conversations about risk and serves as an important segue to discussions about safe storage and disposal. The current opioid abuse epidemic may have begun with misuse of prescription opioids, often diverted from people with cancer. The enormity of these thefts is often underappreciated by clinicians, as patients may be reluctant to report the loss. They fear loss of access to medications or their ability to continue to live independently. Preventing diversion, and educating patients about their role in these efforts, will ensure a safe community.
Reference:
Paice JA, et al. J Clin Oncol. 2016;doi:10.1200/JCO.2016.68.5206.
Judith A. Paice, PhD, RN, is director of the cancer pain program at Northwestern University Feinberg School of Medicine. She can be reached at j-paice@northwestern.edu. Disclosure: Paice reports no relevant financial disclosures.
It depends.
Some assessments recommended for noncancer pain require more evidence before being implemented for patients with cancer-related pain.
Studies using screening questionnaires to assess risk for alcohol or opioid misuse from large cancer centers in North America indicated at least one in five patients may be at risk for opioid use disorder. Several studies using screening questionnaires demonstrated associations between high-risk patients and aberrant behavior, prolonged opioid use, higher morphine equivalent daily dose, greater health care use and symptom burden. It is unclear whether one assessment tool is preferable to another; however, the ease of use, high prevalence of at-risk patients and the association with key clinical outcomes, suggest a screening questionnaire should be used for all patients.
Similarly, prescription drug monitoring programs (PDMPs) should be used to identify patients on high opioid doses, those receiving medications from multiple providers, or those who may be on potentially lethal combinations of opioids and benzodiazepines. Unfortunately, accessing the PDMP is more burdensome and time consuming for clinicians than questionnaires, and the effect on improving clinical outcomes has been inconsistent. However, some states have reported a reduction in opioid dose and number of prescriptions and many recommend or mandate that clinicians access their state’s PDMP database when prescribing opioids.
Urine drug screening should be reserved for selected patients at risk for polysubstance abuse or diversion. There is insufficient evidence supporting its routine use among all patients with cancer. The experience derived from managing chronic noncancer pain has largely determined the approach to managing opioid risk in patients with cancer. However, the evidence for managing opioid use disorder even in noncancer pain is surprisingly limited. Studies of patients with cancer have shown a wide variation in use of cannabis and illicit drugs such as cocaine and heroin, as well as possible diversion of prescribed opioids.
There also are several limitations of urine drug screening in clinical practice, including the variability of the tests, and their sensitivities and specificities. Clinicians will need to become more familiar with the interpretation of abnormal results and their management. For the vulnerable patient with cancer who is often burdened by multiple stressors, it is especially important to avoid false accusations of opioid misuse and diversion.
Egidio G. Del Fabbro, MD, is associate professor in the division of internal medicine and director of the palliative care program at Virginia Commonwealth University School of Medicine. He can be reached at egidio.delfabbro@vcuhealth.org. Disclosure: Del Fabbro reports no relevant financial disclosures.