Dangerous Variation or Patient-Centered Care? Palliative Care and Pain Providers' Comfort, Experiences, and Approaches when Treating Cancer Pain With Coexisting Aberrant Behaviors.
Rachel A Hadler, Rachel Klinedinst, Christopher A Jones, Yuhua Bao, Ravi Pathak, Ali J Zarrabi, William E Rosa
Author Information
Rachel A Hadler: Department of Anesthesiology, Emory University, Atlanta, GA, USA. ORCID
Rachel Klinedinst: Palliative Care Alliance, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA.
Christopher A Jones: Palliative Care Program, Department of Medicine, Duke University, Durham, NC, USA.
Yuhua Bao: Department of Population Health Sciences, Weill-Cornell Medicine, New York, NY, USA.
Ravi Pathak: Department of Anesthesiology, Emory University, Atlanta, GA, USA.
Ali J Zarrabi: Division of Palliative Medicine, Department of Family and Preventive Medicine, Emory University, Atlanta, GA, USA.
William E Rosa: Department of Psychiatry and Behavioral Sciences, Memorial Sloan-Kettering Cancer Center, New York, NY, USA. ORCID
BACKGROUND: patients with cancer-related pain are at high risk for aberrant drug use behaviors (ADB), including self-escalation, diversion and concurrent illicit substance or opioid misuse; however, limited evidence is available to guide opioid prescribing for patients with life-limiting illness and concurrent or suspected ADB. We sought to characterize how specialists evaluate for and manage these high-risk behaviors in patients with cancer-related pain. METHODS: We conducted telephonic semi-structured interviews with palliative care and pain medicine providers. Participants discussed their own comfort and experience level with identifying and managing ADB in patients with life-limiting illness. They were subsequently presented with a series of standardized scenarios and asked to describe their concerns and management strategies. RESULTS: 95 interdisciplinary pain and palliative care specialists were contacted; 37 agreed to participate (38.9%). Analysis of interview contents revealed several central themes: (1) widespread discomfort and anxiety regarding safe and compassionate opioid prescribing for high-risk patients, (2) belief that widely used risk-mitigation tools such as opioid contracts and urine drug screens provided inadequate support for decision-making, and (3) lack of institutional and organizational support and guidance for safe prescribing strategies. Most clinicians reported self-education regarding addiction and alternative prescribing/pain management strategies. Providers varied widely in their willingness to discontinue opioid prescribing in a patient with aberrant behavior and pain associated with life-limiting illness. CONCLUSION: Providers caring for patients demonstrating ADB and cancer-related pain struggle to balance safe prescribing with symptom management. Increased guidance is needed regarding opioid prescribing, monitoring, and discontinuation in high-risk patients.
