Analgesics and opioids have been widely used for the treatment and management of chronic pain in the healthcare sector. Opioids provide better and faster relief to patients with chronic pain compared to non-opioid analgesics. However, the long-term effects of opioids can be devastating. Cancer patients often require comprehensive treatment with respect to pain management. Opioids is considered as the gold standard for most cancer patients with chronic pain which may relate to improved quality of life and improved patient satisfaction. Opioids have a history for substance abuse and the same appears to be a risk to cancer patients. Based on recent evidence, long term opioid use has been associated with addiction among cancer patients (Meera 2011). In a recent review, a team of researchers have reported that prescription opioid abuse has become common among cancer patients with chronic pain, specifically among those with no history of substance abuse (Grattan, et al. 2012). In the pretext to avoid risk of opioid abuse, addiction, and depressive symptoms, researchers and healthcare providers are keen on reviewing and assessing patients regularly to identify patients that may have a high risk of addiction (Jamison, Serraillier, & Michna 2011). In a recent review, a team of researchers stated that 1 inn 5 cancer patients with chronic pain are at risk of opioid addiction/abuse (Carmichael, Morgan, & Del Fabbro 2016). In a systematic review, a team of researchers focused on the use of Opioid Assessment for Patients with Pain, CAGE, Opioid Risk Tool and Screener to identify high risk patients. They also focus on key areas to identity addiction traits due to long-term exposure to opioids which may include analgesia, anxiety, activity, ambiguous drug behaviour, and adverse effects (Jovey 2012). Thus, it has become a national level issue and implementing a risk assessment tool has become empirical to prevent and control opioid abuse among cancer patients with chronic pain.
Clinical practice question
Does the use of an Opioid Risk Tool (ORT) help in identifying and preventing opioid misuse/abuse among cancer patients with chronic pain?
Clinical Appraisal Component
In the past decade, there has been a substantial increase in the need for opioid abuse/misuse risk assessment among cancer patients with chronic pain. In a single-centre, small-scale observational study, a team of researchers assessed the impact of using the ORT to predict and identify individuals that may have developed aberrant behaviours due to long-term opioid use. A total of 185 patients were provided the ORT wherein the various risk factors were identified such as history of substance abuse, psychological disease, history of pre-adolescent sexual abuse, and familial history of substance abuse. The scoring system was as follows: <3: Low risk; 4 to 7: Moderate risk; and >8: High risk. The researchers reported that those with low risk had no aberrant behaviour while those with high risk scores, 99% of them displayed aberrant behaviour. The researchers utilized t-statistics to assess the specificity and sensitivity of the ORT. To conclude, the ORT was helpful in identify high risk patients for opioid abuse/misuse, specifically due to aberrant behaviour while the ORT was found to have a high degree of specificity and sensitivity for the same. A key limitation of the study was that it involved a small sample size, the results of the study may have been over estimated or under estimated, and the study took place in a single centre only. Large scale observation or prospective studies would be required to confirm the usefulness of the ORT with respect to identifying patients at risk of developing opioid dependence (Webster & Webster 2005).
In a retrospective study, a team of researchers aimed to identify how the ORT could help clinicians and healthcare providers identify cancer patients with long-term opioid use to be at risk for opioid dependence or substance abuse. The study was conducted due to the lack of scientific evidence on how early risk assessment can prevent opioid abuse among long-term opioid users for palliative cancer care. The research also aimed to help family members and caregivers who had experienced substance abuse among their loved ones with chronic cancer pain and long-term opioid exposure. The researchers identified key high risk variables, ORT scores, urine drug screen results, and insurance status. A total of 112 patients were identified and retrospectively assessed based on charts and records obtained from the Virginia Palliative Care Clinic. The study was conducted in accordance to clinical research ethical codes and permission from local authorities was taken prior to study commencement. The mean ORT score was 3.79 but there were 43% of patients who were identified to be at moderate or high risk for substance abuse based on ORT scores. 23% of patients had a personal history of alcohol abuse, 21% of patients had a history of illicit drug use while 23% of patients were between 16 to 45 years of age. The researchers also reported that out of the 40% of patients who appeared for the urine drug screen, there were 45.6% of abnormal findings. To conclude, the ORT has been proven to be an effective tool in assessing high risk patients for substance abuse. The need for opioid risk assessment has been identified to be of help to caregivers and family members while for clinicians it may help them to reassess and modify opioid management for cancer patients with chronic pain. A key limitation of the study was the small sample size, missing data of ORT scores, wherein only 31% of patients were identified in the total sample, and the risk for over estimation of the study (Barclay, Owens, & Blackhall 2012).
Thus, from both the studies, it can be concluded that the use of the ORT can help in identifying and preventing opioid misuse/abuse among cancer patients with chronic pain.
Conclusion
The ORT is a useful tool for identifying opioid dependence among patients while nurses can make use of the tool in caring and managing cancer patients who are at risk for opioid dependence. Large scale studies are required to recommend the use of ORT. It is helpful for clinicians to modify opioid management and reduce risk of opioid dependence while for family members, it can help reduce depressive and anxiety symptoms for the loved one (Barclay, Owens, & Blackhall 2012 and Webster & Webster 2005).
References
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Grattan, A., Sullivan, M. D., Saunders, K. W., Campbell, C. I., & Von Korff, M. R. (2012).
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