Analysis of long-term opioid prescribing practices in cancer patients at a pediatric tertiary institution
Jan, Jenny Lin
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INTRODUCTION: Pain is common in cancer. Pain can present at the time of diagnosis or it can develop during treatment. Cancer-related chronic pain is often treated with long-term (3 or more consecutive refills) opioid prescriptions. Opioids are a controlled substance and are thus regulated at the federal, state, and local levels. OBJECTIVES: The first goal of this study is to examine Boston Children's Hospital's general compliance with federal, state, and local opioid prescribing policies. The second goal of this study is to distinguish cancer patients requiring long-term opioids from non-cancer patients requiring long-term opioids. METHODS: This study was a retrospective chart review using summative qualitative content analysis. This is the process where content is grouped into themes and then is further quantified within each theme. RESULTS: Documents required to ensure compliance with opioid prescribing regulations at the local level are not always well documented. These include the Long-Term Opioid Agreement and the risk evaluation of opioid misuse and abuse using one of several tools annually. At Boston Children's Hospital (BCH), the CRAFFT (car, relax, alone, forget, friends, trouble) questionnaires are used for this purpose. State policies require that, if a patient is not seen at least once every 6 months, physicians must document explicitly why a clinic visit was not possible. These reasons are never clearly listed within the medical record. Additionally, data shows that cancer patients using long-term opioids tend to be younger (mean age 14.4) than non-cancer patients (mean age 26.7). Cancer pain can present either at diagnosis, during treatment, or be present during both. Where n=16 cancer patients, 62.53% experienced pain both at diagnosis and during treatment, 25% experienced pain only during treatment, and 12.5% experience pain only at diagnosis. Finally, data also show that anxiety and comorbidity are common, 34.6% of n=29 patients in both cancer and non-cancer patients using long-term opioids. 34.6% of patients experienced comorbidities of either anxiety or depression. CONCLUSIONS: Despite these discrepancies with documentation, review of patients on long-term opioids revealed those with complex and painful medical conditions generally had valid reasons to require long-term opioids. Therefore, there is no evidence that BCH prescribers are involved in any sort of inappropriate opioid prescribing. Finally, no meaningful conclusions were drawn from data regarding pain score and weight because of inconsistencies in electronic medical record documentation in these areas.