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Patients with cancer may be at risk for opioid misuse

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September 26, 2018

Individuals treated with opioids for cancer pain may be at risk for aberrant drug behaviors, including misuse and addiction, study results suggest.

Sriram Yennurajalingam, MD, MS, of the department of palliative care, rehabilitation and integrative medicine at The University of Texas MD Anderson Cancer Center, and colleagues sought to determine the risk for such behaviors among patients after they received outpatient care at a comprehensive cancer center. They noted that as many as 90% of patients with cancer are treated for pain with opioids.

“In the current study, we observed a high frequency (approximately 20%) of an elevated risk of aberrant opioid use behaviors among patients with cancer,” Yennurajalingam and colleagues wrote. “Male patients and those who had anxiety, financial distress and prior alcoholism/illicit drug use are at increased risk.”

Researchers also sought to compare the screening performance of the adapted Cut Down-Annoyed-Guilty-Eye Opener (CAGE-AID) questionnaire for drug use with the 14-item Screener and Opioid Assessment for Patients With Pain (SOAPP-14) tool, designed to predict aberrant medication-related behaviors among patients with chronic pain.

The researchers used SOAPP scores of 7 or higher as the gold standard to identify patients at risk for aberrant opioid or drug use behaviors. CAGE-AID scores of 2 to 4 are considered positive for alcoholism and raise concern for opioid misuse and chemical coping.

The analysis included 751 consecutive patients, who researchers also assessed using the Edmonton Symptom Assessment Scale (ESAS).

Eligibility criteria included a cancer diagnosis and at least 1 week of opioid treatment for pain.

Results showed that of the 729 evaluable patients, 19.6% (n = 143) fit criteria for SOAPP positivity, whereas 10.5% (n = 73) were positive on the CAGE-AID scale.

A positive SOAPP score correlated with a positive CAGE-AID score (OR = 2.3; P < .0001), according to multivariate analysis results.

Findings from the multivariate analysis also showed associations between a positive SOAPP score and male sex (OR = 2.08; P = .0013). Further, each point increase on the ESAS scales for pain (OR = 1.1; P = .014), anxiety (OR = 1.13; P = .0015) and financial distress (OR = 1.09; P = .012) correlated with positive SOAPP scores.

A CAGE-AID cutoff score of 1 in 4 was found to be 43.3% sensitive and 90.93% specific in identifying patients at increased risk for aberrant drug and opioid use when a SOAPP score of 7 or higher was used as the gold standard.


A number of trends in SOAPP questionnaire responses emerged among study participants who demonstrated aberrant opioid use behaviors. For instance, patients at risk for aberrant opioid use also reported mood swings, family members with alcohol or drug problems, and close friends with similar problems. However, there were fewer positive responses to many other SOAPP items, suggesting a more streamlined version of the survey could be used.

“Unfortunately, routine screening for the risk of aberrant opioid behaviors is not frequently performed in routine clinical practice among patients with cancer who are receiving opioids,” the researchers wrote.

“No set guidelines are currently available for the management of patients with cancer who are positive for a risk of aberrant opioid use behavior,” they added. “However, based on prior studies in cancer, patients without cancer, and our clinical experience, various strategies may guide us to optimize opioid prescription in these patients.” by Rob Volansky

Disclosures: Yennurajalingam reports grants from Bayer, Genentech and Helsinn, outside the submitted work. One other author reports grants from Helsinn outside the submitted work.

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