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CME / ABIM MOC / CE

Are Adolescents and Young Adults With Sarcoma at Risk for Persistent Opioid Use?

  • Authors: News Author: Megan Brooks; CME Author: Laurie Barclay, MD
  • CME / ABIM MOC / CE Released: 7/15/2022
  • Valid for credit through: 7/15/2023
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  • Credits Available

    Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™

    ABIM Diplomates - maximum of 0.25 ABIM MOC points

    Nurses - 0.25 ANCC Contact Hour(s) (0.25 contact hours are in the area of pharmacology)

    Pharmacists - 0.25 Knowledge-based ACPE (0.025 CEUs)

    Physician Assistant - 0.25 AAPA hour(s) of Category I credit

    IPCE - 0.25 Interprofessional Continuing Education (IPCE) credit

    You Are Eligible For

    • Letter of Completion
    • ABIM MOC points

Target Audience and Goal Statement

This activity is intended for hematologists/oncologists, pediatricians, family medicine and primary care practitioners, nurses, pharmacists, internists, physician assistants, and other members of the healthcare team for adolescents and young adults treated for sarcoma.

The goal of this activity is for learners to be better able to describe patterns of new persistent opioid use among adolescents and young adults in the year after treatment for sarcoma.

Upon completion of this activity, participants will:

  • Describe patterns of new persistent opioid use among AYAs in the year after treatment for sarcoma, according to an analysis of the IBM MarketScan Research Database from 2008 to 2016
  • Identify clinical implications of patterns of new persistent opioid use among AYAs in the year after treatment for sarcoma, according to an analysis of the IBM MarketScan Research Database from 2008 to 2016
  • Outline implications for the healthcare team


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News Author

  • Megan Brooks

    Freelance writer, Medscape

    Disclosures

    Megan Brooks has no relevant financial relationships.

CME Author

  • Laurie Barclay, MD

    Freelance writer and reviewer
    Medscape, LLC

    Disclosures

    Laurie Barclay, MD, has the following relevant financial relationships:
    Formerly owned stocks in: AbbVie Inc.

Editor/Compliance Reviewer

  • Yaisanet Oyola, MD

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Yaisanet Oyola, MD, has no relevant financial relationships.

Compliance Reviewer

  • Amanda Jett, PharmD, BCACP

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Amanda Jett, PharmD, BCACP, has no relevant financial relationships.


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CME / ABIM MOC / CE

Are Adolescents and Young Adults With Sarcoma at Risk for Persistent Opioid Use?

Authors: News Author: Megan Brooks; CME Author: Laurie Barclay, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 7/15/2022

Valid for credit through: 7/15/2023

processing....

Clinical Context

Nearly 80% of adolescents and young adults (AYAs) with cancer are expected to become long-term survivors. Minimizing their long-term treatment-related sequelae is essential to lower morbidity, optimize health-related quality of life (QoL), and improve long-term survival.

Potential for long-term opioid use among previously opioid-naive AYAs is of increasing concern. The Centers for Disease Control and Prevention states that AYAs are more likely than other age groups to misuse and overdose on opioids. Acute or chronic pain is an identified risk factor for opioid misuse in the general AYA population.

Study Synopsis and Perspective

Young people with sarcoma may be at heightened risk for long-term opioid use after their cancer treatment.

In a nationally representative cohort of adolescents and young adults with sarcoma, nearly two-thirds took opioids during treatment, and almost one-quarter of those patients continued to use opioids after treatment ended.

"As a healthcare member, the finding that most adolescents and young adults treated for sarcoma receive opioid prescriptions is not surprising," lead author Melissa Beauchemin, PhD, RN, with Columbia University School of Nursing in New York, New York. "We use intense treatments to achieve the highest chance of a cure, and these treatments come with side effects. Opioids are very effective at preventing and treating pain, and they are often a key component of high-quality cancer care."

Still, "we were surprised" that nearly a quarter of patients who were prescribed opioids during treatment continued to use the painkillers after treatment, she said. "That to me is the important finding of this study."

Intense Treatment, Lingering Pain?

Adolescents and young adults with sarcoma experience disease- and treatment-related pain. Research shows that older patients are at high risk for persistent opioid use after therapy, but few studies have examined opioid use among younger patients.

Using the IBM MarketScan Research Database, Beauchemin and colleagues identified 938 patients with opioid-naive sarcoma aged 10 to 26 years. More than half (56%) were male, and 62% were aged younger than 18 years.

A total of 599 patients (64%) filled an opioid prescription during their cancer treatment. Of these patients, the number of opioid prescriptions ranged from 1 to 97; 44% received 1 prescription, 31% received 2 to 4 prescriptions, and 24% received 5 or more.

Overall, 77% (n = 464) of these patients discontinued opioid use after completing treatment. The other 23%, however, met criteria for new persistent opioid use: defined as filling at least 2 opioid prescriptions in the 12 months after the end of treatment.

In multivariable analysis that adjusted for age, pretreatment mental health (MH), and substance use (SU) disorders, having Medicaid insurance was associated with higher likelihood of new persistent opioid use compared with having commercial insurance (odds ratio [OR] 1.74).

Compared with patients with soft tissue sarcoma, patients with bone tumors -- specifically, Ewing sarcoma (OR 3.23) and osteosarcoma (OR 2.05) -- had significantly higher odds for new persistent opioid use after completing treatment.

"Our study provides new knowledge about the prevalence of opioid prescriptions and clinical factors, and future research should focus on optimizing pain management through safe and sustainable interventions and developing guidelines for safe opioid prescribing and monitoring," the authors wrote.

And, Beauchemin noted, "new persistent use may signal an inflection point at which clinicians can intervene, discuss with patients what the source of the pain might be, strategize how to reduce opioid exposure, and utilize other strategies to improve quality of life."

William Dahut, MD, chief scientific officer for the American Cancer Society, saidthat the study involved patients who would experience "significant pain" during their cancer treatment, particularly those who had bone sarcomas.

"It's a dilemma," said Dahut, who was not involved in the study, "because there's definitely a significant risk for opioid addiction. I think it just shows that we need to find newer and better ways to treat pain beyond opioids."

The study was partially funded by the National Cancer Institute, the Breast Cancer Research Foundation, the American Cancer Society, and the Herbert Irving Comprehensive Cancer Center. Beauchemin and Dahut have disclosed no relevant financial relationships.

Study Highlights

  • Researchers identified opioid-naive patients aged 10 to 26 years diagnosed with sarcoma from 2008 to 2016 with the IBM MarketScan Research Database.
  • Inclusion criteria were International Classification of Diseases, Ninth Revision or Tenth Revision code for sarcoma, anticancer treatment within 30 days of first diagnosis code, and continuous insurance coverage for ≥ 12 months before diagnosis and after treatment completion.
  • New persistent opioid use was the primary outcome.
  • Covariates included age, sex, insurance, tumor type, surgical procedure, MH or substance use diagnoses before or during treatment, and concomitant lorazepam use.
  • Of 938 included patients, 55.5% were male; 61.6% were aged < 18 years; 78% had commercial insurance; and 29% had MH diagnosis either before or during treatment.
  • 49% used opioids during cancer treatment only.
  • Of patients using opioids during treatment, 23% had new persistent opioid use (≥ 2 prescriptions in the 12 months after treatment completion), and 77% received no further prescriptions.
  • Bivariate analysis showed significant associations among new MH diagnoses (P = .03), SU disorders (P = .02), and lorazepam use (P < .01) with new persistent opioid use.
  • In multivariable analysis controlling for other factors, having ≥ 1 lorazepam prescription during treatment was associated with 3-fold risk for new persistent use.
  • The investigators concluded that among these previously opioid-naive AYAs treated for sarcoma, 64% received opioid prescriptions during treatment, and 23% of these became new persistent users.
  • The percentage of new persistent users was lower than in prior analyses from older time periods, which may reflect a more stringent definition of new persistent use, and/or recently decreased opioid prescribing because of increased awareness of the opioid epidemic.
  • Patients with sarcoma are often prescribed opioids for painful surgery, which may trigger opioid misuse and overdose.
  • Significantly higher odds for new persistent opioid use with bone vs soft tissue sarcomas may reflect the need for more extensive resections or amputation and radiation.
  • Risks associated with persistent opioid use urgently mandate studies of novel, AYA-specific pain management strategies, age-appropriate education, and anticipatory guidance because high-quality pain management is a critical component of cancer care, and AYAs are a vulnerable population at risk for opioid misuse and overdose.
  • According to these studies, strategies to identify at-risk AYAs with cancer-related pain could be developed and tested, and safe and effective pain management interventions could be designed.
  • Such research could inform guidelines for optimizing pain management through safe, sustainable interventions and for safe opioid prescribing and monitoring.
  • New persistent use may represent a window of opportunity for clinicians to intervene, inquire as to the source of the pain, strategize how to reduce opioid exposure, and employ other interventions to improve QoL.
  • Lorazepam is currently recommended for chemotherapy-induced nausea and vomiting only if first-line interventions fail, with discontinuation as soon as symptoms resolve.
  • The relationship between Medicaid insurance and opioid use is poorly understood. Insurance status may be a proxy for other social determinants of poorer health, including access to quality health care, education, and social support, all of which affect health outcomes and disparities regarding opioid misuse and overdose.
  • Strategies targeting vulnerable populations, such as mitigating food insecurity through Medicaid programming, may allow testing future opioid safety prescribing and monitoring interventions.

Clinical Implications

  • Among previously opioid-naive AYAs treated for sarcoma, 64% received opioid prescriptions during treatment, and 23% of these became new persistent users.
  • Age-appropriate education, novel pain management strategies, and guidelines are needed for AYA treated for sarcoma.
  • Implications for the Healthcare Team: New persistent use may represent a window of opportunity for healthcare team members to intervene, inquire as to the source of the pain, strategize how to reduce opioid exposure, and employ other interventions to improve QoL.

 

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