Aberrant Opioid Use and Urine Drug Testing in Outpatient Palliative Care

Abstract

Aberrant opioid use is a public health issue, which has not been adequately described in the palliative care literature. With the increasing integration of palliative care into oncologic care, palliative care clinicians are seeing patients earlier in the disease trajectory, and therefore, more outpatients with chronic pain requiring chronic opioid therapy. This may have resulted in a concomitant rise in the number of patients with aberrant opioid use. In this article, we report on two patients with aberrant opioid-related behavior seen at our palliative care clinic. A high suspicion of opioid abuse, misuse, or diversion based on certain behavioral cues necessitated the ordering of a urine drug test (UDT). The tests helped the medical team to confirm an already existing pattern of maladaptive opioid use. In both cases, we provided ample opioid education and implemented effective strategies to address their aberrant opioid use. These cases suggest the need for palliative care clinicians to develop strategies to effectively address this issue in our field of medicine. It also highlights the usefulness of UDT in the outpatient palliative care setting.

Predicting the risk for aberrant opioid use behavior in patients receiving outpatient supportive care consultation at a comprehensive cancer center

“…One of the more contentious issue in patients receiving palliative care is the use of UDS to screen and monitor for aberrant drug behavior. Prior studies by our team suggest the very limited use of screening measures like UDS among patients who are receiving supportive care . Further studies are needed to determine the utility of routine UDS as a screening tool in the palliative care setting.…”

Frequency, predictors, and outcomes of urine drug testing among patients with advanced cancer on chronic opioid therapy at an outpatient supportive care clinic

“…This finding suggests that there may have been missed opportunities during those visits, and the test could have been ordered earlier. Such patients may initially demonstrate opioid‐adherent behaviors; therefore, it is sometimes unclear at which point during their treatment they transition to a pattern of aberrant opioid use . This highlights the need for ongoing risk evaluation and regular monitoring of all patients who are receiving COT with the use of screening tools, such as the CAGE‐AID, the revised Screener and Opioid Assessment for Patients with Pain, and the Opioid Risk Tool, supplemented by other strategies like the use of UDTs and prescription drug monitoring programs .…”

“…With the increasing integration of palliative care into oncologic care, palliative care clinicians are encountering more patients in the outpatient setting who have chronic pain and require chronic opioid therapy (COT). This may result in an associated increase in the number of patients with aberrant opioid use . The urine drug test (UDT) is an important opioid risk‐management tool that is frequently used in patients with noncancer pain who are receiving COT .…”

“…This may result in an associated increase in the number of patients with aberrant opioid use. 5 The urine drug test (UDT) is an important opioid risk-management tool that is frequently used in patients with noncancer pain who are receiving COT. 6 However, the published data are very limited on its use among patients with advanced cancer, and the frequency of aberrant drug-related behavior in this patient population is not well known.…”

Prospective, Longitudinal Study to Evaluate the Clinical Utility of a Predictive Algorithm to Detect Opioid Use Disorder in Chronic Pain Patients

“…Patient selfreported questionnaires like the Opioid Risk Tool (ORT), and Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP ® -R) use family, social and medical history to evaluate the risk of aberrant opioid behavior and addiction [15,16]. Although easy to use, these subjective questionnaires pose variable reliability [17]. Regardless of how accurate patients answer the questions, physicians still have only a 50% chance of predicting the development of OUD [18].…”