Oncology Nurses Have a Responsibility to Identify and Prevent Opioid Abuse in Patients With Cancer

“Opioid statistics continue to grow, and it has created an impact in society,” Chang said. The rate of opioid drug use has been rising since the late 1990s. Because of this, the rates of opioid abuse, overdose, and death are increasing as well.

Opioid abuse increases sociologic issues as well as costs related to their management. In a 2007 study (https://www.asam.org/docs/advocacy/societal-costs-of-prescription-opioid-abuse-dependence-and-misuse-in-the-united-states.pdf), the total societal cost from opioid abuse to the United States was $55.7 billion, including:

• $25.6 billion in workplace related costs
• $25.0 billion in healthcare related costs
• $5.1 billion in criminal justice related costs

“Just like Parkinson disease or Alzheimer disease, addiction is a disease of the brain,” Chang said. “And just like other chronic diseases, addiction can be managed successfully.”

Patients with cancer do have an increased risk of opioid abuse. Studies on the subject are sparse, but two investigations showed that 15 of 38 patients with cancer (39.5%) (http://www.jnccn.org/cgi/pmidlookup?view=long&pmid=23946178) receiving chronic opioid therapy were at high risk for opioid abuse and 43% of 114 patients with cancer (https://doi.org/10.1007/s00520-014-2167-6) receiving opioid treatment in a palliative care clinic were at medium to high risk for opioid abuse, based on a self-reported opioid risk tool.

According to Chang, challenges to managing substance use disorder (SUD) and pain in patients with cancer include:

• The need to treat both conditions
• Overlap between pain and SUD
• Coexisting mental conditions
• Compliance with cancer treatment
• Perceptions and inadequate training in providers
• Lack of established policies outlining how to care for those with identified problems
• Use of nonpharmacological interventions
• Stigma

However, strategies for successful management of chronic pain (while avoiding opioid abuse), include using patient assessments to identify patients at higher risk for SUD, participating in urine drug tests, arranging frequent visits with medium- to high-risk patients, and engaging in state-run prescription drug monitoring programs.

According to Edwards, knowing aberrant opioid behaviors can enable nurses to stay more in tune with patients’ possible opioid abuse, and all members of the clinic or facility need to be aware and educated.

“We truly need all hands on deck when we focus on this,” Edwards said. “We need to figure out what we can do to curb this, and sometimes it’s as simple as education.”

Edwards cited the following aberrant drug-related behaviors, but she noted that it’s not an exhaustive list and that oncology nurses should further inquire into any suspicious patient behaviors:

• Selling prescription drugs
• Stealing drugs from others
• Obtaining prescriptions from nonmedical sources
• Concurrently using alcohol or illicit drugs
• Requesting repeated dose escalation or noncompliance
• Resisting changes in therapy despite evidence of adverse events
• Hoarding the drug
• Requesting specific drugs, dosages, or routes

Once aberrant behavior is established, nurses should act quickly but not be judgmental. Edwards suggested actions such as limiting a patient’s opioid quantity, decreasing the time interval between follow-ups for refills, or shortening the duration that a patient is on opioids.

“Duration is the strongest predictor of opioid misuse,” Edwards said.

To support patients who might abuse opioids, Edwards developed the Compassionate High Alert Team (CHAT), which involves a concentrated, interprofessional team to deliver

• Comprehensive education about safe opioid use
• Longitudinal counseling
• Sensitive communication
• Frequent monitoring
• Structured opioid use documentation
• Personalized treatment recommendations
• Logistic and caregiver support for patients at high risk of opioid misuse.

CHAT team members (i.e., a palliative care physician and at least two more members, such as a nurse, pharmacist, counselor, etc.), huddle before and debrief after each patient visit. The team ensures that patients demonstrate compliance and educate them on safety in an open, communicative forum.

Edwards also created an aberrant behavior algorithm called “BITES” that the entire CHAT team uses as a quick reference:

• Behavioral changes
• Inappropriate for refills
• Telephone calls frequently
• Emergency visits frequently
• Safety is compromised