Risk Assessment and Monitoring of Patients with Cancer Receiving Opioid Therapy

Abstract

The primary objective of this article is to assist oncologists and advanced practice prescribers to safely and effectively minimize risk when providing opioids for cancer pain relief. The majority of people with cancer are unlikely to misuse or divert opioid medications, yet the prescriber is often unaware of those who are at risk for these behaviors. To provide skillful pain management to each patient in the oncology setting, while limiting harm to the community, all prescribers must consider the potential for risk of misuse, addiction, or diversion. To minimize this risk to the greatest degree possible, it is imperative to include a thorough risk assessment when conducting a comprehensive pain evaluation. This information is then used to triage pain relief interventions based upon the degree of risk, including whether or not to incorporate opioids into the plan of care. Risk mitigation strategies, incorporating universal precautions, are implemented to assess, monitor, and reduce the potential for opioid misuse. Universal precautions include strategies such as the use of urine toxicology, state prescription drug monitoring programs, and agreements. Ongoing monitoring is conducted with the goal being to identify aberrant behaviors early so that they can be addressed and managed appropriately. Referral to addiction specialists may be warranted when substance use disorder precludes safe use of opioids. Implications for Practice Throughout the trajectory of cancer care, opioid use is often indicated, and, in fact, it may be unethical to limit or prohibit the use of opioids when pain is severe. Oncologists face the significant challenge of providing cancer pain control that is safe and effective, while limiting individual risk for abuse or overdose and keeping the community free of diverted substances. Most oncology providers report inadequate training in chronic pain principles and in managing addiction. Risk assessment and mitigation measures can be incorporated within oncology care to enhance effective pain management while reducing the potential for harm.

Addiction in Patients With Cancer: Challenges and Opportunities

“…Accurate interpretation of results is critical to prevent false accusations of nonadherence or misuse. Unexpected findings should be discussed with the patient ( McNally et al, 2019 ; Paice, 2019 ). Select patients may necessitate weekly prescriptions, limiting the quantity dispensed, and thus reducing the number of available pills.…”

“…Integrating harm reduction tactics as universal precautions into routine oncology practice, that is, employing techniques to every patient, not only reduces stigma but also improves clinical care outcomes ( Gourlay et al, 2005 ; Hawk et al, 2017 ; Paice, 2019 ; Sager & Childers, 2019 ). Oncology providers can implement harm reduction principles as a unique strategy to minimize risk while improving treatment adherence and cancer outcomes ( Hawk et al, 2017 ).…”

“…Providers may also consider using a controlled medication management form or agreement (i.e., contract; McNally et al, 2019 ; Paice, 2019 ). Urine toxicology screens should be performed in patients receiving controlled medication prescriptions, noting the absence of the prescribed medication(s) and presence of nonprescribed/illicit substances.…”

Recomendaciones para la prescripción segura de opioides en pacientes con historia o riesgo de abuso

“…En los pacientes oncológicos, la adicción no es frecuente y mucho menos en individuos sin antecedentes (20). Se han detectado algunos factores de riesgo que facilitan el consumo inapropiado de opiáceos como: fumar o la ingesta de alcohol, el sexo masculino, jóvenes, pacientes con dolor intenso, tener familiares con antecedente de mal uso de opioides, historia de abuso sexual o físico, trastorno psiquiátricos como ansiedad, depresión, estrés postraumático, o historia de enfermedad psiquiátrica grave (4), e incluso se ha visto mayor riesgo en algunos tipos de tumores como los de cabeza y cuello (4,14).…”

“…Se ha identificado una falta de educación en los médicos sobre la adecuada prescripción de opioides, en especial en pacientes con adicción (4). Es de gran importancia la selección cuidadosa de los pacientes y la identificación del riesgo de abuso, mientras se logra optimizar el manejo del dolor.…”