The following article features coverage from the Oncology Nursing Society (ONS) 2019 Annual Congress. Click here to read more of Oncology Nurse Advisor‘s conference coverage.

Opioid misuse, addiction, and diversion can afflict patients being treated for cancer and may complicate treatment. Healthcare providers in oncology must be ready to deal with the public health issues surrounding opioids. Harm reduction, a feasible approach to managing opioid misuse/diversion in oncology patients, was discussed in a presentation at the Oncology Nursing Society (ONS) 44th Annual Congress, held in Anaheim, California.

Successfully addressing the opioid epidemic is prompting a large-scale effort similar to that which has been deployed to deal with the epidemic of acquired immune deficiency syndrome (AIDS). Gretchen McNally, PhD, ANP-BC, AOCNP, of The Ohio State University James Cancer Hospital (Columbus, Ohio), describes addiction as more than a behavioral disorder. It is a complex, multifactorial, chronic condition that is not just about drugs, but about what is happening in the brain.

Patients with cancer who are struggling with opioid addiction should be thought of as dealing with 2 potentially fatal conditions, explains Dr McNally. Risks associated with access to opioids may also extend to patient caregivers through diversion.

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The principle behind harm reduction is to improve outcomes by reducing harm/minimizing risks of dangerous consequences regarding drug use. In the context presented by Dr McNally, harm reduction is not an attempt at abstinence, nor is it an active treatment for addiction, which is beyond the scope of care provided by oncology advance practice providers APPs — in this context, nurse practitioners and physician assistants.

Harm reduction strategies recognize that all patients are susceptible to drug misuse/diversion. Ask every patient about past, as well as current, substance use/addiction. Use screening questionnaires and direct observation, patient/family history, clinical judgment, and urine toxicology screens. Red flags to watch out for include claims of lost or stolen pills or prescriptions, early requests for refills, visits with multiple prescribers, frequent ED visits, sharing medications, refusing urine toxicology screens, and requests for specific drugs or escalating doses.

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Prescribing practices to consider include use of prescription drug monitoring program (PDMP), have patients sign a controlled medicine management contract and complete a pain diary, limit prescription quantity, decrease the pill load (sustained vs immediate release), pill counts, and urine toxicology screens.

With education specific to addiction and harm reduction strategies, APPs are well-positioned to implement these tactics and make a positive impact on patient outcomes.


McNally G. Harm reduction: reframing perceptions and informing practices of hematology/oncology advance practice providers. Poster presentation at: ONS 44th Annual Congress; April 11-14, 2019; Anaheim, CA.