Risks Associated with Self-Management of Opioids in Outpatient Setting of Cancer Treatment

Research published in the Journal of Pain and Symptom Management indicated that risks related to self-management of opioids among cancer outpatients need to be addressed, including the risk of potential overdose.¹

The findings indicated that interventions may be necessary to improve clinician-patient communication, patient education, safety, and access to effective alternatives to opioids.

“Currently, opioid adherence monitoring focuses on misuse aspects (e.g. urine drug screen) and opioid risk tools. The findings of our study challenge this singular focus on improving opioid safety,” said lead-investigator Salimah H. Meghani, PhD, MBE, RN, FAAN, from the University of Pennsylvania. “Clinical tools to systematically elicit patient’s self-management practices, especially under-use and dose conserving practices of opioids, are lacking and need to be employed in clinical practice.”

In this multimethod study, researchers looked to obtain participants’ most prominent concerns in using pain medications through freelisting. Additionally, interviews were conducted to identify both opioid access and adherence for pain between African Americans and white patients, given previous reports of racial disparities. 

“Pain relief” was found to be the most important concern in relation to taking pain medications, followed by (in descending order) “addiction,” “dislike” for pain medications, concern for “side effects,” “sleep,” and “normalcy.”

In interviews, participants described a number of potentially unsafe practices including reducing opioid use 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 opioids. 

“Based on our study, we realize that patients have unique heuristics to achieve a self-defined normal dose and pattern of opioid use,” Meghani noted. “However, some signs may be persistent pain, use of non-prescribed substances, requests for early or late opioid refills, or history of opioid-related toxicity or healthcare use.”

Though most patients in the sample described easy access to opioids from their oncology clinicians, African American patients in this study more often described having difficulty accessing opioids for pain relief due to insurance barriers and preauthorization requirements.

Moreover, even though most patients in the study had access to prescription opioids for pain, some were troubled that opioids were their sole pain management option, with many finding difficulties in obtaining alternative or integrative therapies from their clinicians. And though some patients trusted their clinicians to disclose any opioid risks, others described disappointment and regret in their clinicians monitoring of opioid pain medications.

The researchers recommended that patients with cancer be included in opioid stewardship programs being developed in many healthcare systems in the US.² The goal of these programs should also be to work towards reducing stigma for oncology patients who continue to need opioids to relieve moderate to severe pain.

“No programs to our knowledge include interventions to reduce stigma for patients [with cancer] who need opioids to manage pain and daily function,” Meghani explained. “Patient education and self-advocacy interventions may be helpful, but more responsibility should be placed on health systems to develop programs with different patient populations and subgroups in mind.”

A Patient Counseling Guide has also been developed as part of the FDA Risk Evaluation and Mitigation Strategy (REMS) for opioids, which could prove to be a useful clinical tool to counsel patients and caregivers about safe use practices and safety risks.

There is a critical need to clarify what constitutes best practices in opioid self-management and translate the evidence into patient-centered interventions, according to the authors. Additionally, patient self-management practices should be assessed as part of the clinical quality measures, similar to other measures for assessing risks and addressing harms of opioids.

References:

1. Meghani SH, Wool J, Davis J, Yeager KA, Mao JJ, Barg FK. When Patients Take Charge of Opioids: Self-Management Concerns and Practices Among Cancer Outpatients in the Context of Opioid Crisis. Journal of Pain and Symptom Management. doi:10.1016/j.jpainsymman.2019.10.029. 

2. Opioid Self-management Practices and Potential Safety Risks Among Patients with Cancer [news release]. Philadelphia, PA. Published December 19, 2019. newswise.com/articles/opioid-self-management-practices-and-potential-safety-risks-among-patients-with-cancer?sc=mwhr&xy=10024642. Accessed January 2, 2020.