Opioids and benzodiazepines in oncology: Perspectives on coprescribing and mitigating risks.
Amy O'Regan, Jeehye Rose Lee, Cara L McDermott, Harvey Jay Cohen, Jessica S Merlin, Andrea Des Marais, Aaron N Winn, Salimah H Meghani, Devon K Check
Author Information
Amy O'Regan: Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States.
Jeehye Rose Lee: Duke University Trinity College of Arts and Sciences, Durham, NC, United States.
Cara L McDermott: Division of Geriatrics, Duke University School of Medicine, Durham, NC, United States.
Harvey Jay Cohen: Department of Medicine, Duke University School of Medicine, Durham, NC, United States.
Jessica S Merlin: Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States.
Andrea Des Marais: Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States.
Aaron N Winn: Department of Pharmacy Systems, Outcomes, and Policy, University of Illinois at Chicago, Chicago, IL, United States.
Salimah H Meghani: Department of Biobehavioral Health Sciences, School of Nursing, University of Pennsylvania, Philadelphia, PA, United States.
Devon K Check: Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States. Electronic address: devon.check@duke.edu.
INTRODUCTION: Opioids and benzodiazepines are commonly prescribed for cancer symptoms. In combination, they can increase the risk of adverse events, particularly for older adults with multimorbidity, who represent most patients with cancer. We aimed to understand cancer care providers' practices for opioid and benzodiazepine coprescribing and mitigating potential harms. MATERIALS AND METHODS: We interviewed oncology and palliative care providers from two health systems. Interviews focused on attitudes about and current practices for coprescribing opioids and benzodiazepines. We analyzed interview transcripts using a staged approach to thematic analysis. RESULTS: Twenty providers (10 oncology, 10 palliative care) participated. We identified three key themes. (1) Reluctance to prescribe benzodiazepines: providers reported rarely coprescribing because they do not routinely prescribe benzodiazepines, which were viewed as having a poor safety profile. (2) Medication safety precautions: these included starting at a low dose and titrating up slowly, consolidating prescriptions under one provider whenever possible, and providing patient and caregiver education around side effects, overdose, and naloxone. Compared to oncologists, palliative care providers more often described providing naloxone to patients and caregivers. (3) Risk assessment and monitoring: most providers mentioned checking state Prescription Drug Monitoring Program databases and conducting chart reviews to identify evidence of substance misuse history. Several oncologists expressed discomfort in asking about substance misuse history due to concerns about stigma. Providers described sometimes relying on their perception of a patient's trustworthiness, with some acknowledging the potential for bias. DISCUSSION: We highlight opportunities to improve medication review and reconciliation practices in oncology, increase uptake of naloxone in oncology practice, systematize efforts to screen patients for substance misuse, and strengthen integration of addiction and psychiatry services into oncology and palliative care settings. Regular use of geriatric assessment in oncology would also address many of the safety concerns we observed.
