Letter to the Editor: Universal Screening for Substance Use Disorder in a Palliative Care Clinic: Results and Longitudinal Outcomes for Patients with Cancer

Abstract

Dear Editor:

Management of substance use disorder in patients being treated for cancer-related pain is challenging. Our palliative care clinic instituted universal screening with the Opioid Risk Tool (ORT), and routine urine drug screens (UDS) with a standardized protocol for aberrant drug use including short fills, frequent visits and UDS, and weaning from opioids or transition to buprenorphine for the highest risk patients. We present outcomes from this program.

Methods

This retrospective chart review study included palliative clinic patients at the University of Virginia during the month of September 2019. Inclusion criteria were cancer diagnosis, prescribed opioids, UDS results, and three or more clinic visits. For each patient, all notes were examined from 2001 until February 2021.

Using a standardized review form, data were collected from each patient on ORT score, UDS results, aberrant behaviors, modifications to treatment plans after evidence of aberrant drug use, and outcomes. UDS results were deemed abnormal if illicit substances were present, or prescribed opioids were inappropriately absent. Presence of cannabis was not considered an aberrant result.

The University of Virginia Institutional Review Board issued an exempt determination for this study.

Results

The charts for 335 patients were reviewed. Two hundred ten met inclusion criteria and 97.1% (204/210) had ORT scores and UDS consistent with policy. One hundred eighty-seven patients (91.7%) had no abnormal UDS. Seventeen patients (8.3%) had at least one abnormal UDS. Most of these had one abnormal UDS, and only six patients (2.9%) had persistently (>50%) abnormal UDS. Cocaine was the most frequent abnormality. The mean ORT score was higher in patients with abnormal UDS (7.4 vs. 2.8).

The characteristics and outcomes of the six patients with persistently abnormal UDS results are shown in Table 1. No patients were discharged from the palliative clinic. None were referred to substance use clinics because of limited resources. None required emergency medical care for complications of aberrant substance use.

Table 1.

Characteristics and Longitudinal Outcomes of the Patients with Persistently Abnormal Urine Drug Screen Results

Patient	ORT score	Total No. of UDS performed	No. of abnormal UDS	Abnormalities found in UDS	Actions taken	No. of visits to ED or hospital for aberrant opioid use	Outcomes
1	12	4	2	Cocaine	Rotated opioids to transdermal buprenorphine, frequent clinic visits	None	Died with hospice care
2	0	27	16	Cocaine	Weaned off opioids, then prescribed again when disease recurred; frequent clinic visits	None	Died with hospice care
3	10	5	5	Cocaine	Frequent visits and short supplies of opioids	None	Died three months after first visit
4	4	9	8	Cocaine, inappropriately negative	Weaned off opioids after frequent visits	None	Continues with maintenance chemotherapy
5	7	17	15	Cocaine, ethanol	Rotated opioids to transdermal buprenorphine, frequent clinic visits	None	Continues with regular visits to palliative clinic
6	5	8	6	Amphetamines	Rotated to transdermal buprenorphine	None	No follow-up with oncology, no opioid prescriptions per PMP

ED, emergency department; ORT, Opioid Risk Tool; UDS, urine drug screens.

Discussion

This study differed from prior reports due to the setting of universal screening and the longitudinal data on the treatment and outcomes of patients with evidence of aberrant drug use. The prevalence of abnormal UDS was lower than previously reported. Only 8.3% had an abnormal UDS, and only 2.9% had persistently abnormal results. Prior studies have reported higher rates (28–73%)^1–3 likely because UDS were performed only in patients already deemed to be high risk, and because the presence of cannabis was considered aberrant.

When screening and testing are universal, the risks of “profiling” certain patient populations are lessened. More accurate identification of aberrant behaviors can allow targeted interventions.

Conclusion

This study suggests that aberrant drug use is less common than previously reported, but a small number of patients have persistently risky behaviors. Universal screening helps to avoid negative discrimination and more accurately identify these patients. Even patients with active substance misuse can be treated for cancer with opioids if appropriate safety protocols are in place.

References

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. Urine drug testing in cancer pain management. Oncologist, 2020; 25(2):99–104; doi: 10.1634/theoncologist.2019-0525

Barclay

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. Screening for substance abuse risk in cancer patients using the Opioid Risk Tool and urine drug screen. Support Care Cancer, 2014; 22(7):1883–1888; doi: 10.1007/s00520-014-2167-6

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. Do palliative care clinics screen for substance abuse and diversion? Results of a national survey. J Palliat Med, 2015; 18(9):752–757; doi: 10.1089/jpm.2015.0098