Original Article
Chronic Pain and Risk Factors for Opioid Misuse in a Palliative Care Clinic
American Journal of Hospice & Palliative Medicine® 2015, Vol. 32(6) 654-659 ª The Author(s) 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1049909114531445 ajhpm.sagepub.com
Julie W. Childers, MD1, Linda A. King, MD1, and Robert M. Arnold, MD1
Abstract Objectives: To describe the prevalence of chronic pain and the risk of opioid misuse in a palliative care clinic. Methods: We reviewed patient records for 6 months for source of pain, treatment status, opioid misuse risk (Cut down, Annoyed, Guilty, and Eye-opener [CAGE] and Screener and Opioid Assessment for Patients with Pain version 1.0—Short Form [SOAPP-SF] scores), and urine drug screens. Results: Of 323 patients, 91% had cancer, 56% undergoing cancer treatment, while 28% had no evidence of disease. Eighty-six (27%) patients had noncancer pain. In all, 46% of new patients had positive scores on the SOAPP-SF and 15% had a positive CAGE. Of the less than 5% of visits that included a urine drug screen, 56% had aberrant results. Conclusion: Chronic pain and indicators of opioid misuse risk were prevalent. Outpatient palliative care practices should develop policies to address these issues. Keywords palliative, pain, opioid misuse, chronic pain, cancer pain, addiction, outpatient
Introduction Palliative care consultation has occurred primarily in the inpatient setting, where the clinician–patient relationship is brief, the focus is on the management of acute pain and symptoms, and life expectancy is often limited to a few days or weeks.1,2 Ambulatory palliative care clinics are a new domain for palliative care and are still evolving.3 Palliative care outpatient clinics extend palliative care services upstream to patients who are seriously ill but have longer prognoses. These clinics are typically small, frequently only serve patients for 1 or 2 half days per week and are often located within a cancer center.4,5 Previous studies of patients with cancer (usually advanced or metastatic) in ambulatory palliative care settings have found outpatient palliative care referral to be correlated with improved pain scores, sense of well-being, depression, and other symptoms.6-10 Previous to 2010, studies of ambulatory palliative care populations, which reported survival, have found mean life expectancies of 6 to 10 weeks dating from the initial visit.11,12 A 2010 study of early outpatient palliative care referral for patients with metastatic lung cancer showed a median survival of 11.6 months.13 However, as criteria for ambulatory palliative care referral broaden, providers may treat more patients with chronic cancer pain or chronic pain unrelated to their lifelimiting diagnoses. There has been little research that evaluates the extent to which palliative care clinics are treating chronic pain. If chronic pain is becoming commonly seen in the palliative care outpatient setting, providers may be encountering opioid abuse and addiction more frequently.
Chronic pain clinics primarily serving patients with nonmalignant pain have a prevalence of substance use disorders of up to 48%.14-16 There are no studies to our knowledge that describe the prevalence of chronic pain or the frequency of aberrant drug-related behavior in cancer pain or palliative care clinics. In this study, we assessed the types of pain and the risk of opioid misuse in patients seen in a palliative care clinic located in a cancer center.
Methods This study is a retrospective chart review of patients seen at the Cancer Pain and Supportive Care Clinic between June 1, 2011, and November 30, 2011. The Cancer Pain and Supportive Care Clinic is located in the Hillman Cancer Center and provides consultation and management of pain and symptoms as well as discussions of goals of care and referral to ancillary services. The clinic was established in October 2002 and at that time had 2 sessions per week with services provided by only 1 physician. In 2010, the clinic provided services for 6 1
Department of Medicine, Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, PA, USA
Corresponding Author: Julie W. Childers, MD, Department of Medicine, Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh, 200 Lothrop Street, Suite 9W, Pittsburgh, PA 15213, USA. Email: [email protected]
Downloaded from ajh.sagepub.com at CMU Libraries - library.cmich.edu on October 5, 2015
Childers et al
655
half-day sessions per week, evaluating approximately 250 new patients with 1200 total patient visits. Services are provided by 5 physicians who are board certified in Hospice and Palliative Medicine. Psychiatry, psychology, social work, and nutrition support are also available within the cancer center but are not integrated into the clinic. Data were gathered from several sources within the clinic. First, the type of cancer or other life-limiting illness, the physician’s assessment of the type of pain treated (tumor related, chemotherapy-related, radiation therapy-related, surgeryrelated, noncancer-related, or nonpain symptoms only), and the patient’s disease status as recorded by the physician as active treatment (including palliative chemotherapy), completely palliative (patient not receiving chemotherapy but may receive palliative radiation therapy), or no evidence of disease were recorded at the end of the visit, including both initial visits and follow-up visits. Patients were identified as having no evidence of disease if they had minimal or no cancer on scans and were seeing their oncologist for surveillance only. Physicians could indicate more than 1 type of pain treated, but only 1 treatment status, and up to 3 life-limiting illnesses. Data gathered from patient-completed intake forms completed on an initial clinic visit included 2 measures for opioid misuse. First, patients were asked whether they drink alcohol, and if the answer was ‘‘yes,’’ the patient completed the Cut down, Annoyed, Guilty, and Eye-opener (CAGE) questions, a 4-item screening questionnaire for alcohol abuse.17 Two positive answers to the CAGE questionnaire have been shown to have a sensitivity of >90% and a specificity of >95% for detecting alcoholism.18 In addition, on their initial clinic visit, patients completed the Screener and Opioid Assessment for Patients with Pain version 1.0—Short Form (SOAPP-SF), derived from the previously validated 14-question SOAPP.19 The SOAPP-SF consists of 5 questions about behaviors associated with opioid misuse, answered on a scale of 0 to 4, where 0 ¼ ‘‘never’’ and 4 ¼ ‘‘very often.’’ A total SOAPP-SF score from 0 to 20 is calculated; preliminary validation of the measure showed that a score of 4 or more has 85% sensitivity and 67% specificity for the development of opioid misuse in patients with chronic pain.20 At the time of this study, the Cancer Pain and Supportive Care clinic had no policy regarding the use or frequency of urine drug screens, which were ordered at the discretion of the physician. Most urine drug screens ordered included gas chromatography/mass spectroscopy analysis, which distinguish between specific opioids such as heroin, codeine, and morphine in their reporting. Results of urine drug screens were gathered from the medical record. The electronic medical record and local obituary records were also searched for patient death date during or 6 months after the study period. Study data were collected and managed using REDCap electronic data capture tools hosted at the University of Pittsburgh and statistically analyzed using SAS version 9.3. This study was funded by the Shadyside Foundation and was approved as exempt by the institutional review board of the University of Pittsburgh.
Results Patient Characteristics The clinic patient population is described in Table 1. A total of 323 patients were seen in the clinic during the 6-month period; 77 of these were new patients. The majority (91%) had a cancer diagnosis. In all, 86 (27%) patients were noted by their physicians to have some noncancer pain; 5 (1.5%) of the 323 patients were seen for a nonpain diagnosis. In all, 53% of the patients with cancer were undergoing active treatment and 90 (28%) patients with cancer had no evidence of disease. Of the 323 patients seen during the 6-month period, 101 (31%) patients died within 6 months of their visit.
Opioid Misuse Measures Of the 76 new patients seen, 57 completed the full clinic intake, including the SOAPP and CAGE screens. Of these, 26 (46%) had a positive score of 4 or more on the SOAPP and 5 (15%) scored positive on the CAGE. Of the 644 total patient visits, 27 (4.2%) visits included a urine drug screen. In all, 15 (56%) screens had results that were aberrant, including 6 screens that were negative for prescribed opioids, 1 that was positive for a nonprescribed benzodiazepine, 4 that were positive for cocaine, 6 positive for marijuana, and 1 that was positive for heroin. Results from urine drug screens are presented in Table 2. Review of the electronic medical record also indicated 25 urine drug screens ordered in the emergency department, hospital, or by other outpatient providers, and these results included 4 results positive for marijuana and 3 positive for cocaine. Table 3 shows the association of patient characteristics with opioid misuse measures. Patients with a positive SOAPP score tended to be younger (50.4 years as opposed to 61.0 years, P ¼ .007). There were no other significant associations with SOAPP or CAGE scores with type of pain or with treatment status. Urine drug screens were more likely to be ordered on patients without cancer (P value .0419) and patients with noncancer pain. However, one-quarter of the patients with aberrant urine drug screens had tumor-related pain, and nearly 20% of them were undergoing active treatment for cancer.
Discussion In this population, the prevalence of chronic nonmalignant pain and patients with no evidence of disease were high. This is likely related to the marketing of the clinic, which is commonly known within the cancer center as the ‘‘pain clinic.’’ At least a portion of this population may be similar to patients seen in chronic nonmalignant pain clinics. Many patients were chronic: two-thirds of the patients survived at least 6 months beyond their initial study visit. Second, a high proportion (46%) of patients who completed the SOAPP-SF questionnaire had a positive score. Data from chronic nonmalignant pain clinics show that the percentage of patients who score positive on a 24-item SOAPP ranged between 54% and 75%, while
Downloaded from ajh.sagepub.com at CMU Libraries - library.cmich.edu on October 5, 2015
American Journal of Hospice & Palliative Medicine® 32(6)
656 Table 1. Characteristics of Patients Seen in the Palliative Care Clinic.
Unique patients seen Number of visits Initial intake visit Visits per patient (mean, range) Age (mean, SD, range) Male (number and % males) Race White African American Other Primary diagnosisa—cancer Colorectal Lung Breast Genitourinary Head/neck Hematologic Other cancer Primary diagnosis—noncancer Sickle cell disease Neurologic disease Cardiac disease Pulmonary disease Otherb Type of painc Tumor-related Chemotherapy-related Radiation therapy-related Surgery-related Noncancer pain Nonpain symptoms Item not completed Average number of types of pain (mean and standard deviation at first visit) Treatment statusd Active treatment Palliative only No evidence of diseasee Missing Deathsf Survival from initial clinic visit in days (N ¼ 101) SOAPP score 4 (n ¼ 57) CAGE score 2 (n ¼ 32)
N
%
323 644 76 2 (min ¼ 1, max ¼ 10) 54 (SD 13) (min ¼ 21, max ¼ 90) 163
50
276 47 0 294 27 39 27 18 56 53 73 29 3 2 0 2 22
85 15 0 91 8 12 8 6 17 16 23 11 1 1 0 1 7
146 53 43 48 86 5 20 1.2 (min ¼ 1, max ¼ 3)
45 16 13 15 27 2 6 0.5
164 18 90 22 101 143 (SD 94) 26 5
56 6 31 7 31 46 16
Abbreviations: CAGE, Cut down, Annoyed, Guilty, and Eye-opener; SOAPP, Screener and Opioid Assessment for Patients with Pain version 1.0; SD, standard deviation. a First life-limiting diagnosis as recorded by the treating physician. b Other noncancer diagnoses seen in the clinic included aplastic anemia, Waldenstrom macroglobulinemia, diabetes, lupus, osteoarthritis, chronic abdominal pain, cirrhosis, and antiphospholipid antibody syndrome. c Type of pain recorded by physician at the first visit in the study period. d Treatment status for patients with cancer only, as recorded by the physician in the first visit during the study period. e ‘‘No evidence of disease’’ was defined as having minimal to no cancer burden on recent scans and receiving surveillance visits only from oncology. f Deaths within the 6-month study period or during the following 6 months.
in another cancer pain clinic, the SOAPP-SF was positive in 26% of patients on initial intake.21-23 Opioid prescribing for chronic nonmalignant pain is controversial, and providers are recommended to carefully screen patients before initiating opioid therapy.24 This is particularly important in the setting of the growing incidence of prescription drug abuse and the epidemic of opioid overdoses seen
nationally.25 Patients with chronic nonmalignant pain and a history of a substance use disorder are more likely to misuse prescribed opioids and to develop aberrant drug-related behaviors.26-28 However, opioids are the standard of care for cancer pain.29 This study points to the need to consider screening for opioid risk and managing the risk of misuse within the cancer pain population.
Downloaded from ajh.sagepub.com at CMU Libraries - library.cmich.edu on October 5, 2015
Childers et al
657
Table 2. Urine Drug Screen (UDS) Results in the Palliative Care Clinic. Results
n (number of visits)
%
27
6
14 2 3 15 6 0 4 1 4 6 1 1
74 11 16 56 22 0 15 4 15 22 4 4
Visits with urine drug screena performed during study period Number of clinic patients who had urine screen performed Number of urine screens per patient who had a urine screen at our clinic 1 2 3 Number of aberrant UDS results Negative for prescribed opioids Negative for prescribed benzodiazepines Positive for nonprescribed opioids Positive for nonprescribed benzodiazepines Cocaine present Marijuana present Heroin or metabolite Other substance presentb a
Two urine drug screens ordered were immunoassay only; all other tests included gas chromatography/mass spectroscopy analysis. Phenobarbital was present in 1 sample.
b
Table 3. Association of Patient Characteristics With Opioid Misuse Measures. SOAPP scores
Characteristic
SOAPP < 4 SOAPP 4 (N ¼ 31) (N ¼ 26)
Age, mean, years 61.0 Cancer, % 90.3 Tumor-related 41.9 pain, % Chemotherapy12.9 related pain, % XRT-related 9.7 pain, % Surgery-related 12.9 pain, % Noncancer 25.8 pain, % Nonpain 9.7 symptoms, % Pain item not 3.2 completed, % Treatment status, % Active 71.0 treatment 9.7 Palliative treatment only No evidence 9.7 of disease No cancer 3.2 history Item not 6.5 completed
CAGE scores P value
UDS status
CAGE < 2 CAGE 2 P (N ¼ 27) (N ¼ 5) value
None ordered (N ¼ 304)
UDS as expected (N ¼ 8)
1 aberrant P UDSa (N ¼ 11) value
50.4 96.2 53.8
0.0070 0.3907 0.3697
56.0 96.3 48.1
48.0 80.0 40.0
.2431 .1667 .7373
54.9 90.1 47.0
45.0 62.5 0.0
49.4 90.9 27.3
.0552 .0419 .0147
19.2
0.5141
14.8
40.0
.1851
17.4
0.0
9.1
.3366
15.4
0.5132
11.1
40.0
.1022
12.8
25.0
18.2
.5394
7.7
0.5232
14.8
0.0
.3575
13.5
25.0
36.4
.0747
19.2
0.5556
14.8
40.0
.1851
25.0
62.5
45.5
.0215
0.0
0.1032
3.7
0.0
.6620
1.6
0.0
0.0
.8532
11.5
0.2211
7.4
20.0
.3749
5.9
0.0
0.0
.5512
57.7
0.6645
74.1
40.0
.1451
54.3
0.0
18.2
.0001
7.7
3.7
0.0
5.6
0.0
18.2
11.5
11.1
0.0
27.6
62.5
54.5
3.8
3.7
20.0
4.9
37.5
9.1
19.2
7.4
40.0
7.6
0.0
0.0
Abbreviations: CAGE, Cut down, Annoyed, Guilty, and Eye-opener; SOAPP, Screener and Opioid Assessment for Patients with Pain version 1.0; UDS, urine drug screen; XRT, radiotherapy. a An aberrant UDS could include absence of prescribed opioids or benzodiazepines and presence of nonprescribed medications or illicit substances.
Downloaded from ajh.sagepub.com at CMU Libraries - library.cmich.edu on October 5, 2015
American Journal of Hospice & Palliative Medicine® 32(6)
658 Only 4.2% of clinic patients had a urine drug screen. Aberrant results were found in more than half of those patients screened and included patients with all types of pain and patients undergoing active cancer treatments as well as patients with chronic nonmalignant or postcancer pain. We could find no published recommendations for urine drug screening or other opiate risk assessment measures in palliative care or cancer pain populations. In the chronic nonmalignant pain setting, urine drug testing at regular intervals is recommended, particularly for high-risk patients.30 Without guidelines, the decision is left up to clinicians, whose estimates of the likelihood of aberrant drug-related behavior are inaccurate31 and may be biased by sociodemographic factors. This study is preliminary, and the numbers of patients included, particularly of those who completed the opioid misuse measures, was small. Our data are limited to information routinely collected at clinic visits, and as medical assistants did not always remember to hand out clinic intake forms to new patients, only 57 of the 76 new patients completed a form. The type of pain and treatment status was determined by individual physician judgment. From this retrospective data, we were not able to collect information on the particular opioids prescribed or doses. Future studies that prospectively and systematically evaluate types of pain, patterns of opioid prescribing, and the incidence of opioid misuse in multiple outpatient palliative care settings are warranted. In addition, there are unanswered questions about the differences between this population and the chronic nonmalignant pain. One question from the SOAPP-SF, the frequency of mood swings, may be more likely to be positive in patients with cancer who are often undergoing a high level of stressful events such as chemotherapy and surgery and may have recently heard bad news. In order to accurately predict opioid misuse, further testing of the SOAPP and other opioid misuse measures should be conducted in patients with cancer pain and other life-limiting illness, and results should be correlated with other risk tools and with actual opioid misuse. As palliative care outpatient practices mature, their practices may shift to include more patients with chronic pain both related and unrelated to their life-limiting illness. Many of these patients will continue in clinic as patients with shorter prognoses die. In order to be able to continue to accommodate new patients with shorter prognoses, palliative care clinics may need to consider referral to chronic pain clinics, survivorship clinics, or back to primary care physicians. Ambulatory palliative care practices that include some patients with chronic pain will need to adapt to include strategies for detecting and managing opioid misuse. Acknowledgment The authors would like to acknowledge the Shadyside Foundation for their support of this research and the assistance of Marnie Bartolet with statistical analysis.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The project was also supported by the National Institutes of Health through Grant Number UL1TR000005.
References 1. Morrison RS, Maroney-Galin C, Kralovec PD, Meier DE. The growth of palliative care programs in US hospitals. J Palliat Med. 2005;8(6):1127-1134. 2. Fromme EK, Bascom PB, Smith MD, et al. Survival, mortality, and location of death for patients seen by a hospital-based palliative team. J Palliat Med. 2006;9(4):903-911. 3. Meier DE, Beresford L. Outpatient clinics are a new frontier for palliative care. J Palliat Med. 2008;11(6):823-828. 4. Rabow MW, Smith AK, Braun JL, Weissman DE. Outpatient palliative care practices. Arch Intern Med. 2010;170:654-655. 5. Berger GN, O’Riordan DL, Kerr K, Pantilat SZ. Prevalence and characteristics of outpatient palliative care services in California. Arch Intern Med. 2011;171(22):2057-2059. 6. Jacobsen J, Jackson V, Dahlin C, et al. Components of early outpatient palliative care consultation in patients with metastatic nonsmall cell lung cancer. J Pall Med. 2011;14(4): 459-464. 7. Follwell M, Burman D, Le LW, et al. Phase II study of an outpatient palliative care intervention in patients with metastatic cancer. J Clin Oncol. 2009;27(2):206-213. 8. Muir JC, Daly F, Davis MS, et al. Integrating palliative care into the outpatient, private practice oncology setting. J Pain Symptom Manage. 2010;40(1):126-135. 9. Porta-Sales J, Codorniu N, Go´mez-Batiste X, et al. Patient appointment process, symptom control and prediction of followup compliance in a palliative care outpatient clinic. J Pain Symptom Manage. 2005;30(2):145-153. 10. Bruera E, Michaud M, Vigano A, Neumann CM, Watanabe S, Hanson J. Multidisciplinary symptom control clinic in a cancer center: a retrospective study. Support Care Cancer. 2001;9(3): 162-168. 11. Casarett DJ, Hirschman KB, Coffey JF, Pierre L. Does a palliative care clinic have a role in improving end-of-life care? Results of a pilot program. J Palliat Med. 2002;5(3):387-396. 12. Strasser F, Sweeney C, Willey J, Benisch-Tolley S, Palmer JL, Bruera E. Impact of a half-day multidisciplinary symptom control and palliative care outpatient clinic in a comprehensive cancer center on recommendations, symptom intensity, and patient satisfaction: a retrospective descriptive study. J Pain Symptom Manage. 2004;27(6):481-491. 13. Temel JS, Green JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010;363(8):733-742. 14. Fleming MF, Balousek SL, Klessig CL, Mundt MP, Brown DD. Substance use disorders in a primary care sample receiving daily opioid therapy. J Pain. 2007;8(7):573-582. 15. Manchikanti L, Cash KA, Damron KS, Manchukonda R, Pampati V, McManus CD. Controlled substance abuse and illicit drug use
Downloaded from ajh.sagepub.com at CMU Libraries - library.cmich.edu on October 5, 2015
Childers et al
16.
17. 18.
19.
20.
21.
22.
23.
659
in chronic pain patients: an evaluation of multiple variables. Pain Physician. 2006;9(3):215-226. Morasco BJ, Gritzner S, Lewis L, Oldham R, Turk DC, Dobscha SK. Systematic review of prevalence, correlates, and treatment outcomes for chronic non-cancer pain in patients with comorbid substance use disorder. Pain. 2011;152(3):488-497. Ewing JA. Detecting alcoholism. The CAGE questionnaire. JAMA. 1984;252(14):1905-1907. Dhalla S, Kopec JA. The CAGE questionnaire for alcohol misuse: a review of reliability and validity studies. Clin Invest Med. 2007; 30(1):33-41. Butler SF, Fernandez K, Benoit C, Budman SH, Jamison RN. Validation of the revised screener and opioid assessment for patients with pain (SOAPP-R). J Pain. 2008;9(4):360-372. Inflexxion. Screener and Opioid Assessment for Patients with Pain (SOAPP) version 1.0 SF;2008. https://www.painedu.org/ soapp.asp. Accessed April 6, 2014. Akbik H, Butler SF, Budman SH, Fernandez K, Katz NP, Jamison RN. Validation and clinical application of the screener and opioid assessment for patients with pain (SOAPP). J Pain Symptom Manage. 2006;32(3):287-293. Moore TM, Jones T, Browder JH, Daffron S, Passik SD. A comparison of common screening methods for predicting aberrant drugrelated behavior among patients receiving opioids for chronic pain management. Pain Med. 2009;10(8):1426-1433. Koyyalagunta D, Bruera E, Aigner C, Nusrat H, Driver L, Novy D. Risk stratification of opioid misuse among patients with cancer pain using the SOAPP-SF. Pain Med. 2013;14(5):667-675.
24. Opioids in the management of chronic non-cancer pain: an update of the American Society of Interventional Pain Physicians’ (ASIPP) Guidelines. Pain Physician. 2008;11(2 suppl):S5-S62. 25. Substance Abuse and Mental Health Services Administration. Results From the 2006 National Survey on Drug Use and Health Report. Rockville, MD: Office of Applied Studies; 2007. NSDUH Series H-32; DHHS publication no. SMA 07-4293. 26. Chabal C, Erjavec MK, Jacobson L, Mariano A, Chaney E. Prescription opiate abuse in chronic pain patients: clinical criteria, incidence, and predictors. Clin J Pain. 1997;13(2): 150-155. 27. Fishbain DA, Cole B, Lewis J, Rosomoff HL, Rosomoff RS. What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuse/addiction and/or aberrant drug-related behaviors? A structured evidencebased review. Pain Med. 2008;9(4):444-459. 28. Dunn KM, Saunders KW, Rutter CM, et al. Opioid prescriptions for chronic pain and overdose: a cohort study. Ann Intern Med. 2010;152(2):85-92. 29. Portenoy RK. Treatment of cancer pain. Lancet. 2011;377(9784): 2236-2247. 30. Chou R, Fanciullo GJ, Fine PG, et al. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009;10(2):113-130. 31. Wasan AD, Butler SF, Budman SH, Benoit C, Fernandez K, Jamison RN. Psychiatric history and psychologic adjustment as risk factors for aberrant drug-related behavior among patients with chronic pain. Clin J Pain. 2007;23(4):307-315.
Downloaded from ajh.sagepub.com at CMU Libraries - library.cmich.edu on October 5, 2015
Chronic Pain and Risk Factors for Opioid Misuse in a Palliative Care Clinic
American Journal of Hospice & Palliative Medicine® 2015, Vol. 32(6) 654-659 ª The Author(s) 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1049909114531445 ajhpm.sagepub.com
Julie W. Childers, MD1, Linda A. King, MD1, and Robert M. Arnold, MD1
Abstract Objectives: To describe the prevalence of chronic pain and the risk of opioid misuse in a palliative care clinic. Methods: We reviewed patient records for 6 months for source of pain, treatment status, opioid misuse risk (Cut down, Annoyed, Guilty, and Eye-opener [CAGE] and Screener and Opioid Assessment for Patients with Pain version 1.0—Short Form [SOAPP-SF] scores), and urine drug screens. Results: Of 323 patients, 91% had cancer, 56% undergoing cancer treatment, while 28% had no evidence of disease. Eighty-six (27%) patients had noncancer pain. In all, 46% of new patients had positive scores on the SOAPP-SF and 15% had a positive CAGE. Of the less than 5% of visits that included a urine drug screen, 56% had aberrant results. Conclusion: Chronic pain and indicators of opioid misuse risk were prevalent. Outpatient palliative care practices should develop policies to address these issues. Keywords palliative, pain, opioid misuse, chronic pain, cancer pain, addiction, outpatient
Introduction Palliative care consultation has occurred primarily in the inpatient setting, where the clinician–patient relationship is brief, the focus is on the management of acute pain and symptoms, and life expectancy is often limited to a few days or weeks.1,2 Ambulatory palliative care clinics are a new domain for palliative care and are still evolving.3 Palliative care outpatient clinics extend palliative care services upstream to patients who are seriously ill but have longer prognoses. These clinics are typically small, frequently only serve patients for 1 or 2 half days per week and are often located within a cancer center.4,5 Previous studies of patients with cancer (usually advanced or metastatic) in ambulatory palliative care settings have found outpatient palliative care referral to be correlated with improved pain scores, sense of well-being, depression, and other symptoms.6-10 Previous to 2010, studies of ambulatory palliative care populations, which reported survival, have found mean life expectancies of 6 to 10 weeks dating from the initial visit.11,12 A 2010 study of early outpatient palliative care referral for patients with metastatic lung cancer showed a median survival of 11.6 months.13 However, as criteria for ambulatory palliative care referral broaden, providers may treat more patients with chronic cancer pain or chronic pain unrelated to their lifelimiting diagnoses. There has been little research that evaluates the extent to which palliative care clinics are treating chronic pain. If chronic pain is becoming commonly seen in the palliative care outpatient setting, providers may be encountering opioid abuse and addiction more frequently.
Chronic pain clinics primarily serving patients with nonmalignant pain have a prevalence of substance use disorders of up to 48%.14-16 There are no studies to our knowledge that describe the prevalence of chronic pain or the frequency of aberrant drug-related behavior in cancer pain or palliative care clinics. In this study, we assessed the types of pain and the risk of opioid misuse in patients seen in a palliative care clinic located in a cancer center.
Methods This study is a retrospective chart review of patients seen at the Cancer Pain and Supportive Care Clinic between June 1, 2011, and November 30, 2011. The Cancer Pain and Supportive Care Clinic is located in the Hillman Cancer Center and provides consultation and management of pain and symptoms as well as discussions of goals of care and referral to ancillary services. The clinic was established in October 2002 and at that time had 2 sessions per week with services provided by only 1 physician. In 2010, the clinic provided services for 6 1
Department of Medicine, Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, PA, USA
Corresponding Author: Julie W. Childers, MD, Department of Medicine, Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh, 200 Lothrop Street, Suite 9W, Pittsburgh, PA 15213, USA. Email: [email protected]
Downloaded from ajh.sagepub.com at CMU Libraries - library.cmich.edu on October 5, 2015
Childers et al
655
half-day sessions per week, evaluating approximately 250 new patients with 1200 total patient visits. Services are provided by 5 physicians who are board certified in Hospice and Palliative Medicine. Psychiatry, psychology, social work, and nutrition support are also available within the cancer center but are not integrated into the clinic. Data were gathered from several sources within the clinic. First, the type of cancer or other life-limiting illness, the physician’s assessment of the type of pain treated (tumor related, chemotherapy-related, radiation therapy-related, surgeryrelated, noncancer-related, or nonpain symptoms only), and the patient’s disease status as recorded by the physician as active treatment (including palliative chemotherapy), completely palliative (patient not receiving chemotherapy but may receive palliative radiation therapy), or no evidence of disease were recorded at the end of the visit, including both initial visits and follow-up visits. Patients were identified as having no evidence of disease if they had minimal or no cancer on scans and were seeing their oncologist for surveillance only. Physicians could indicate more than 1 type of pain treated, but only 1 treatment status, and up to 3 life-limiting illnesses. Data gathered from patient-completed intake forms completed on an initial clinic visit included 2 measures for opioid misuse. First, patients were asked whether they drink alcohol, and if the answer was ‘‘yes,’’ the patient completed the Cut down, Annoyed, Guilty, and Eye-opener (CAGE) questions, a 4-item screening questionnaire for alcohol abuse.17 Two positive answers to the CAGE questionnaire have been shown to have a sensitivity of >90% and a specificity of >95% for detecting alcoholism.18 In addition, on their initial clinic visit, patients completed the Screener and Opioid Assessment for Patients with Pain version 1.0—Short Form (SOAPP-SF), derived from the previously validated 14-question SOAPP.19 The SOAPP-SF consists of 5 questions about behaviors associated with opioid misuse, answered on a scale of 0 to 4, where 0 ¼ ‘‘never’’ and 4 ¼ ‘‘very often.’’ A total SOAPP-SF score from 0 to 20 is calculated; preliminary validation of the measure showed that a score of 4 or more has 85% sensitivity and 67% specificity for the development of opioid misuse in patients with chronic pain.20 At the time of this study, the Cancer Pain and Supportive Care clinic had no policy regarding the use or frequency of urine drug screens, which were ordered at the discretion of the physician. Most urine drug screens ordered included gas chromatography/mass spectroscopy analysis, which distinguish between specific opioids such as heroin, codeine, and morphine in their reporting. Results of urine drug screens were gathered from the medical record. The electronic medical record and local obituary records were also searched for patient death date during or 6 months after the study period. Study data were collected and managed using REDCap electronic data capture tools hosted at the University of Pittsburgh and statistically analyzed using SAS version 9.3. This study was funded by the Shadyside Foundation and was approved as exempt by the institutional review board of the University of Pittsburgh.
Results Patient Characteristics The clinic patient population is described in Table 1. A total of 323 patients were seen in the clinic during the 6-month period; 77 of these were new patients. The majority (91%) had a cancer diagnosis. In all, 86 (27%) patients were noted by their physicians to have some noncancer pain; 5 (1.5%) of the 323 patients were seen for a nonpain diagnosis. In all, 53% of the patients with cancer were undergoing active treatment and 90 (28%) patients with cancer had no evidence of disease. Of the 323 patients seen during the 6-month period, 101 (31%) patients died within 6 months of their visit.
Opioid Misuse Measures Of the 76 new patients seen, 57 completed the full clinic intake, including the SOAPP and CAGE screens. Of these, 26 (46%) had a positive score of 4 or more on the SOAPP and 5 (15%) scored positive on the CAGE. Of the 644 total patient visits, 27 (4.2%) visits included a urine drug screen. In all, 15 (56%) screens had results that were aberrant, including 6 screens that were negative for prescribed opioids, 1 that was positive for a nonprescribed benzodiazepine, 4 that were positive for cocaine, 6 positive for marijuana, and 1 that was positive for heroin. Results from urine drug screens are presented in Table 2. Review of the electronic medical record also indicated 25 urine drug screens ordered in the emergency department, hospital, or by other outpatient providers, and these results included 4 results positive for marijuana and 3 positive for cocaine. Table 3 shows the association of patient characteristics with opioid misuse measures. Patients with a positive SOAPP score tended to be younger (50.4 years as opposed to 61.0 years, P ¼ .007). There were no other significant associations with SOAPP or CAGE scores with type of pain or with treatment status. Urine drug screens were more likely to be ordered on patients without cancer (P value .0419) and patients with noncancer pain. However, one-quarter of the patients with aberrant urine drug screens had tumor-related pain, and nearly 20% of them were undergoing active treatment for cancer.
Discussion In this population, the prevalence of chronic nonmalignant pain and patients with no evidence of disease were high. This is likely related to the marketing of the clinic, which is commonly known within the cancer center as the ‘‘pain clinic.’’ At least a portion of this population may be similar to patients seen in chronic nonmalignant pain clinics. Many patients were chronic: two-thirds of the patients survived at least 6 months beyond their initial study visit. Second, a high proportion (46%) of patients who completed the SOAPP-SF questionnaire had a positive score. Data from chronic nonmalignant pain clinics show that the percentage of patients who score positive on a 24-item SOAPP ranged between 54% and 75%, while
Downloaded from ajh.sagepub.com at CMU Libraries - library.cmich.edu on October 5, 2015
American Journal of Hospice & Palliative Medicine® 32(6)
656 Table 1. Characteristics of Patients Seen in the Palliative Care Clinic.
Unique patients seen Number of visits Initial intake visit Visits per patient (mean, range) Age (mean, SD, range) Male (number and % males) Race White African American Other Primary diagnosisa—cancer Colorectal Lung Breast Genitourinary Head/neck Hematologic Other cancer Primary diagnosis—noncancer Sickle cell disease Neurologic disease Cardiac disease Pulmonary disease Otherb Type of painc Tumor-related Chemotherapy-related Radiation therapy-related Surgery-related Noncancer pain Nonpain symptoms Item not completed Average number of types of pain (mean and standard deviation at first visit) Treatment statusd Active treatment Palliative only No evidence of diseasee Missing Deathsf Survival from initial clinic visit in days (N ¼ 101) SOAPP score 4 (n ¼ 57) CAGE score 2 (n ¼ 32)
N
%
323 644 76 2 (min ¼ 1, max ¼ 10) 54 (SD 13) (min ¼ 21, max ¼ 90) 163
50
276 47 0 294 27 39 27 18 56 53 73 29 3 2 0 2 22
85 15 0 91 8 12 8 6 17 16 23 11 1 1 0 1 7
146 53 43 48 86 5 20 1.2 (min ¼ 1, max ¼ 3)
45 16 13 15 27 2 6 0.5
164 18 90 22 101 143 (SD 94) 26 5
56 6 31 7 31 46 16
Abbreviations: CAGE, Cut down, Annoyed, Guilty, and Eye-opener; SOAPP, Screener and Opioid Assessment for Patients with Pain version 1.0; SD, standard deviation. a First life-limiting diagnosis as recorded by the treating physician. b Other noncancer diagnoses seen in the clinic included aplastic anemia, Waldenstrom macroglobulinemia, diabetes, lupus, osteoarthritis, chronic abdominal pain, cirrhosis, and antiphospholipid antibody syndrome. c Type of pain recorded by physician at the first visit in the study period. d Treatment status for patients with cancer only, as recorded by the physician in the first visit during the study period. e ‘‘No evidence of disease’’ was defined as having minimal to no cancer burden on recent scans and receiving surveillance visits only from oncology. f Deaths within the 6-month study period or during the following 6 months.
in another cancer pain clinic, the SOAPP-SF was positive in 26% of patients on initial intake.21-23 Opioid prescribing for chronic nonmalignant pain is controversial, and providers are recommended to carefully screen patients before initiating opioid therapy.24 This is particularly important in the setting of the growing incidence of prescription drug abuse and the epidemic of opioid overdoses seen
nationally.25 Patients with chronic nonmalignant pain and a history of a substance use disorder are more likely to misuse prescribed opioids and to develop aberrant drug-related behaviors.26-28 However, opioids are the standard of care for cancer pain.29 This study points to the need to consider screening for opioid risk and managing the risk of misuse within the cancer pain population.
Downloaded from ajh.sagepub.com at CMU Libraries - library.cmich.edu on October 5, 2015
Childers et al
657
Table 2. Urine Drug Screen (UDS) Results in the Palliative Care Clinic. Results
n (number of visits)
%
27
6
14 2 3 15 6 0 4 1 4 6 1 1
74 11 16 56 22 0 15 4 15 22 4 4
Visits with urine drug screena performed during study period Number of clinic patients who had urine screen performed Number of urine screens per patient who had a urine screen at our clinic 1 2 3 Number of aberrant UDS results Negative for prescribed opioids Negative for prescribed benzodiazepines Positive for nonprescribed opioids Positive for nonprescribed benzodiazepines Cocaine present Marijuana present Heroin or metabolite Other substance presentb a
Two urine drug screens ordered were immunoassay only; all other tests included gas chromatography/mass spectroscopy analysis. Phenobarbital was present in 1 sample.
b
Table 3. Association of Patient Characteristics With Opioid Misuse Measures. SOAPP scores
Characteristic
SOAPP < 4 SOAPP 4 (N ¼ 31) (N ¼ 26)
Age, mean, years 61.0 Cancer, % 90.3 Tumor-related 41.9 pain, % Chemotherapy12.9 related pain, % XRT-related 9.7 pain, % Surgery-related 12.9 pain, % Noncancer 25.8 pain, % Nonpain 9.7 symptoms, % Pain item not 3.2 completed, % Treatment status, % Active 71.0 treatment 9.7 Palliative treatment only No evidence 9.7 of disease No cancer 3.2 history Item not 6.5 completed
CAGE scores P value
UDS status
CAGE < 2 CAGE 2 P (N ¼ 27) (N ¼ 5) value
None ordered (N ¼ 304)
UDS as expected (N ¼ 8)
1 aberrant P UDSa (N ¼ 11) value
50.4 96.2 53.8
0.0070 0.3907 0.3697
56.0 96.3 48.1
48.0 80.0 40.0
.2431 .1667 .7373
54.9 90.1 47.0
45.0 62.5 0.0
49.4 90.9 27.3
.0552 .0419 .0147
19.2
0.5141
14.8
40.0
.1851
17.4
0.0
9.1
.3366
15.4
0.5132
11.1
40.0
.1022
12.8
25.0
18.2
.5394
7.7
0.5232
14.8
0.0
.3575
13.5
25.0
36.4
.0747
19.2
0.5556
14.8
40.0
.1851
25.0
62.5
45.5
.0215
0.0
0.1032
3.7
0.0
.6620
1.6
0.0
0.0
.8532
11.5
0.2211
7.4
20.0
.3749
5.9
0.0
0.0
.5512
57.7
0.6645
74.1
40.0
.1451
54.3
0.0
18.2
.0001
7.7
3.7
0.0
5.6
0.0
18.2
11.5
11.1
0.0
27.6
62.5
54.5
3.8
3.7
20.0
4.9
37.5
9.1
19.2
7.4
40.0
7.6
0.0
0.0
Abbreviations: CAGE, Cut down, Annoyed, Guilty, and Eye-opener; SOAPP, Screener and Opioid Assessment for Patients with Pain version 1.0; UDS, urine drug screen; XRT, radiotherapy. a An aberrant UDS could include absence of prescribed opioids or benzodiazepines and presence of nonprescribed medications or illicit substances.
Downloaded from ajh.sagepub.com at CMU Libraries - library.cmich.edu on October 5, 2015
American Journal of Hospice & Palliative Medicine® 32(6)
658 Only 4.2% of clinic patients had a urine drug screen. Aberrant results were found in more than half of those patients screened and included patients with all types of pain and patients undergoing active cancer treatments as well as patients with chronic nonmalignant or postcancer pain. We could find no published recommendations for urine drug screening or other opiate risk assessment measures in palliative care or cancer pain populations. In the chronic nonmalignant pain setting, urine drug testing at regular intervals is recommended, particularly for high-risk patients.30 Without guidelines, the decision is left up to clinicians, whose estimates of the likelihood of aberrant drug-related behavior are inaccurate31 and may be biased by sociodemographic factors. This study is preliminary, and the numbers of patients included, particularly of those who completed the opioid misuse measures, was small. Our data are limited to information routinely collected at clinic visits, and as medical assistants did not always remember to hand out clinic intake forms to new patients, only 57 of the 76 new patients completed a form. The type of pain and treatment status was determined by individual physician judgment. From this retrospective data, we were not able to collect information on the particular opioids prescribed or doses. Future studies that prospectively and systematically evaluate types of pain, patterns of opioid prescribing, and the incidence of opioid misuse in multiple outpatient palliative care settings are warranted. In addition, there are unanswered questions about the differences between this population and the chronic nonmalignant pain. One question from the SOAPP-SF, the frequency of mood swings, may be more likely to be positive in patients with cancer who are often undergoing a high level of stressful events such as chemotherapy and surgery and may have recently heard bad news. In order to accurately predict opioid misuse, further testing of the SOAPP and other opioid misuse measures should be conducted in patients with cancer pain and other life-limiting illness, and results should be correlated with other risk tools and with actual opioid misuse. As palliative care outpatient practices mature, their practices may shift to include more patients with chronic pain both related and unrelated to their life-limiting illness. Many of these patients will continue in clinic as patients with shorter prognoses die. In order to be able to continue to accommodate new patients with shorter prognoses, palliative care clinics may need to consider referral to chronic pain clinics, survivorship clinics, or back to primary care physicians. Ambulatory palliative care practices that include some patients with chronic pain will need to adapt to include strategies for detecting and managing opioid misuse. Acknowledgment The authors would like to acknowledge the Shadyside Foundation for their support of this research and the assistance of Marnie Bartolet with statistical analysis.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The project was also supported by the National Institutes of Health through Grant Number UL1TR000005.
References 1. Morrison RS, Maroney-Galin C, Kralovec PD, Meier DE. The growth of palliative care programs in US hospitals. J Palliat Med. 2005;8(6):1127-1134. 2. Fromme EK, Bascom PB, Smith MD, et al. Survival, mortality, and location of death for patients seen by a hospital-based palliative team. J Palliat Med. 2006;9(4):903-911. 3. Meier DE, Beresford L. Outpatient clinics are a new frontier for palliative care. J Palliat Med. 2008;11(6):823-828. 4. Rabow MW, Smith AK, Braun JL, Weissman DE. Outpatient palliative care practices. Arch Intern Med. 2010;170:654-655. 5. Berger GN, O’Riordan DL, Kerr K, Pantilat SZ. Prevalence and characteristics of outpatient palliative care services in California. Arch Intern Med. 2011;171(22):2057-2059. 6. Jacobsen J, Jackson V, Dahlin C, et al. Components of early outpatient palliative care consultation in patients with metastatic nonsmall cell lung cancer. J Pall Med. 2011;14(4): 459-464. 7. Follwell M, Burman D, Le LW, et al. Phase II study of an outpatient palliative care intervention in patients with metastatic cancer. J Clin Oncol. 2009;27(2):206-213. 8. Muir JC, Daly F, Davis MS, et al. Integrating palliative care into the outpatient, private practice oncology setting. J Pain Symptom Manage. 2010;40(1):126-135. 9. Porta-Sales J, Codorniu N, Go´mez-Batiste X, et al. Patient appointment process, symptom control and prediction of followup compliance in a palliative care outpatient clinic. J Pain Symptom Manage. 2005;30(2):145-153. 10. Bruera E, Michaud M, Vigano A, Neumann CM, Watanabe S, Hanson J. Multidisciplinary symptom control clinic in a cancer center: a retrospective study. Support Care Cancer. 2001;9(3): 162-168. 11. Casarett DJ, Hirschman KB, Coffey JF, Pierre L. Does a palliative care clinic have a role in improving end-of-life care? Results of a pilot program. J Palliat Med. 2002;5(3):387-396. 12. Strasser F, Sweeney C, Willey J, Benisch-Tolley S, Palmer JL, Bruera E. Impact of a half-day multidisciplinary symptom control and palliative care outpatient clinic in a comprehensive cancer center on recommendations, symptom intensity, and patient satisfaction: a retrospective descriptive study. J Pain Symptom Manage. 2004;27(6):481-491. 13. Temel JS, Green JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010;363(8):733-742. 14. Fleming MF, Balousek SL, Klessig CL, Mundt MP, Brown DD. Substance use disorders in a primary care sample receiving daily opioid therapy. J Pain. 2007;8(7):573-582. 15. Manchikanti L, Cash KA, Damron KS, Manchukonda R, Pampati V, McManus CD. Controlled substance abuse and illicit drug use
Downloaded from ajh.sagepub.com at CMU Libraries - library.cmich.edu on October 5, 2015
Childers et al
16.
17. 18.
19.
20.
21.
22.
23.
659
in chronic pain patients: an evaluation of multiple variables. Pain Physician. 2006;9(3):215-226. Morasco BJ, Gritzner S, Lewis L, Oldham R, Turk DC, Dobscha SK. Systematic review of prevalence, correlates, and treatment outcomes for chronic non-cancer pain in patients with comorbid substance use disorder. Pain. 2011;152(3):488-497. Ewing JA. Detecting alcoholism. The CAGE questionnaire. JAMA. 1984;252(14):1905-1907. Dhalla S, Kopec JA. The CAGE questionnaire for alcohol misuse: a review of reliability and validity studies. Clin Invest Med. 2007; 30(1):33-41. Butler SF, Fernandez K, Benoit C, Budman SH, Jamison RN. Validation of the revised screener and opioid assessment for patients with pain (SOAPP-R). J Pain. 2008;9(4):360-372. Inflexxion. Screener and Opioid Assessment for Patients with Pain (SOAPP) version 1.0 SF;2008. https://www.painedu.org/ soapp.asp. Accessed April 6, 2014. Akbik H, Butler SF, Budman SH, Fernandez K, Katz NP, Jamison RN. Validation and clinical application of the screener and opioid assessment for patients with pain (SOAPP). J Pain Symptom Manage. 2006;32(3):287-293. Moore TM, Jones T, Browder JH, Daffron S, Passik SD. A comparison of common screening methods for predicting aberrant drugrelated behavior among patients receiving opioids for chronic pain management. Pain Med. 2009;10(8):1426-1433. Koyyalagunta D, Bruera E, Aigner C, Nusrat H, Driver L, Novy D. Risk stratification of opioid misuse among patients with cancer pain using the SOAPP-SF. Pain Med. 2013;14(5):667-675.
24. Opioids in the management of chronic non-cancer pain: an update of the American Society of Interventional Pain Physicians’ (ASIPP) Guidelines. Pain Physician. 2008;11(2 suppl):S5-S62. 25. Substance Abuse and Mental Health Services Administration. Results From the 2006 National Survey on Drug Use and Health Report. Rockville, MD: Office of Applied Studies; 2007. NSDUH Series H-32; DHHS publication no. SMA 07-4293. 26. Chabal C, Erjavec MK, Jacobson L, Mariano A, Chaney E. Prescription opiate abuse in chronic pain patients: clinical criteria, incidence, and predictors. Clin J Pain. 1997;13(2): 150-155. 27. Fishbain DA, Cole B, Lewis J, Rosomoff HL, Rosomoff RS. What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuse/addiction and/or aberrant drug-related behaviors? A structured evidencebased review. Pain Med. 2008;9(4):444-459. 28. Dunn KM, Saunders KW, Rutter CM, et al. Opioid prescriptions for chronic pain and overdose: a cohort study. Ann Intern Med. 2010;152(2):85-92. 29. Portenoy RK. Treatment of cancer pain. Lancet. 2011;377(9784): 2236-2247. 30. Chou R, Fanciullo GJ, Fine PG, et al. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009;10(2):113-130. 31. Wasan AD, Butler SF, Budman SH, Benoit C, Fernandez K, Jamison RN. Psychiatric history and psychologic adjustment as risk factors for aberrant drug-related behavior among patients with chronic pain. Clin J Pain. 2007;23(4):307-315.
Downloaded from ajh.sagepub.com at CMU Libraries - library.cmich.edu on October 5, 2015
