Katie Fitzgerald Jones1,2, Dmitry Khodyakov3, Robert Arnold4, Hailey Bulls5, Emily Dao3, Jennifer Kapo6, Diane Meier7, Judith Paice8, Jane Liebschutz9, Christine Ritchie10, Jessica Merlin5. 1. William F. Connell School of Nursing, Boston College, Chestnut Hill, Massachusetts. 2. VA Boston Healthcare System, Boston, Massachusetts. 3. RAND Corporation, Santa Monica, California. 4. Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, Pennsylvania. 5. CHAllenges in Managing and Preventing Pain (CHAMPP) Clinical Research Center, Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania. 6. MSCE Palliative Medicine, Yale University School of Medicine, New Haven, Connecticut. 7. Department of Geriatrics and Palliative Medicine, Center to Advance Palliative Care, Icahn School of Medicine at Mount Sinai, New York, New York. 8. RN Feinberg School of Medicine, Division of Hematology-Oncology, Northwestern University, Chicago, Illinois. 9. Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania. 10. Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston.
Abstract
Importance: Opioid misuse and opioid use disorder (OUD) are important comorbidities in people with advanced cancer and cancer-related pain, but there is a lack of consensus on treatment. Objective: To develop consensus among palliative care and addiction specialists on the appropriateness of various opioid management strategies in individuals with advanced cancer-related pain and opioid misuse or OUD. Design, Setting, and Participants: For this qualitative study, using ExpertLens, an online platform and methodology for conducting modified Delphi panels, between August and October 2020, we conducted 2 modified Delphi panels to understand the perspectives of palliative and addiction clinicians on 3 common clinical scenarios varying by prognosis (weeks to months vs months to years). Of the 129 invited palliative or addiction medicine specialists, 120 participated in at least 1 round. A total of 84 participated in all 3 rounds. Main Outcomes and Measures: Consensus was investigated for 3 clinical scenarios: (1) a patient with a history of an untreated opioid use disorder, (2) a patient taking more opioid than prescribed, and (3) a patient using nonprescribed benzodiazepines. Results: Participants were mostly women (47 [62%]), White (94 (78 [65%]), and held MD/DO degrees (115 [96%]). For a patient with untreated OUD, regardless of prognosis, it was deemed appropriate to begin treatment with buprenorphine/naloxone and inappropriate to refer to a methadone clinic. Beginning split-dose methadone was deemed appropriate for patients with shorter prognoses and of uncertain appropriateness for those with longer prognoses. Beginning a full opioid agonist was deemed of uncertain appropriateness for those with a short prognosis and inappropriate for those with a longer prognosis. Regardless of prognosis, for a patient with no medical history of OUD taking more opioids than prescribed, it was deemed appropriate to increase monitoring, inappropriate to taper opioids, and of uncertain appropriateness to increase the patient's opioids or transition to buprenorphine/naloxone. For a patient with a urine drug test positive for non-prescribed benzodiazepines, regardless of prognosis, it was deemed appropriate to increase monitoring, inappropriate to taper opioids and prescribe buprenorphine/naloxone. Conclusions and Relevance: The findings of this qualitative study provide urgently needed consensus-based guidance for clinicians and highlight critical research and policy gaps.
Importance: Opioid misuse and opioid use disorder (OUD) are important comorbidities in people with advanced cancer and cancer-related pain, but there is a lack of consensus on treatment. Objective: To develop consensus among palliative care and addiction specialists on the appropriateness of various opioid management strategies in individuals with advanced cancer-related pain and opioid misuse or OUD. Design, Setting, and Participants: For this qualitative study, using ExpertLens, an online platform and methodology for conducting modified Delphi panels, between August and October 2020, we conducted 2 modified Delphi panels to understand the perspectives of palliative and addiction clinicians on 3 common clinical scenarios varying by prognosis (weeks to months vs months to years). Of the 129 invited palliative or addiction medicine specialists, 120 participated in at least 1 round. A total of 84 participated in all 3 rounds. Main Outcomes and Measures: Consensus was investigated for 3 clinical scenarios: (1) a patient with a history of an untreated opioid use disorder, (2) a patient taking more opioid than prescribed, and (3) a patient using nonprescribed benzodiazepines. Results: Participants were mostly women (47 [62%]), White (94 (78 [65%]), and held MD/DO degrees (115 [96%]). For a patient with untreated OUD, regardless of prognosis, it was deemed appropriate to begin treatment with buprenorphine/naloxone and inappropriate to refer to a methadone clinic. Beginning split-dose methadone was deemed appropriate for patients with shorter prognoses and of uncertain appropriateness for those with longer prognoses. Beginning a full opioid agonist was deemed of uncertain appropriateness for those with a short prognosis and inappropriate for those with a longer prognosis. Regardless of prognosis, for a patient with no medical history of OUD taking more opioids than prescribed, it was deemed appropriate to increase monitoring, inappropriate to taper opioids, and of uncertain appropriateness to increase the patient's opioids or transition to buprenorphine/naloxone. For a patient with a urine drug test positive for non-prescribed benzodiazepines, regardless of prognosis, it was deemed appropriate to increase monitoring, inappropriate to taper opioids and prescribe buprenorphine/naloxone. Conclusions and Relevance: The findings of this qualitative study provide urgently needed consensus-based guidance for clinicians and highlight critical research and policy gaps.
Authors: Dmitry Khodyakov; Sean Grant; Brian Denger; Kathi Kinnett; Ann Martin; Marika Booth; Courtney Armstrong; Emily Dao; Christine Chen; Ian Coulter; Holly Peay; Glen Hazlewood; Natalie Street Journal: Med Decis Making Date: 2019-11-13 Impact factor: 2.583
Authors: Dmitry Khodyakov; Sean Grant; Daniella Meeker; Marika Booth; Nathaly Pacheco-Santivanez; Katherine K Kim Journal: J Am Med Inform Assoc Date: 2017-05-01 Impact factor: 4.497
Authors: Joseph W Frank; Travis I Lovejoy; William C Becker; Benjamin J Morasco; Christopher J Koenig; Lilian Hoffecker; Hannah R Dischinger; Steven K Dobscha; Erin E Krebs Journal: Ann Intern Med Date: 2017-07-11 Impact factor: 25.391
Authors: Katie Fitzgerald Jones; Mei R Fu; Jessica S Merlin; Judith A Paice; Rachelle Bernacki; Christopher Lee; Lisa J Wood Journal: J Pain Symptom Manage Date: 2020-08-19 Impact factor: 3.612