Opioids are one strategy to help manage the cancer-related pain that nearly 75% of patients with cancer experience throughout the disease or its treatment. However, the prevalence of opioid misuse disorder (OUD) among patients with cancer is believed to be at least equal to that of the general population, Debra Rodrigue, MA, RN-BC, AOCNS®, explained during a session for the ONS BridgeTM virtual conference on September 9, 2021.
Rodrigue cited key statistics regarding opioid misuse, such as from 2017–2018, 2.1 million people experienced OUD and more than 130 people died daily from opioid-related drug overdoses. Although opioids provide effective cancer pain management, they also bind to the brain’s limbic system and can produce reward responses, resulting in dependence and drug-seeking behaviors. As a result, some clinicians are reluctant to prescribe opioids.
However, practitioners can use opioids to manage patients’ pain without missing potential misuse scenarios, Rodrigue said. She described a project at Memorial Sloan Kettering Cancer Center in which clinicians developed strategies to determine addiction history in patients with cancer and established a task force to address the opioid crisis and follow the Joint Commission’s Pain Assessment and Management Standards.
“To ensure the initiative’s success, we identified key stakeholders and integrated them into the development and implementation,” Rodrigue explained. The task force included representation from different nurses, informatics staff, educators, physicians, and hospital leadership.
Task force members conducted a literature review, critically appraising articles for reliability, validity, and quality. Two categories emerged: screening and interventions. The evidence supported implementing:
- A validated risk screening tool to appropriately screen all patients for the risk of misuse
- A universal precautions approach to assessing patients for risk of misuse
- Patient and staff education
Rodrigue reported that the hospital system developed a comprehensive awareness program and mandatory online learning module for its 4,000 nurses and 1,700 prescribers. Training covered concepts related to cancer pain and opioid misuse, the new screening process, updates to documentation and workflows, and education for at-risk patients.
Nursing documentation was customized to allow clinicians to accurately document screening, interventions (pharmacologic and nonpharmacologic), and responses to interventions. Standardized discharge instructions were created for patients being sent home with opioid prescriptions.
Project managers identified several screening tools and assessed the benefits and risks of each. For example, a screening tool for adolescent patients with cancer (aged 12–17 years) includes the Car, Relax, Alone, Forget, Friends, Trouble tool. Investigators also considered feasibility of using the tools in the clinical setting. Some questionnaires were too complicated for use in a busy oncology practice, Rodrigue explained. The multidisciplinary task force identified the Drug Abuse Screening Test–2 and CAGE–Adapted to Include Drugs as appropriate for use in nursing clinical practice.
The National Comprehensive Cancer Network and Joint Commission recommend a functional assessment to evaluate how pain affects a patient’s daily function and activity level. Rodrigue’s institution implemented the Pain, Enjoyment, and General Activity scale to meet the functional assessment requirement.
To ensure that patients who screened positive for increased risk of adverse events related to opioid prescriptions were managed safely across settings, the group developed a pain close care designation. This alert autopopulates into the electronic health record header when a patient meets the designation’s criteria. In the chronic pain population, protocols including regular urine toxicology and use of medications such as methadone and buprenorphine. In patients with cancer-related pain, treatment plans must be individualized based on risk and clinical status.