Health Care Provider Attitudes and Beliefs Toward Nonmedical Opioid Use in Patients with Cancer Pain

Abstract

Background:

Data on health care providers' (HCPs’) perceptions about patients with cancer pain and nonmedical opioid use (NMOU) are lacking. We examined the perceptions and attitudes of HCPs and assessed the usefulness of an interdisciplinary opioid stewardship program (OSP) while caring for these patients.

Methods:

An anonymous cross-sectional survey was conducted among the supportive care HCPs between September and November 2021.

Results:

Of 85 HCPs, 64 responded (75%) to the survey. Participants perceived that NMOU is underdiagnosed (42/64; 67%), and caring for such patients is difficult (58/64, 91%) and time consuming (54/64, 87%). A majority (50/51, 98%) were aware of the OSP, and (48/51; 94%) found it helpful.

Conclusion:

HCPs reported that NMOU is underdiagnosed and is challenging to manage. They endorsed the utility of an OSP in managing patients with concurrent cancer pain and NMOU. Future research should identify ways to standardize care and integrate OSP in routine supportive oncology practice.

Introduction

Cancer-related pain is one of the most prevalent and distressing symptoms, affecting 70%–90% of those with advanced disease. Opioids remain the gold standard for treating cancer pain.^1–3 Chronic opioid therapy (COT) requires careful monitoring and management of nonmedical opioid use (NMOU), a collection of behaviors previously identified through research studies suggesting maladaptive use of opioids such as frequent calls for early opioid refills, reports of stolen opioids, and resistance to making adjustments to their existing plan despite clear clinical indications. These are more prevalent among these patients than initially suspected.^4,5

Our outpatient supportive care center (SCC) developed an interdisciplinary opioid stewardship program (OSP) (initially referred to as the “Compassionate High Alert Team” during its inception) to assist in the management of cancer pain among patients who exhibit aberrant opioid-related behavior.^6,7 A previous study by our group showed a reduction in the frequency of NMOU-related behaviors after implementing the OSP intervention.⁶ In this era of a global crisis with ongoing opioid epidemic, it is vital to update our understanding of health care providers' (HCPs’) perception of opioids, cancer pain, and NMOU.

The main objective of our study was to assess the attitudes, beliefs, and self-perceived competence among palliative care providers in managing NMOU in patients with cancer pain. We also evaluated providers' perceptions toward the usefulness of the OSP in caring for such patients.

Methods

Survey design

We conducted an anonymous cross-sectional survey among HCPs at The University of Texas MD Anderson Cancer Center's supportive and palliative care service. Participants were eligible if they were licensed and actively cared for patients in the inpatient and/or outpatient settings. Participation was voluntary, and no remuneration was offered. Approval for the study was obtained from the institutional review board at the University of Texas MD Anderson Cancer Center (MDACC ID: 2020-0474).

Participants

Eligible participants were identified using the department's staff roster. Eighty-five providers were invited to participate; 13 nurses and 4 medical assistants work in the outpatient SCC, 22 advanced practice providers work in the inpatient consult service, and 5 counselors, 3 psychologists, 2 pharmacists, 11 fellows, and 25 attending physicians work in both outpatient and inpatient settings.

Study procedure

Participants were invited through e-mail to complete an anonymous web-based Qualtrics survey. The invitation indicated that participation was voluntary and would not affect participants' clinical practice, employment status, or potential for promotion. Up to eight follow-up reminder e-mails were automatically generated and sent by the Qualtrics software weekly to those who had not yet completed the survey. The anonymity of the survey participants was maintained throughout the study.

Survey development

The survey consisted of 5-point Likert scale options. It was developed based on previous studies that assessed clinician beliefs, attitudes, and practices regarding cancer pain management using tested instruments such as the Knowledge and Attitudes Survey Regarding Pain (KASRP).^8–10 To ascertain face validity, the survey was pretested among five randomly selected team members, and underwent further revision considering their constructive feedback. The final version of the questionnaire was a concise list of 31 items subcategorized under 5 sections, with an estimated completion time of ∼10 minutes.

Providers' attitudes and beliefs regarding patients with cancer pain and NMOU were assessed with seven questions (1a–g) about their views on pain assessment, opioid use, and associated misuse. Self-perceived competence in cancer pain management was measured through five questions (2a–e). Similar questions were used in previous studies.¹¹ Providers' perceptions regarding the OSP were evaluated by seven questions (4a–g) about the clinic workflow, availability of adequate support, resources, and overall usefulness. Participants' background information such as age, gender, years of experience, and clinical role were also obtained (questions 3a–d) (Supplementary Appendix SAI).

Statistical analysis

Descriptive statistics such as frequencies and percentages were used to summarize the participants' survey responses. We calculated the percentage of responders who selected agree or strongly agree (for each individual survey question) along with 95% confidence intervals (CI). Furthermore, responses to survey items were tallied, and their responding proportions were calculated with 95% CI. When analyzing the data for survey questions 1, 2, and 4, strongly agree was combined with agree; strongly disagree was combined with disagree and neutral.

Results

Between September and November 2021, 64 out of 85 (75%) invited HCPs participated in the survey. Participants' demographic and clinical characteristics are summarized in Table 1. Approximately 54% were ≥40 years. Majority were female (n = 48; 76%) and had >5 years of clinical experience (n = 43; 69%). Table 2 gives provider attitudes, beliefs, and self-perceived competence toward cancer pain and NMOU. Only a small proportion of providers thought opioids were used more than necessary (11/64; 17%). Providers unanimously agreed to use opioids for cancer patients with a history of substance use disorder (SUD).

Table 1.

Demographic and Clinical Characteristics of the Study Participants (N = 64)

Covariate	Level	No. (%)^a
Clinical area of work	Outpatient only	11 (17)
	Inpatient only	15 (24)
	Both inpatient and outpatient	37 (59)
Clinical role	Nurse or pharmacist	12 (19)
	Counselor/psychologist	6 (9)
	Advanced practice provider	16 (25)
	Fellow	9 (14)
	Attending physician	20 (32)
Age	20–40 Years	29 (46)
	41–60 Years	31 (49)
	>60 Years	3 (5)
Gender	Female	48 (76)
Years of clinical experience	<2 Years	7 (11)
	3–5 Years	13 (21)
	6–10 Years	12 (19)
	11–15 Years	13 (21)
	>15 Years	18 (29)

There was missing information for some covariates.

Table 2.

Health Care Provider Attitudes, Beliefs, and Self-Perceived Competence Regarding Cancer Pain and Nonmedical Opioid Use

	Agree/strongly agree, n (%)^a	95% CI
HCP attitudes and beliefs (N = 64)
a. I feel that it takes longer to care for patients with NMOU behaviors than those without NMOU behaviors	58 (91)	81–96
b. I feel it is more difficult to take care of patients with NMOU behaviors than those without those behaviors.	56 (87)	77–94
c. I find that taking care of patients with NMOU behaviors is stressful	54 (84)	74–91
d. The most likely reason why a patient with pain would request increased doses of pain medication is because he/she is experiencing increased pain	48 (76)	64–85
e. Patients with cancer pain and NMOU or SUD are not diagnosed frequently enough	42 (67)	54–77
f. Opioids are used more than is needed in patients with cancer pain	11 (17)	10–28
g. Opioids should not be used in patients with a history of substance abuse	0 (0)	0–6
HCP self-perceived competence
a. I feel confident in my ability to determine the nature of the patient's pain complaint	48 (79)	67–87
b. I feel confident that I am able to recognize it when patient is requesting opioids inappropriately	47 (77)	65–86
c. I feel confident in my ability to care for patients with cancer pain and nonmedical opioid use	41 (69)	57–80
d. I have adequate training in caring for patients with cancer pain and NMOU	35 (59)	47–71
e. I have insufficient knowledge about the management of cancer pain and NMOU	11 (18)	10–29

There was missing information for some covariates.

CI, confidence intervals; NMOU, nonmedical opioid use; SUD, substance use disorder.

The majority of the providers agreed that NMOU was underdiagnosed (42/64; 67%), challenging to manage (56/64; 87%), time consuming (58/64; 91%), and are stressful to care for (54/64; 84%). The majority also reported confidence in recognizing situations when a patient is requesting opioids inappropriately (47/62; 77%). Similarly, over 50% reported that they have adequate training when treating cancer pain among patients with NMOU behavior (35/59; 59%). Table 3 gives provider perception toward the OSP. Among the providers who work at the outpatient SCC, 98% (50/51) were aware of OSP in our department and found it helpful (48/51; 94%) when managing patients with concurrent cancer pain and NMOU.

Table 3.

Provider Perception Toward Opioid Stewardship Program Available at the Outpatient Supportive Care Center (N = 64)

Survey questions	Agree/strongly agree, n (%)^a	95% CI
I am aware of the opioid safety program at the SCC	50 (98)	90–100
Overall, I find that the opioid safety program is useful for the management of NMOU patients	48 (94)	84–98
I understand the components of the opioid safety program at the outpatient SCC	47 (90)	79–96
I have sufficient interdisciplinary support to help manage patients with NMOU at the SCC	45 (87)	75–93
The opioid safety program improves the workflow at the SCC	38 (75)	61–85
There is a uniform process for managing NMOU patients in the SCC	36 (71)	57–81
Overall, the opioid safety program slows down the workflow in the clinic	25 (50)	37–63

There was missing information for some covariates.

SCC, supportive care center.

Discussion

Majority of the HCPs agreed that opioids are essential in managing cancer pain, irrespective of a patient's past or current history of SUD. This is consistent with most cancer pain guidelines that identify opioids as the gold standard for pain management.^3,12 Regrettably, because of the opioid crisis, clinicians have been increasingly hesitant to prescribe opioids for patients with cancer in fear of addiction or overdose.^13–15 This might inadvertently result in undertreatment of cancer pain.^16–18 There is a need to mitigate the potential harms associated with opioid use while ensuring that those who need the opioids get adequate access. It is reassuring that participants in this study overwhelmingly agreed with the use of opioids for patients with cancer pain.

Most HCPs reported that NMOU behavior is underdiagnosed. Unfortunately, NMOU behavior among patients with cancer pain on COT is more prevalent than previously thought,^4,19 and maybe as high as 19% or more.⁴ These patients can display NMOU behaviors by reporting stolen opioids that are unverifiable, requesting frequent and early refills, demanding an escalation of the opioid dose, or requesting unjustified changes to the regimen.^5,20

Best practices require HCPs to implement measures to minimize the risk of accidental overdoses and ensure safe opioid use. These may include educating the patients, scheduling closer follow-ups, and carefully utilizing all risk mitigation measures while being mindful that advanced cancer patients may require opioid use for optimal pain control. Such highly essential measures consume a significant amount of time and resources.

A high proportion of providers found the OSP to be a helpful resource when managing patients with NMOU. The OSP was effective in managing patients with concurrent NMOU and cancer pain, as shown in previous studies,^6,20 and associated with a significant reduction in the frequency of NMOU-related behaviors.⁶ OSP incorporates a sensitive and compassionate approach to care and aims to modify behavior, increase compliance, and improve symptom management. Integrating such interdisciplinary teams and programs into cancer care will likely result in timely identification and appropriate management of patients with NMOU behavior^6,20,21 and provide an extra layer of support for HCPs.

Although providers endorsed the usefulness of the OSP, they acknowledged that it could potentially prolong the time needed for clinical care due to the coordination with multiple team members, the patient, and any caregivers involved. It is not surprising that a large proportion of the survey respondents reported that caring for patients with NMOU is generally stressful and time consuming.^6,7,20 Allowing ample time specifically for such visits may prevent burnout among the providers. Further research is needed to refine the OSP intervention to enhance its integration into routine outpatient care and minimize any potential interruption in a busy palliative and supportive care workflow.²²

It is reassuring that many palliative care providers in our department find themselves knowledgeable and confident in identifying and managing patients with cancer pain exhibiting NMOU behavior. This could likely be related to our department's academic curriculum with biweekly didactic sessions and yearly seminars dedicated to managing cancer pain and NMOU.⁸

This study has some limitations, including a relatively small sample size, a single tertiary center setting, and a focus on cancer-related pain. The results may, therefore, not be generalizable to noncancer patients or smaller community settings where there may be limited access to interdisciplinary colleagues. Similar surveys at multiple centers involving palliative care and pain management providers with diverse training backgrounds are needed. In addition, the questionnaire used in the study was locally designed by the authors based on previous literature and was not a validated tool.

Conclusion

Most HCPs expressed a good understanding of cancer pain management and underscored the role of opioids in managing pain irrespective of patients' risk for SUD. They felt that NMOU is underdiagnosed, challenging to manage, and time consuming while reporting to be knowledgeable and confident in caring for these patients. Providers found the OSP helpful in managing these patients. Future research needs to focus on standardizing care for cancer patients with concurrent NMOU and identifying barriers to implementing interdisciplinary OSPs at other clinical centers.

Footnotes

Authors' Contributions

Conceptualization, formal analysis, investigation, methodology, project administration, resources, analysis and interpretation of data, supervision, validation, visualization, and critical revision of the article for important intellectual content were carried out by all authors; data curation was done by J.A.-D., Z.S., Y.R., and M.H (equal); and statistical analysis was carried out by J.D. and D.U. Primary investigator for the NIH award: E.B.

Funding Information

This study was supported by the National Institutes of Health through Award Number 1UL1TR003167.

Author Disclosure Statement

No competing financial interests exist.

Supplementary Material

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Supplementary Material

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