Screening for Opioid Misuse in the Nonhospitalized Seriously Ill Patient.

Background: Responding to an epidemic of opioid-related deaths, guidelines and laws have been implemented to promote safe opioid prescribing practices. Objective: This study evaluates differences in screening practices and knowledge of laws between oncologists and cardiologists who prescribe opiates. Design: Surveys regarding screening practices and knowledge of opioid prescribing laws were distributed in March 2017 to oncology and congestive heart failure (CHF) clinicians at the University of Virginia. Chi-square and Wilcoxon rank sum tests were used. Results: Forty-six of 129 (35.6%) oncology providers and 7 of 14 (50%) CHF providers reported prescribing opiates in their clinic with usable survey results. The majority of oncology (65.22%) and cardiology (85.71%) providers report screening for substance abuse "when indicated" (p = 0.053). Only 19.6% of oncologists reported always using the prescription monitoring program (PMP), while 71.43% of cardiologists reported using it always (p = 0.014). Of the oncology providers, 66.67% report never using the urine drug screen (UDS), while 86.7% of cardiologists reported using it "when indicated" (p = 0.0086). Up to 34.78% of the oncologists and 57.14% of the cardiologists reported of never screening the family members for misuse (p = 0.317). Knowledge of laws was similar between groups, with 14.29% of cardiology and 17.39% of oncology providers reporting no knowledge of opioid prescribing laws (p = 0.2869). Conclusions: Routine screening for substance misuse risk was uncommon for both groups, but cardiology providers were more likely to use the PMP or UDS. Knowledge gaps regarding Virginia laws were noted in both groups. Improved education regarding best practices and laws, as well as programs to promote screening, is needed for all providers.

Opioid use among female breast cancer patients using different adjuvant endocrine therapy regimens.

PURPOSE: To explore differences in opioid use across different adjuvant endocrine therapy (AET) regimens, factors associated with opioid use, and the impact of opioid use on overall survival in female breast cancer patients treated with AET. METHODS: This retrospective study analyzed 2006-2012 SEER-Medicare datasets, following patients for at least two years from the index date, defined as the first date they filled an AET prescription. The study included adult women with incident, primary, hormone-receptor-positive, stage I-III breast cancer. They were also first-time AET users, and fee-for-service Medicare enrollees continuously enrolled in Medicare Parts A, B, and D. The main independent variable was the AET regimen. We measured whether patients used opioids after the initiation of AET. RESULTS: After the adjustment of inverse probability treatment weights and unbalanced covariates, the average treatment effect probabilities of opioid use were similar between those who used aromatase inhibitors (AI) only and those used tamoxifen (TAM) only (56.2 vs. 55.3%, respectively). Opioid use probabilities for those who switched from AI to TAM were higher than those for the TAM-only and AI-only groups. Opioid use was also significantly associated with AET non-adherence. Opioid users had a significantly higher risk of death (adjusted hazard ratio [HR] = 1.59, p < 0.001). CONCLUSIONS: Switching from AI to TAM was associated with a high likelihood of opioid use. Opioid use was significantly associated with AET non-adherence and higher risk of mortality in female Medicare beneficiaries with breast cancer even after adjusting for adherence.

Early Palliative Care Reduces End-of-Life Intensive Care Unit (ICU) Use but Not ICU Course in Patients with Advanced Cancer.

BACKGROUND: Early palliative care for advanced cancer patients improves quality of life and survival, but less is known about its effect on intensive care unit (ICU) use at the end of life. This analysis assessed the effect of a comprehensive early palliative care program on ICU use and other outcomes among patients with advanced cancer. PATIENTS AND METHODS: A retrospective cohort of patients with advanced cancer enrolled in an early palliative care program (n = 275) was compared with a concurrent control group of patients receiving standard care (n = 195) during the same time period by using multivariable logistic regression analysis. The multidisciplinary outpatient palliative care program used early end-of-life care planning, weekly interdisciplinary meetings to discuss patient status, and patient-reported outcomes assessment integrated within the electronic health record. RESULTS: Patients in the control group had statistically significantly higher likelihood of ICU admission at the end of life (odds ratios [ORs]: last 6 months, 3.07; last month, 3.59; terminal admission, 4.69), higher likelihood of death in the hospital (OR, 4.14) or ICU (OR, 5.57), and lower likelihood of hospice enrollment (OR, 0.13). Use of chemotherapy or radiation did not significantly differ between groups, nor did length of ICU stay, code status, ICU procedures (other than cardiopulmonary resuscitation), disposition location, and outcomes after ICU admission. CONCLUSION: Early palliative care significantly reduced ICU use at the end of life but did not change ICU events. This study supports early initiation of palliative care for advanced cancer patients before hospitalizations and intensive care. The Oncologist 2017;22:318-323 IMPLICATIONS FOR PRACTICE: Palliative care has shown clear benefit in quality of life and survival in advanced cancer patients, but less is known about its effect on intensive care. This retrospective cohort study at a university hospital showed that in the last 6 months of life, palliative care significantly reduced intensive care unit (ICU) and hospital admissions, reduced deaths in the hospital, and increased hospice enrollment. It did not, however, change patients' experiences within the ICU, such as number of procedures, code status, length of stay, or disposition. The findings further support that palliative care exerts its benefit before, rather than during, the ICU setting.

Longitudinal patterns of cancer patient reported outcomes in end of life care predict survival.

PURPOSE: Patients with advanced cancer typically demonstrate sharp deterioration in physical function and psychological status during the last months of life. This study evaluates the relationship between survival in patients with advanced cancer and longitudinal assessment of anxiety, depression, fatigue, pain interference, and/or physical function using the US National Institute of Health Patient Reported Outcomes Information System. METHODS: Mixed-effects models were used to evaluate patient-reported outcome trajectories over time among patients with advanced loco-regional or metastatic cancer receiving care in a hospital-based palliative care clinic. Cox regression analysis was used to assess the statistical significance of differences in the probability of survival associated with patient-reported outcome scores. RESULTS: A total of 472 patients completed 1992 assessments during the 18-month study period. Longitudinal scores for fatigue, pain interference, and physical function demonstrated statistically significant non-linear trajectories. Scores for depression, fatigue, pain interference, and physical function were highly statistically significant predictors of survival (p < 0.01). Clinically meaningful differences in the probability of survival were demonstrated between patients with scores at the 25th vs. 75th percentiles, with absolute differences in survival at 6 and 12 months after assessment from 10 to 18 percentage points. CONCLUSIONS: Patient-reported outcomes can be used to reliably estimate where patients are along the trajectory of deteriorating health status leading toward the end of life, and for identifying patients with declining symptoms in need of referral to palliative care or more aggressive symptom management.

CARE Track for Advanced Cancer: Impact and Timing of an Outpatient Palliative Care Clinic.

BACKGROUND: Studies suggest that outpatient palliative care can reduce hospitalization and increase hospice utilization for patients with cancer, however there are insufficient resources to provide palliative care to all patients from time of diagnosis. It is also unclear whether inpatient consultation alone provides similar benefits. A better understanding of the timing, setting, and impact of palliative care for patients with cancer is needed. OBJECTIVES: The purpose of this study was to measure timing of referral to outpatient palliative care and impact on end-of-life (EOL) care. DESIGN: The Comprehensive Assessment with Rapid Evaluation and Treatment (CARE Track) program is a phased intervention integrating outpatient palliative care into cancer care. In Year 1 patients were referred at the discretion of their oncologist. SETTING: Academic medical center. MEASUREMENTS: We compared EOL hospitalization, hospice utilization, and costs of care for CARE Track patients compared to those never seen by palliative care or seen only in hospital. RESULTS: Patients were referred a median of 72.5 days prior to death. CARE Track patients had few hospitalizations at end of life, were less likely to die in hospital, had increased hospice utilization, and decreased costs of care; these results were significant even after controlling for differences between groups. Inpatient consultation alone did not impact these variables. However, only approximately half of patients with incurable cancers were referred to this program. CONCLUSION: Referral outpatient palliative care within 3 months of death improved EOL care and reduced costs, benefits not seen with inpatient care only. However, many patients were never referred, and methods of systematically identifying appropriate patients are needed.

Do Palliative Care Clinics Screen for Substance Abuse and Diversion? Results of a National Survey.

BACKGROUND: Opioids are the mainstay of treatment of cancer pain. With increased use there have been concerns about rising rates of prescription drug abuse and diversion. Although there has been an increase in research and practice guidelines about the scope of the problem for chronic, nonmalignant pain, less information is available about both the frequency of the problem and current practices regarding screening for substance abuse and diversion in patients and family members seen in palliative care clinics. OBJECTIVE: The aim of this study was to evaluate the degree to which palliative programs felt that substance abuse and diversion was an issue, and to identify practices regarding care of patients with potential substance misuse issues. METHODS: We sent a survey regarding substance abuse perception, policies, training, and screening to 94 accredited palliative medicine fellowship program directors as obtained by the Accreditation Council for Graduate Medical Education (ACGME) directory. RESULTS: We received usable responses from 38 (40.4%) programs. Policies for screening patients (40.5%) or family members (16.2%), dealing with diversion (27%), and use of a screening tool (32.4%) were reported infrequently. Despite this, one-half of respondents indicated that substance abuse and diversion was an issue for their clinics, with only 25% indicating substance abuse was not an issue. Additionally, the majority of fellows (83%) and about half (47%) of staff received mandatory training for dealing with substance misuse. All programs provided some screening of patients, with 48.7% screening all patients for abuse. Screening of family members was relatively rare, as was routine use of the urine drug screen (UDS). CONCLUSION: Despite increased concerns about substance abuse, the majority of programs did not have substance abuse and diversion policies or report screening all patients, with screening of caregivers rarely reported. Consensus guidelines addressing substance abuse and diversion for palliative patients are needed to address this growing problem.

Screening for substance abuse risk in cancer patients using the Opioid Risk Tool and urine drug screen.

PURPOSE: The use of opioids for management of cancer-related pain has increased significantly and has been associated with a substantial rise in rates of substance abuse and diversion. There is a paucity of data not only on the prevalence of substance abuse in cancer patients, but also for issues of drug use and diversion in family caregivers. This study aimed to evaluate the frequency of risk factors for substance abuse and diversion, and abnormal urine drug screens in cancer patients receiving palliative care. METHODS: A retrospective chart review was performed for patients with cancer who were seen in the University of Virginia Palliative Care Clinic during the month of September 2012. We evaluated Opioid Risk Tool variables and total scores, insurance status, and urine drug screen results. RESULTS: Of the 114 cancer patients seen in September 2012, the mean Opioid Risk Tool score was 3.79, with 43% of patients defined as medium to high risk. Age (16-45 years old, 23%) and a personal history of alcohol (23%) or illicit drugs (21%) were the most common risk factors identified. We obtained a urine drug screen on 40% of patients, noting abnormal findings in 45.65%. CONCLUSIONS: Opioids are an effective treatment for cancer-related pain, yet substantial risk for substance abuse exits in the cancer population. Screening tools, such as the Opioid Risk Tool, should be used as part of a complete patient assessment to balance risk with appropriate relief of suffering.

Amyotrophic lateral sclerosis and palliative care: where we are, and the road ahead.

Patients with amyotrophic lateral sclerosis (ALS) have high symptom burdens, including pain, fatigue, dyspnea, and sialorrhea, and they must make difficult decisions about the use of life-prolonging therapies, such as long-term mechanical ventilation. The impact of ALS is also felt by family caregivers who often struggle to meet the heavy physical, financial, and emotional demands associated with the illness. Expert multidisciplinary care may improve both quality and length of life of patients with ALS. However, although advances have been made in the treatment of some symptoms, others, including pain management, remain poorly studied. Involvement of palliative care specialists as part of the ALS multidisciplinary team is recommended, as we continue to work toward improving the quality of life for patients and their families.

Providing palliative care in the ambulatory care setting.

Palliative care that provides specialized attention to pain and symptom management is important for patients with cancer. Palliative care aims to reduce pain and other symptoms through an interdisciplinary approach involving physicians, nurses, social workers, and other members of the healthcare team. Families are included in care planning. Patients and families benefit from the availability of palliative care services early in the disease process, particularly when symptoms impact quality of life. One way to implement early palliative interventions is the establishment of an ambulatory care clinic dedicated to palliative care. This article describes the experience of an outpatient palliative care clinic at a large teaching hospital by using case studies to highlight the benefits of ambulatory palliative care and concluding with recommendations for research.

Palliative educational outcome with implementation of PEACE tool integrated clinical pathway.

BACKGROUND: House officers frequently lack basic competency in end-of-life care. Few studies have evaluated educational interventions deliberately utilizing physicians' learning strategies, particularly in the context of a concomitant effort at modification of practice patterns. STUDY DESIGN: Prospective controlled trial utilizing pre-intervention and post-intervention cross-sectional surveys. PARTICIPANTS: Internal medicine residents at a university hospital in their first, second, and third years of training. SURVEY: A 25-item survey modified from previously published instruments. INTERVENTION: Residents in the intervention group utilized an experiential learning intervention (integrated, end-of-life clinical pathway: PEACE Tool). The control group delivered care in a standard fashion. DATA ANALYSIS: SURVEY item and test responses were tabulated and pair-wise comparisons between group means evaluated statistically using two-sample t tests. RESULTS: Fifty-four internal medicine residents (n = 24, first-year; n = 17, second-year; and n = 13, third-year) completed the survey. Pre-intervention mean scores on a 16-item knowledge scale were 7.4 (46% correct) for first-year, 8.1 (51%) for second-year, and 9.2 (58%) for third-year residents. Eighteen first-year residents participated in the intervention phase (8 in the intervention, 10 in the control). Mean overall knowledge scores were 46% higher in the intervention group compared to the control group (11.8 versus 8.1 p < 0.001). CONCLUSIONS: A time-effective, practice-based strategy led to a significant improvement in knowledge of end-of-life care. Prior to implementation of this strategy competency in end-of-life care was suboptimal among internal medicine residents, in spite of desirable attitudes. Factual knowledge improved slightly with standard, pre-intervention training and experience.