"1,000 conversations I'd rather have than that one:" A qualitative study of prescriber experiences with opioids and the impact of a prescription drug monitoring program.

BACKGROUND: Prescription Drug Monitoring Programs (PDMPs) have shown impacts on a number of opioid-related outcomes but their role in clinician emotional experience of opioid prescribing has not been studied. OBJECTIVES: This study explores the impact of PDMPs on clinician attitudes toward and comfort with opioid prescribing, their satisfaction with patient interactions involving discussion of opioid prescriptions, and their recognition of opioid use disorder (OUD) and ability to refer patients to treatment. METHODS: Researchers conducted semi-structured interviews with five physicians and two nurse practitioners from a variety of specialties and practice environments. RESULTS: Many participants reported negative emotions surrounding opioid-related patient encounters, with decreased anxiety related to PDMP availability. These effects were less pronounced with clinicians who had greater opioid prescribing experience (either longer careers or higher-volume pain practices). Many participants felt uncomfortable around opioid prescribing. Data from the PDMP often changed prescribing practices, sometimes leading to greater comfort writing a prescription that might have felt riskier without PDMP data. Clinicians easily recognized patient behaviors, symptoms, and prescription requests suggesting that opioid-related adverse events were accumulating, but did not usually apply a label of OUD to these situations. PDMP findings occasionally contributed to a diagnosis and treatment referral for OUD. CONCLUSIONS: PDMP data is part of a nuanced approach to prescribing opioids. The objectivity of the data may be helpful in mitigating clinician negative emotions that are common around opioid therapy.

Shared Decision-Making in Managing Breakthrough Cancer Pain in Patients With Advanced Cancer.

BACKGROUND: Pain is a significant problem in patients with cancer. Breakthrough cancer pain contributes to the pain experience, but it is often underassessed and underrecognized. Shared decision-making (SDM), where patient preferences, goals, and concerns are discussed and integrated into a shared decision, can potentially foster earlier identification of pain, including breakthrough cancer pain, and improve pain management. OBJECTIVES: To explore the use of SDM to evaluate its impact on cancer pain management. METHODS: This prospective, multisite study engaged patients with advanced cancer to explore the use of SDM in managing cancer pain using a digital platform with an expanded pain assessment. Decision preferences were noted and incorporated into care. Outcomes included pain and patient-perceived pain care quality. RESULTS: 51 patients with advanced cancer enrolled in the study. The mean pain score was 5 out of 10 throughout the three study time points. 88% of patients experienced breakthrough cancer pain of severe intensity at baseline and approximately 70% at visits two and three. The majority of breakthrough cancer pain episodes lasted longer than 30 minutes. The majority (86%) of participating patients desired shared decision-making or patient-driven decision-making. Most patients expressed satisfaction with the level of shared decision-making in managing their cancer pain. Breakthrough cancer pain remained significant for most patients. CONCLUSIONS: SDM incorporated into pain discussions has the potential to improve pain outcomes, but significant challenges remain in managing breakthrough cancer pain.

Digital Literacy at an Urban Cancer Center: Implications for Technology Use and Vulnerable Patients.

PURPOSE: eHealth literacy, or the ability to seek, find, understand, and appraise health information from electronic sources, has become increasingly relevant in the era of COVID-19, when so many aspects of patient care became dependent on technology. We aimed to understand eHealth literacy among a diverse sample of patients with cancer and discuss ways for health systems and cancer centers to ensure that all patients have access to high-quality care. METHODS: A cross-sectional survey of patients with cancer and caregivers was conducted at an NCI-designated cancer center to assess access to the Internet, smartphone ownership, use of mobile apps, willingness to engage remotely with the health care team, and use of the patient portal. Descriptive statistics and bivariate analyses were used to assess frequencies and significant differences between variables. RESULTS: Of 363 participants, 55% (n = 201) were female, 71% (n = 241) identified as non-Hispanic White, and 29% (n = 85) reported that their highest level of education was a high school diploma. Most (90%, n = 323) reported having access to the Internet and most (82%, n = 283) reported owning a smartphone. Younger patients or those with a college degree were significantly more likely to own a smartphone, access health information online, know how to download an app on their own, have an interest in communicating with their health care team remotely, or have an account on the electronic patient portal. CONCLUSION: As cancer centers increasingly engage patients through electronic and mobile applications, patients with low or limited digital literacy may be excluded, exacerbating current cancer health disparities. Patient-, provider- and system-level technology barriers must be understood and mitigated.

Validity of the screener and opioid assessment for patients with pain-revised (SOAPP-R) in patients with cancer.

OBJECTIVE: To determine the utility of the screener and opioid assessment for patients with pain-revised (SOAPP-R) for patients with cancer-related pain. DESIGN: The authors performed a retrospective analysis of cancer patients screened with the SOAPP-R. Opiate abuse was determined using a combination of urine drug screens and analysis of patients' electronic medical records. SETTING/PATIENTS: Patients who were seen at a palliative care clinic presenting with pain or needing an opioid prescription at an academic medical center with any type of cancer were screened using the SOAPP-R (N = 69). OUTCOME MEASURES: Aberrant opioid-related behavior was determined using a combination of provider notes and urine drug screens. RESULTS: A positive SOAPP-R score (⩾18) was observed in 27 participants (39.1 percent). The sensitivity and specificity of the SOAPP-R in the study population was 0.75 and 0.80, respectively. CONCLUSIONS: The SOAPP-R, in its current form, may have value in screening patients with cancer for substance abuse. Incorporation of the screening tool in palliative and oncology settings may help reduce opioid abuse in cancer patients.

Managing Cancer Pain, Monitoring for Cancer Recurrence, and Mitigating Risk of Opioid Use Disorders: A Team-Based, Interdisciplinary Approach to Cancer Survivorship.

Background: Palliative care (PC) teams increasingly care for patients with cancer into survivorship. Cancer survivorship transcends distinctions between acute, chronic, malignant, and nonmalignant pain. Partnering with oncologists, PC teams manage pain that persists after disease-directed treatment, evaluate changing symptoms as possible signs of cancer recurrence, taper opioids and mitigate risk of opioid misuse, and manage comorbid opioid use disorder (OUD). While interdisciplinary guidelines exist for pain management in survivorship, there is a need to develop a conceptual model that fully translates the biopsychosocial framework of PC into survivorship pain management. Objective: This review frames a model for pain management in cancer survivorship that balances analgesia with the imperative to minimize risk of OUD, recognizes signs of disease recurrence, and provides whole-person care. Methods: Comprehensive narrative review of the literature. Results: Little guidance exists for co-management of pain, psychological distress, and opioid misuse in survivorship. We identified themes for whole-person pain management in survivorship: use of opioids and co-analgesic medications to prevent recurrent pain from residual tissue damage following cancer treatment, opioid tapering to the lowest effective dose, utilization of nonpharmacologic psychological interventions shown to reduce pain, screening for and management of OUD in partnership with addiction medicine specialists, maintaining vigilance for disease recurrence, and engaging in shared medical decision making. Conclusions: The management of pain in cancer survivorship is complex and requires interdisciplinary care that balances analgesia with the imperative to reduce long-term inappropriate opioid use and manage OUD, while maintaining therapeutic presence with patients in the spirit of PC.