Expert consensus-based guidance on approaches to opioid management in individuals with advanced cancer-related pain and nonmedical stimulant use.
Katie Fitzgerald Jones, Dmitry Khodyakov, Benjamin H Han, Robert M Arnold, Emily Dao, Jeni Morrison, Jennifer Kapo, Diane E Meier, Judith A Paice, Jane M Liebschutz, Christine S Ritchie, Jessica S Merlin, Hailey W Bulls
Author Information
Katie Fitzgerald Jones: New England Geriatric Research, Education and Clinical Center and Division of Palliative Care, VA Boston Healthcare System, Boston, Massachusetts, USA. ORCID
Dmitry Khodyakov: RAND Corporation, Santa Monica, California, USA.
Benjamin H Han: Division of Geriatrics, Gerontology, and Palliative Care, University of California, San Diego, California, USA.
Robert M Arnold: Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
Emily Dao: RAND Corporation, Santa Monica, California, USA.
Jeni Morrison: Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
Jennifer Kapo: Palliative Medicine, Yale University School of Medicine, New Haven, Connecticut, USA.
Diane E Meier: Department of Geriatrics and Palliative Medicine, Center to Advance Palliative Care, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
Judith A Paice: Division Hematology-Oncology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA.
Jane M Liebschutz: Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
Christine S Ritchie: Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.
Jessica S Merlin: Challenges in Managing and Preventing Pain Clinical Research Center, Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
Hailey W Bulls: Challenges in Managing and Preventing Pain Clinical Research Center, Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA. ORCID
BACKGROUND: Clinicians treating cancer-related pain with opioids regularly encounter nonmedical stimulant use (i.e., methamphetamine, cocaine), yet there is little evidence-based management guidance. The aim of the study is to identify expert consensus on opioid management strategies for an individual with advanced cancer and cancer-related pain with nonmedical stimulant use according to prognosis. METHODS: The authors conducted two modified Delphi panels with palliative care and addiction experts. In Panel A, the patient's prognosis was weeks to months and in Panel B the prognosis was months to years. Experts reviewed, rated, and commented on the case using a 9-point Likert scale from 1 (very inappropriate) to 9 (very appropriate) and explained their responses. The authors applied the three-step analytical approach outlined in the RAND/UCLA to determine consensus and level of clinical appropriateness of management strategies. To better conceptualize the quantitative results, they thematically analyzed and coded participant comments. RESULTS: Consensus was achieved for all management strategies. The 120 Experts were mostly women (47 [62%]), White (94 [78%]), and physicians (115 [96%]). For a patient with cancer-related and nonmedical stimulant use, regardless of prognosis, it was deemed appropriate to continue opioids, increase monitoring, and avoid opioid tapering. Buprenorphine/naloxone transition was inappropriate for a patient with a short prognosis and of uncertain appropriateness for a patient with a longer prognosis. CONCLUSION: Study findings provide urgently needed consensus-based guidance for clinicians managing cancer-related pain in the context of stimulant use and highlight a critical need to develop management strategies to address stimulant use disorder in people with cancer. PLAIN LANGUAGE SUMMARY: Among palliative care and addiction experts, regardless of prognosis, it was deemed appropriate to continue opioids, increase monitoring, and avoid opioid tapering in the context of cancer-related pain and nonmedical stimulant use. Buprenorphine/naloxone transition as a harm reduction measure was inappropriate for a patient with a short prognosis and of uncertain appropriateness for a patient with a longer prognosis.
