Managing Opioids, Including Misuse and Addiction, in Patients with Serious Illness in Ambulatory Palliative Care: a qualitative study (GP765)

Merlin, Jessica S.; Young, Sarah; Arnold, Robert C.; Bulls, Hailey W.; Childers, Julie; Gauthier, Lynn R.; Giannitrapani, Karleen F.; Kavalieratos, Dio; Schenker, Yael; Wilson, J. Deanna; Liebschutz, Jane M.

doi:10.1016/j.jpainsymman.2020.04.192

Cited by 5 publications

(8 citation statements)

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“…This underscores the importance of access to OUD treatment in cancer treatment settings, including nonaddiction specialists waivered to prescribe buprenorphine/naloxone and addiction specialists for more complex cases. However, a limited number of clinicians who care for patients with cancer (eg, oncologists, palliative care clinicians) are waivered to prescribe buprenorphine/naloxone, which is a barrier to implementation …”

Section: Discussionmentioning

confidence: 99%

“…Further, expertise can influence response appropriateness: participants with addiction expertise may have experience with OUD but may have less experience prescribing opioids for pain and high-risk opioid prescribing, whereas palliative care clinicians may lack direct experience with methadone treatment programs. We intended to capture the expertise of palliative care clinicians frequently called on to manage complex cancer pain and opioid misuse/OUD, but this can reduce generalizability of our findings in other settings where cancer patients are treated . Lastly, the management of cancer-related pain and opioid misuse/OUD is an area of rapidly changing practice and literature.…”

Section: Discussionmentioning

confidence: 99%

“…However, a limited number of clinicians who care for patients with cancer (eg, oncologists, palliative care clinicians) are waivered to prescribe buprenorphine/naloxone, which is a barrier to implementation. 38 Participants grappled with how and when to safely use methadone in patients with cancer, pain, and a recent history of OUD. Our findings indicate a belief that methadone can be a tool for cancer-related pain and OUD, but methadone treatment programs were not deemed appropriate for this population.…”

Section: On Active Cancer Treatmentmentioning

confidence: 99%

“…We intended to capture the expertise of palliative care clinicians frequently called on to manage complex cancer pain and opioid misuse/OUD, but this can reduce generalizability of our findings in other settings where cancer patients are treated. 35,38,52 Lastly, the management of cancer-related pain and opioid misuse/OUD is an area of rapidly changing practice and literature. Delphi studies are considered level 5 (expert opinion) evidence.…”

Section: Limitationsmentioning

confidence: 99%

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Consensus-Based Guidance on Opioid Management in Individuals With Advanced Cancer-Related Pain and Opioid Misuse or Use Disorder

et al. 2022

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ImportanceOpioid 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.ObjectiveTo 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 ParticipantsFor 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 MeasuresConsensus 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.ResultsParticipants 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 RelevanceThe findings of this qualitative study provide urgently needed consensus-based guidance for clinicians and highlight critical research and policy gaps.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: On Active Cancer Treatmentmentioning

confidence: 99%

Section: Limitationsmentioning

confidence: 99%

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Consensus-Based Guidance on Opioid Management in Individuals With Advanced Cancer-Related Pain and Opioid Misuse or Use Disorder

et al. 2022

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“…Preliminary data suggest that management may differ according to prognosis 27 . Patients expected to live weeks to months rather than years may have less opportunity to experience stimulant harms or engage in treatment for stimulant use disorder.…”

Section: Methodsmentioning

confidence: 99%

Expert consensus‐based guidance on approaches to opioid management in individuals with advanced cancer‐related pain and nonmedical stimulant use

Jones,

Khodyakov,

Han

et al. 2023

Cancer

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BackgroundClinicians treating cancer‐related pain with opioids regularly encounter nonmedical stimulant use (i.e., methamphetamine, cocaine), yet there is little evidence‐based management guidance. The aim of the study is to identify expert consensus on opioid management strategies for an individual with advanced cancer and cancer‐related pain with nonmedical stimulant use according to prognosis.MethodsThe authors conducted two modified Delphi panels with palliative care and addiction experts. In Panel A, the patient’s prognosis was weeks to months and in Panel B the prognosis was months to years. Experts reviewed, rated, and commented on the case using a 9‐point Likert scale from 1 (very inappropriate) to 9 (very appropriate) and explained their responses. The authors applied the three‐step analytical approach outlined in the RAND/UCLA to determine consensus and level of clinical appropriateness of management strategies. To better conceptualize the quantitative results, they thematically analyzed and coded participant comments.ResultsConsensus was achieved for all management strategies. The 120 Experts were mostly women (47 [62%]), White (94 [78%]), and physicians (115 [96%]). For a patient with cancer‐related and nonmedical stimulant use, regardless of prognosis, it was deemed appropriate to continue opioids, increase monitoring, and avoid opioid tapering. Buprenorphine/naloxone transition was inappropriate for a patient with a short prognosis and of uncertain appropriateness for a patient with a longer prognosis.ConclusionStudy findings provide urgently needed consensus‐based guidance for clinicians managing cancer‐related pain in the context of stimulant use and highlight a critical need to develop management strategies to address stimulant use disorder in people with cancer.Plain Language Summary Among palliative care and addiction experts, regardless of prognosis, it was deemed appropriate to continue opioids, increase monitoring, and avoid opioid tapering in the context of cancer‐related pain and nonmedical stimulant use. Buprenorphine/naloxone transition as a harm reduction measure was inappropriate for a patient with a short prognosis and of uncertain appropriateness for a patient with a longer prognosis.

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The Relevance of State Laws Regulating Opioid Prescribing for People Living With Serious Illness

Merlin

Schenker

Bulls

2022

Journal of Pain and Symptom Management

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Managing Opioids, Including Misuse and Addiction, in Patients with Serious Illness in Ambulatory Palliative Care: a qualitative study (GP765)

Cited by 5 publications

References 0 publications

Consensus-Based Guidance on Opioid Management in Individuals With Advanced Cancer-Related Pain and Opioid Misuse or Use Disorder

Consensus-Based Guidance on Opioid Management in Individuals With Advanced Cancer-Related Pain and Opioid Misuse or Use Disorder

Expert consensus‐based guidance on approaches to opioid management in individuals with advanced cancer‐related pain and nonmedical stimulant use

The Relevance of State Laws Regulating Opioid Prescribing for People Living With Serious Illness

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