The opioidepidemic imposes scrutiny on clinicians and patients alike; with particularemphasis on cancer survivors who require the drugs to manage their pain. Howdoes the clinician determine who is at risk for persistent opioid use andabuse? A group of radiation oncologists and pain specialists from theUniversity of California San Diego (UCSD) conducted a study to answer thisvital question, and presented their findings at the 2019 American Society forRadiation Oncology (ASTRO) Annual Meeting, held in Chicago.1

More than 50% of oncology patients who receive curative treatmentsuffer from moderate to severe pain that can be relieved by opioids, according toWHO pain guidelines.2 Although these medications are accepted forrelief of such acute pain, their use in situations where patients have chronicpain (lasting for more than 3 to 6 months) is not so well defined. There arerisks of such long-term administration, such as medication tolerance and lossof efficacy over time. The potential of toxicity can lead to conditions such asdepression, difficulty concentrating, and sedation, and the patient may alsodevelop hyperalgesia or hypogonadism. There are also the well-known risks ofdependence, misuse and abuse, and accidental overdose. The authors of thisstudy support adopting the clinical practice guideline of the American Societyof Clinical Oncology (ASCO) when using opioids to achieve optimal pain management,using risk mitigation strategies such as judicious opioid use, drug screening,adherence monitoring, and strategies for alternative pain management.1,3

Creating a Risk Score

The radiation oncologists sought to identify clinical risk factorsand create a risk score, utilizing an evidence-based risk stratificationapproach to identify patients who might benefit from a proactive approach bythe oncology nurse or other clinician. Their efforts resulted in the Cancer OpioidRisk Tool, a validated prediction tool forassessing the risk of persistent opioid use 1 to 2 years after treatment, estimatingrisk aslow (less than 5%), intermediate (5% to 25%) and high (greaterthan 25%).

The researchers usedthe Veterans Affairs (VA) Informatics and Computing Infrastructure (VINCI)database, which contains detailed electronic health record information on allveterans within the VA health care system. This database provided data on106,732 veteran cancer survivors whose cancer had been diagnosed between 2000and 2015.1

Common diagnosesamong the VA patients were 1 of 12 noncutaneous, nonhematologic malignancies,including cancer of the bladder, breast, colon, esophagus, head and neck,kidney, liver, lung, pancreas, prostate, rectum, or stomach. The study groupincluded patients who were treated with surgery, radiation therapy (RT), orboth and who were alive without disease recurrence 2 years after treatment hadbegun.1

Two models of the Cancer Opioid Risk Tool are available on thewebsite: Full and Lite. Using an automated algorithm, the risk for persistentopioid use is calculated based on data entered by the clinician. The lite modeluses 5 variables: age, presence of depression, alcohol abuse, prior opioid use,and whether treatment included chemotherapy. The more complex, full, model usesthese 5 variables plus employment status, psychiatric diagnoses, race, tobaccouse, body mass index (BMI) category, type of cancer, disease stage, and localtreatment. (Note, although improvements to the tool are ongoing, it istotally functional.) The full version is recommended if providers have time andaccess to all of the relevant information.

Risk Factors for Persistent Opioid Use

The radiationoncologists determined that the rates of persistent posttreatment opioid useamong the VA cohort varied by type of cancer and prior opioid use. Significantfindings included:

Risk factors firstreported in the San Diego study were younger age, white race, BMI, unemploymentat the time of cancer diagnosis, lower median income, use of chemotherapy,increased comorbidity, and tobacco use. Substantially increased odds ofpersistent opioid use were associated with patients who had a history of prioralcohol abuse, nonopioid drug abuse, chronic or intermittent opioid abuse, anddepression.1

Study limitations included whetherresearch on mostly male military veterans would translate to a civilianpopulation of both sexes. Also, veterans who saw combat were exposed to mentaland physical trauma at higher rates than the general population, and this couldincrease their risk for opioid dependence or abuse. Furthermore, thispopulation is more likely to have health insurance and are therefore lesslikely to be financially insecure than the general population.1

Managing patients at risk

The authors notethat the absolute rate of persistent opioid use, abuse, and dependence wasrelatively low among the cohort of VA cancer survivors, especially among thosewho were opioid-nave. They believe that improved risk stratification willallow for personalized risk assessment and improve the safety of painmanagement in cancer survivors. The lite model of the CancerOpioid Risk Tool was validated in an independent test cohort. A more robustvalidation of the newer full tool will require a prospective study.

Strategies thatcan help clinicians better manage patients at risk of persistent opioid use includeestablish a signed treatment agreement, utilize periodic urine drug testing,educate patients and their caregivers on the risks of abuse and/or misuse, offerreferrals to pain and palliative medicine specialists, and avoid high riskformulations while minimizing lower total daily medication doses.

References

1. Vitzthum LK, Riviere P, Sheridan P, et al. Predicting persistent opioid use, abuse and toxicity among cancer survivors [published online November 22, 2019]. J Natl Cancer Inst. doi: 10.1093/jnci/djz200

2. World Health Organization. Cancer Pain Relief : With a Guide to Opioid Availability. 2nd ed. Geneva, Switzerland; 1996. https://apps.who.int/iris/bitstream/handle/10665/37896/9241544821.pdf?sequence=1&isAllowed=y. Accessed January 13, 2020.

3. Paice JA, Portenoy R, Lacchetti C, et al. Management of chronic pain in survivors of adult cancers: American Society of Clinical Oncology Clinical Practice Guideline. J Clin Oncol. 2016;34(27):3325-3345.

This article originally appeared on Oncology Nurse Advisor

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