Opioids in advanced lung malignancy: a clinical audit of opioid prescription, patient education and safeguarding

Abstract

Background Opioids have an important role in symptom management for people with advanced cancer. Clinical guidelines recommend patient education to ensure the safe use of opioids; however, no Australian studies have explored current education and safeguarding practices when opioids are initiated to advanced cancer patients. Aims To investigate risk assessment, safeguarding and education practices when opioids are first prescribed to advanced lung cancer patients. Methods A retrospective medical record audit of outpatients with advanced non‐small cell lung cancer seen at a tertiary Australian hospital between 1 January 2015 and 31 December 2019 and prescribed strong opioids for cancer‐related symptoms. Results Of 1022 patients attending the lung cancer clinic, 205 were newly initiated on an opioid. Opioid‐related risks including previous recreational drug use (28; 13.6%) and history of falls (16; 7.9%) were infrequently documented. Opioid‐related safeguards and adverse effects management were variably instituted: written general practitioner correspondence at opioid initiation (62; 30%), clinic follow up (186; 91%) and laxative co‐prescription (55; 26.8%). Most patients (137; 66.8%) received no documented opioid education on drug initiation. There was no association between age (P = 0.653), number of comorbidities (P = 0.569) or chronic alcohol use (P = 0.263) and the provision of education on opioid initiation. Palliative care doctors or nurse practitioners were eight times more likely to document opioid education than medical oncologists (odds ratio = 8.5; confidence interval = 2.9–24.8; P < 0.0001). Conclusion Guideline‐recommended risk assessment, safeguards and patient education were infrequently documented when opioids were initiated. Clinician training, decision‐assist prompts in electronic prescribing software and written education resources for patients may address these gaps in care.

Expert consensus‐based guidance on approaches to opioid management in individuals with advanced cancer‐related pain and nonmedical stimulant use

“…Building evidence-based approaches for managing co-occurring opioid and nonmedical stimulant use is important in cancer care, given the high rates of stimulant use and ubiquity of prescription opioids. 1,2 Clinicians who treat cancer pain with opioids regularly encounter nonmedical stimulant use (i.e., methamphetamine, cocaine), yet there is little evidence-based management guidance. 3,4 Among people with cancer who receive urine toxicology testing, nonmedical stimulant use is the second most common unexpected substance detected on urine screening after cannabis.…”

Identifying barriers and facilitators for nurse practitioners' opioid management of chronic pain

“…To overcome the possible barrier, NPs may benefit from guideline-based training on how to communicate about common opioid-related adverse effects and potential long-term harm with patients. As a separate issue, patient education tends to be underreported in medical records compared with other aspects of medical care, so it is uncertain how much NPs are currently educating patients about opioids (Anil et al, 2021). Therefore, additional research is needed on NPs' practices with respect to patient education on opioids.…”

Opioid-prescribing considerations in patients with cancer and substance misuse or substance use disorder: a scoping review protocol

“…For example, Merlin et al 6 provide expert consensus on opioid management in people receiving medication treatment for OUD who have co-occurring cancer-related pain. Anil et al 15 reported no association between opioid risk counseling and opioid initiation; however, specialty may influence opioid decision-making documentation, with palliative care clinicians noted to be 8 times more likely to document opioid education than medical oncologists. Collectively, the studies give information on provider-specific and patient-specific factors that may inform opioid-prescribing decisions in people with cancer.…”