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. 2022 Aug 1;8(8):1107-1114.
doi: 10.1001/jamaoncol.2022.2191.

Consensus-Based Guidance on Opioid Management in Individuals With Advanced Cancer-Related Pain and Opioid Misuse or Use Disorder

Katie Fitzgerald Jones  1   2 , Dmitry Khodyakov  3 , Robert Arnold  4 , Hailey Bulls  5 , Emily Dao  3 , Jennifer Kapo  6 , Diane Meier  7 , Judith Paice  8 , Jane Liebschutz  9 , Christine Ritchie  10 , Jessica Merlin  5
Affiliations

Consensus-Based Guidance on Opioid Management in Individuals With Advanced Cancer-Related Pain and Opioid Misuse or Use Disorder

Katie Fitzgerald Jones et al. JAMA Oncol. .

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.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Khodyakov reported grants from Cambia Health Foundation during the conduct of the study; and he is a creator of ExpertLens. ExpertLens is an online modified Delphi platform used to conduct expert panels in this study. Dr Arnold reported board membership of VitalTalk, editorial payment from AAHPM and UpToDate regarding palliative care topics. Dr Bulls reported grants from the National Institutes of Health (NIH) KL2 TR001856 (Rubio) outside the submitted work. Dr Ritchie reported grants from NIH, grants from The John A Hartford Foundation, grants from Boye Foundation, consulting fees from AAHPM Consulting, and West Health Institute Consulting, royalties from McGraw Hill, and Wolters Kluwer, and liscensing fees from UCSF outside the submitted work. Dr Merlin reported grants from Cambia Health Foundation to institution during the conduct of the study. No other disclosures were reported.

Figures

Figure.
Figure.. Summary of Cases and Recommendations
OUD indicates opioid use disorder.
See this image and copyright information in PMC

Comment in

References

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