Tonya Edwards

Aberrant Opioid Use and Urine Drug Testing in Outpatient Palliative Care.

Aberrant opioid use is a public health issue, which has not been adequately described in the palliative care literature. With the increasing integration of palliative care into oncologic care, palliative care clinicians are seeing patients earlier in the disease trajectory, and therefore, more outpatients with chronic pain requiring chronic opioid therapy. This may have resulted in a concomitant rise in the number of patients with aberrant opioid use. In this article, we report on two patients with aberrant opioid-related behavior seen at our palliative care clinic. A high suspicion of opioid abuse, misuse, or diversion based on certain behavioral cues necessitated the ordering of a urine drug test (UDT). The tests helped the medical team to confirm an already existing pattern of maladaptive opioid use. In both cases, we provided ample opioid education and implemented effective strategies to address their aberrant opioid use. These cases suggest the need for palliative care clinicians to develop strategies to effectively address this issue in our field of medicine. It also highlights the usefulness of UDT in the outpatient palliative care setting.

Frequency, predictors, and outcomes of urine drug testing among patients with advanced cancer on chronic opioid therapy at an outpatient supportive care clinic

Data are limited on the use and outcomes of urine drug tests (UDTs) among patients with advanced cancer. The main objective of this study was to determine the factors associated with UDT ordering and results in outpatients with advanced cancer.

The Frequency and Factors Associated With the Use of a Dedicated Supportive Care Center Telephone Triaging Program in Patients With Advanced Cancer at a Comprehensive Cancer Center

CONTEXT There is limited literature on characteristics of telephone triage programs and the nature of interventions in palliative care. OBJECTIVES Our aim was to determine frequency and type of care provided by a Supportive Care Center Telephone Triaging Program (SCCTP) in advanced cancer patients (ACPs). METHODS Electronic medical records were reviewed of 400 consecutive ACPs referred to palliative care at a comprehensive cancer center and given access to the SCCTP: 200 from the outpatient (OP) supportive care center and 200 from inpatient (IP) palliative care given access after discharge. We reviewed call frequency, type, reason, and outcomes including pain and other symptoms (Edmonton Symptom Assessment Scale and Memorial Delirium Assessment Scale [MDAS]) associated with utilization of the SCCTP. RESULTS A total of 375 patients were evaluable. One hundred fifteen of 400 patients (29%) used the SCCTP: 96 OPs (83%) used the SCCTP vs. only 19 IPs (17%) (P < 0.001). The most common reasons for calls were pain (24%), pain medication refills (24%), and counseling (12%). For 115 phone calls, 43% (145 of 340) of recommendations were regarding care at home and 56% were regarding opioids. Patients who used the SCCTP had worse pain (P = 0.006), fatigue (P = 0.045), depression (P = 0.041), and well-being (P = 0.015) and better MDAS scores (P = 0.014) compared with nonusers. OPs had a higher prevalence of symptom distress (P = 0.013), depression (P < 0.001), anxiety (P < 0.01), and insomnia scores (P = 0.001); MDAS scores were significantly higher in IPs (P < 0.001). CONCLUSION In this study, we found that overall utilization of the SCCTP by ACPs referred to palliative care was relatively low at 28.7%. The use of the SCCTP was particularly poor among the IPs on discharge. Patients who used SCCTP had worse pain, fatigue, depression, and well-being scores and better delirium scores.

Predicting the Risk for Aberrant Opioid Use Behavior in Patients Receiving Outpatient Supportive Care Consultation at a Comprehensive Cancer Center: Aberrant Drug Behavior in Cancer

Opioid misuse is a growing crisis. Patients with cancer who are at risk of aberrant drug behaviors are frequently underdiagnosed. The primary objective of this study was to determine the frequency and factors predicting a risk for aberrant opioid and drug use behaviors (ADB) among patients who received an outpatient supportive care consultation at a comprehensive cancer center. In addition, the screening performance of the Cut Down‐Annoyed‐Guilty‐Eye Opener (CAGE) questionnaire adapted to include drug use (CAGE‐AID) was compared with that of the 14‐item Screener and Opioid Assessment for Patients With Pain (SOAPP‐14) tool as instruments for identifying patients at risk for ADB.

Frequency, predictors, and outcomes of urine drug test among patients with advanced cancer on chronic opioid therapy at an outpatient supportive care clinic.

94 Background: Data on the utilization and outcomes of urine drug tests (UDT) among advanced cancer patients is limited. The main objective of this study was to determine the factors associated with UDT ordering and results in advanced cancer outpatients. METHODS A retrospective chart review of 1058 patients seen from March 2014 to November 2015 at an outpatient supportive care clinic was conducted. Sixty-one patients on chronic opioid therapy who underwent UDT were identified. A control group of 120 patients who did not undergo UDT was selected for comparison of information on demographic and clinical characteristics. RESULTS 61/1058 patients (6%) underwent UDT. 33/61 patients (54%) had abnormal results. Multivariate analysis found that the odds ratio for UDT ordering was 3.9 in CAGE positive patients (p = 0.002), 4.41 in patients less than 45years (p < 0.001), 5.58 in patients with moderate to severe pain (ESAS pain score ≥ 4) (p < 0.001), 0.27 in patients with advanced cancer stage, (p = 0.008), and 0.25 in patients with moderate to severe fatigue (p = 0.001). Among 52 abnormal UDT results in 33 patients, the most common opioid findings were: prescribed opioids absent in urine (14/52, 27%) and un-prescribed opioids in urine (13/52, 25%). CONCLUSIONS UDT was used infrequently among advanced cancer patients receiving outpatient chronic opioid therapy. Younger age, CAGE positivity, early cancer stage or NED status, higher pain intensity, and lower fatigue were significant predictors of UDT ordering. More than 50% of UDTs were abnormal. More research is necessary to better characterize aberrant opioid use in advanced cancer patients.

Impact of a dedicated supportive care center telephone triaging program (SCCTP) for patients with advanced cancer.

54 Background: Due to high symptom burden in advanced cancer patients, ongoing symptom management for outpatient palliative care patients is vital. More patients are receiving outpatient care; Yet, most palliative care patients receive less than 2 follow ups. Nurse telephone care can improve quality of life in these patients. Our aim was to determine frequency and care provided by Supportive Care Center Telephone Program (SCCTP) in advanced cancer patients. METHODS 400 consecutive patients who utilized palliative care service, 200 from outpatient Supportive Care Center (SCC) and 200 from inpatient Palliative Care (IPC), were followed for 6 months starting 3/2012 to examine call frequency and reason and outcomes including pain and other symptoms [Edmonton Symptom Assessment Scale (ESAS) and Memorial Delirium Assessment Scale (MDAS)] associated with utilization of SCCTP. We also examined the effect of SCCTP interventions on pain, ESAS and counseling needs. RESULTS 375 patients were evaluable. Median age 59 years, 53% female, 70% white. Most frequent cancer type were gastrointestinal (20%, p < 0.0001) for IPC and thoracic (23%, p <0.0001) for SCC. SCC patients had higher prevalence of CAGE positivity (28% SCC vs 11% IPC, p <0.0001), ESAS SDS(p=0.0134), depression(p=0.0009), anxiety(p=0.0097) and sleep(p=0.0015); MDAS scores were significantly higher in IPC (p<0.0001).115/400 patients (29%) utilized SCCTP. 96/115 outpatients (83%) used the SCCTP vs 19/115 IPC (17%). Common reasons for calls were pain (24%), pain medication refills (24%) and counseling (12%). Of 115 phone calls, 340 recommendations were made; 43% (145/340) were regarding care at home; 56% of these recommendations were regarding opioids. Patients who utilized SCCTP had worse pain(p=0.0059), fatigue(p=0.0448), depression(p=0.0410), FWB(p=0.0149) and better MDAS scores(p=0.0138) compared to non-utilizers. CONCLUSIONS There was more frequent SCCTP use by outpatients than inpatients. Most common reason for utilization was pain control. Frequently, recommendations were made to continue symptom management at home. Patients who utilized SCCTP had worse pain, fatigue, depression, well-being scores and better delirium scores.

Changes in opioid type and dose among cancer patients referred to outpatient palliative care.

106 Background: Opioid prescriptions are regulated at both federal and state levels. Examples of such regulations include use of risk evaluation and mitigation strategies (REMS), mandatory sharing of prescription data with state prescription drug monitoring programs and the reclassification of hydrocodone as schedule II opioid in October 2014. One possible consequence of such changes would be earlier referral to palliative care (PC) for opioid management. Alternatively, primary oncologist may treat patients with weak opioids or use strong opioids with lower daily dose. We hypothesized that during the last six years, the number of referrals to outpatient PC has increased and the morphine equivalent daily dose (MEDD) has decreased. METHODS We reviewed 750 randomly selected patients who were seen as a new consultation from the year 2010 to 2015. Data was collected on demographics, cancer type and stage, referring specialty, symptom assessment, cancer pain classification, performance status, opioid type and MEDD. Data were also collected on first subsequent PC visit among eligible patients. MEDD over the 6 years was evaluated using general linear regression method, adjusted for covariates. RESULTS Hydrocodone was the most common opioid prescribed by the referring team throughout the six-year period. After reclassification, its use declined from 43% in 2014 to 33% in 2015. Tramadol use increased from 9% in 2014 to 19% in 2015 (p < 0.0001). Median MEDD upon referral was 78mg/day in 2010 and progressively decreased to 40mg/day in 2015 (p < 0.0001). Year to year referral increased 24% in the first quarter of 2015 (after hydrocodone rescheduling), compared to 17% in 2014 (p 0.0014). CONCLUSIONS Over the past 6 years, there has been an increase in number of referrals to PC and a decline in MEDD upon referral. Likewise, an increase in weak opioids like tramadol has also been observed. These findings suggest oncologists are sending early referrals before further opioid dose titration and rotations are considered. Further opioid regulations will likely impact the integration of PC services in comprehensive cancer care.