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BACKGROUND: There is limited information regarding the true frequency of nonmedical opioid use (NMOU) among patients receiving opioid therapy for cancer pain. Data to guide patient selection for urine drug testing (UDT) as well as the timing and frequency of ordering UDT are insufficient. This study examined the frequency of abnormal UDT among patients with cancer who underwent random UDT and their characteristics. METHODS: Demographic and clinical information for patients with cancer who underwent random UDT were retrospectively reviewed and compared with a historical cohort that underwent targeted UDT. Random UDT was ordered regardless of a patient’s risk potential for NMOU. Targeted UDT was ordered on the basis of a physician’s estimation of a patient’s risk for NMOU. RESULTS: In all, 552 of 573 eligible patients (96%) underwent random UDT. Among these patients, 130 (24%) had 1 or more abnormal results; 38 of the 88 patients (43%) who underwent targeted UDT had 1 or more abnormal results. When marijuana was excluded, 15% of the random group and 37% of the targeted group had abnormal UDT findings (P < .001). It took a shorter time from the initial consultation to detect 1 or more abnormalities with the random test than the targeted test (median, 130 vs 274 days; P = .02). Abnormal random UDT was independently associated with younger age (P < .0001), male sex (P = .03), Cut Down, Annoyed, Guilty, and Eye Opener–Adapted to Include Drugs positivity (P = .001), and higher Edmonton Symptom Assessment System anxiety (P = .01). CONCLUSIONS: Approximately 1 in 4 patients receiving opioids for cancer pain at a supportive care clinic who underwent random UDT had 1 or more abnormalities. Random UDT detected abnormalities earlier than the targeted test. These findings suggest that random UDT is justified among patients with cancer pain.

Background: Increasing the total opioid dose is the standard approach for managing uncontrolled cancer pain. Other than simply increasing the opioid dose, palliative care interventions are multidim...

PURPOSE: An understanding of opioid prescription and cost patterns is important to optimize pain management for patients with advanced cancer. This study aimed to determine opioid prescription and cost patterns and to identify opioid prescription predictors in patients with advanced cancer who received inpatient palliative care (IPC). MATERIALS AND METHODS: We reviewed data from 807 consecutive patients with cancer who received IPC in each October from 2008 through 2014. Patient characteristics; opioid types; morphine equivalent daily dose (MEDD) in milligrams per day of scheduled opioids before, during, and after hospitalization; and in-admission opioid cost per patient were assessed. We determined symptom changes between baseline and follow-up palliative care visits and the in-admission opioid prescription predictors. RESULTS: A total of 714 (88%) of the 807 patients were evaluable. The median MEDD per patient decreased from 150 mg/d in 2008 to 83 mg/d in 2014 ( P < .001). The median opioid cost per patient decreased and then increased from $22.97 to $40.35 over the 7 years ( P = .03). The median MEDDs increased from IPC to discharge by 67% ( P < .001). The median Edmonton Symptom Assessment Scale pain improvement at follow-up was 1 ( P < .001). Younger patients with advanced cancer (odds ratio [OR[, 0.95; P < . 001) were prescribed higher preadmission MEDDs (OR, 1.01; P < .001) more often in the earlier study years (2014 v 2009: OR, 0.18 [ P = .004] v 0.30 [ P = .02]) and tended to use high MEDDs (> 75 mg/d) during hospitalization. CONCLUSION: The MEDD per person decreased from 2008 to 2014. The opioid cost per patient decreased from 2008 to 2011 and then increased from 2012 to 2014. Age, prescription year, and preadmission opioid doses were significantly associated with opioid doses prescribed to patients with advanced cancer who received IPC.

Background Current understanding of genetic factors associated with pain severity, and improvement of pain with opioids in advanced cancer patients (AC) is inadequate for delivery of personalized pain therapy (PPT). Therefore, the aim of this study was to determine the genetic factors associated with pain severity, daily opioid dose, and pain response in AC patients receiving supportive care. Methods In this prospective study, AC patients were eligible if they had cancer pain ≥4/10 on Edmonton Symptom Assessment Scale (ESAS) - Pain Item and needed opioid rotation for pain control by specialist at the outpatient supportive care center. Association of genetic factors with pain phenotype was assessed using logistic regression models and SKATO (Gene-block) analysis. Results About 174/178 (98%) patient samples were analyzed. After adjustment for demographic and clinical variables, pain severity was negatively associated with intron variant alleles in OPRM1 rs9322446, P = 0.02; rs2270459, P = 0.038; rs62052210, P = 0.038. Opioid daily dose was positively associated NFKBIA rs2233419, P = 0.008; rs2233417, P = 0.007; rs3138054, P = 0.008; rs1050851, P = 0.015; ORPM1 rs9479759, P = 0.046; rs2003185, P = 0.047; rs636433, P = 0.044; COMT (rs9306234, P = 0.014; rs165728, P = 0.014; rs2020917, P = 0.036; rs165728, P = 0.034); ARRB2 (rs1045280, P = 0.045); and pain response to opioids was negatively associated OPRM1 rs1319339, P = 0.024; rs34427887, P = 0.048; and COMT rs4646316, P = 0.03; rs35478083, P = 0.028, respectively. SKATO analysis showed association between pain severity and CXCL8 (P = 0.0056), and STAT6 (P = 0.0297) genes respectively, and pain response with IL-6 (P = 0.00499). Conclusions This study identified that SNPs of OPRM1, COMT, NFKBIA, CXCL8, IL-6, STAT6, and ARRB2 genes were associated with pain severity, opioid daily dose, and pain response in AC receiving supportive care. Additional studies are needed to validate our findings for PPT.

ObjectiveNon-medical opioid use (NMOU) is a growing crisis. Cancer patients at elevated risk of NMOU (+risk) are frequently underdiagnosed. The aim of this paper was to develop a nomogram to predict the probability of +risk among cancer patients receiving outpatient supportive care consultation at a comprehensive cancer center.Method3,588 consecutive patients referred to a supportive care clinic were reviewed. All patients had a diagnosis of cancer and were on opioids for pain. All patients were assessed using the Edmonton Symptom Assessment Scale (ESAS), Screener and Opioid Assessment for Patients with Pain (SOAPP-14), and CAGE-AID (Cut Down-Annoyed-Guilty-Eye Opener) questionnaires. “+risk” was defined as an SOAPP-14 score of ≥7. A nomogram was devised based on the risk factors determined by the multivariate logistic regression model to estimate the probability of +risk.Results731/3,588 consults were +risk. +risk was significantly associated with gender, race, marital status, smoking status, depression, anxiety, financial distress, MEDD (morphine equivalent daily dose), and CAGE-AID score. TheC-index was 0.8. A nomogram was developed and can be accessed athttps://is.gd/soappnomogram. For example, for a male Hispanic patient, married, never smoked, with ESAS scores for depression = 3, anxiety = 3, financial distress = 7, a CAGE score of 0, and an MEDD score of 20, the total score is 9 + 9+0 + 0+6 + 10 + 23 + 0+1 = 58. A nomogram score of 58 indicates the probability of +risk of 0.1.Significance of resultsWe established a practical nomogram to assess the +risk. The application of a nomogram based on routinely collected clinical data can help clinicians establish patients with +risk and positively impact care planning.

There are limited studies on factors associated with cancer patients' perception of curability.To examine advanced cancer patient's perception of curability and its association with patient's sociodemographic and clinical characteristics, decisional control preference (DCP), symptoms, and end-of-life quality care outcomes.Secondary analysis of a study to determine the DCP and illness understanding of advanced cancer patients receiving palliative care (PC).Data of the Illness Understanding survey, the Control Preference Scale, and demographics, symptoms, and end-of-life quality care outcomes were reviewed.Of 121 patients, 104 (86%) were evaluable. Median age was 56 years, 60% were women, and 64% had a Karnofsky performance status ≤60. Thirty-seven percent inaccurately reported that their cancer was curable. Patients with accurate perception were more likely to choose a passive DCP (20% vs. 2.6%, p = 0.04). An accurate perception of curability was associated with a longer time from advanced cancer diagnosis to PC referral (odds ratio [OR] = 1.04, p = 0.04). There was a trend toward an association between inaccurate perception of curability, male gender (OR = 0.29, p = 0.09), and intensive care unit admission within 30 days of death (OR = 0.26, p = 0.09). No other significant associations between perception of curability and patients' demographics, clinical characteristics, symptoms, or end-of-life quality care outcomes were found.Thirty-seven percent of advanced cancer patients receiving PC inaccurately perceived their disease curable. These patients were more likely to have earlier PC referrals. An accurate perception of curability was associated with passive DCP. Further studies are needed to test effective communication strategies to mitigate this misperception.

BACKGROUND Opioid misuse is a growing crisis. Patients with cancer who are at risk of aberrant drug behaviors are frequently underdiagnosed. The primary objective of this study was to determine the frequency and factors predicting a risk for aberrant opioid and drug use behaviors (ADB) among patients who received an outpatient supportive care consultation at a comprehensive cancer center. In addition, the screening performance of the Cut Down-Annoyed-Guilty-Eye Opener (CAGE) questionnaire adapted to include drug use (CAGE-AID) was compared with that of the 14-item Screener and Opioid Assessment for Patients With Pain (SOAPP-14) tool as instruments for identifying patients at risk for ADB. METHODS In total, 751 consecutive patients with cancer who were referred to a supportive care clinic were reviewed. Patients were eligible if they had diagnosis of cancer and had received opioids for pain for at least 1 week. All patients were assessed using the Edmonton Symptom Assessment Scale (ESAS), the SOAPP-14, and the CAGE-AID. SOAPP scores ≥7 (SOAPP-positive) were used to identify patients who were at risk of ADB. RESULTS Among the 729 of 751 (97%) evaluable consults, 143 (19.6%) were SOAPP-positive, and 73 (10.5%) were CAGE-AID-positive. Multivariate analysis revealed that the odds ratio of a positive SOAPP score was 2.3 for patients who had positive CAGE-AID scores (P < .0001), 2.08 for men (P = .0013), 1.10 per point for ESAS pain (P = .014), 1.13 per point for ESAS anxiety (P = .0015), and 1.09 per point for ESAS financial distress (P = .012). A CAGE-AID cutoff score of 1 in 4 had 43.3% sensitivity and 90.93% specificity for screening patients with a high risk of ADB. CONCLUSIONS The current results indicate a high frequency of an elevated risk of ADB among patients with cancer. Men and patients who have anxiety, financial distress, and a prior history of alcoholism/illicit drug use are at increased risk of ADB.

Background: Understanding patients’ decision control preferences is important in providing quality cancer care. Patients’ decisional control preference can be either active (patients prefer to make decisions themselves), shared (collaborative between patient, their physician, and/or family), or passive (patients prefer that the decisions are made by either the physician and/or their family). Aim: To determine the frequency and predictors of passive decision control preferences among advanced cancer patients. We also determined the concordance between actual decision-making and decision control preferences and its association with patient satisfaction. Design: In this cross-sectional survey of advanced cancer patients referred to palliative care across 11 countries, we evaluated sociodemographic variables, Control Preference Scale, and satisfaction with the decisions and care. Results: A total of 1490 participants were evaluable. Shared, active, and passive decision control preferences were 33%, 44%, and 23%, respectively. Passive decision control preferences (odds ratio, p value) was more frequent in India (4.34, Conclusion: Passive decision control preferences were less common (23%) than shared and active decision control preference even among developing countries. Significant predictors of passive decision control preferences were performance status, education, and country of origin.

Introduction: In the United States, opioid regulations have become increasingly stringent in recent years. Increased regulatory scrutiny, in part, is related to heightened awareness through literature and a recent media blitz on the opioid prescription epidemic. These regulations have the potential to impact prescription trends by health care providers. Our objective was to evaluate changes in the type and dose of opioid prescriptions among patients who are referred by oncologists to an outpatient palliative care clinic. Materials and Methods: We reviewed the electronic health records of 750 patients who were seen as new consultations at MD Anderson Cancer Center’s outpatient palliative care clinic between January 1 and April 30 each year from 2010 through 2015. Data collected included demographics, cancer type and stage, symptom assessment, performance status, opioid type, and opioid dose defined as the morphine equivalent daily dose (MEDD). Results: Median age was 59 years (interquartile range [IQR], 51 to 67), 383 (51%) were female, 529 (70%) were white, and 654 (87%)of patients had advanced cancer. In 2010, median MEDD before referral was 78 mg/d (IQR, 30 to 150); however, by 2015, the MEDD had progressively decreased to 40 mg/d (IQR, 19 to 80; P = .001). Hydrocodone was the most common opioid prescribed between 2010 and 2015; however, after its reclassification as a schedule II opioid in October 2014, the use of tramadol, a schedule IV opioid, increased ( P < .001). Conclusion: During the past several years, the MEDD prescribed by referring oncologists has decreased. After hydrocodone reclassification, the use of tramadol with less stringent prescription limits has increased.

Background There are limited data on illness understanding and perception of cure among advanced cancer patients around the world. The aim of the study was to determine the frequency and factors associated with inaccurate perception of curability among advanced cancer patients receiving palliative care across the globe. Materials and Methods Secondary analysis of a study to understand the core concepts in end-of-life care among advanced cancer patients receiving palliative care from 11 countries across the world. Advanced cancer patients were surveyed using a Patient Illness Understanding survey and Control Preference Scale. Descriptive statistics and multicovariate logistic regression analysis were performed. Results Fifty-five percent (763/1,390) of patients receiving palliative care inaccurately reported that their cancer is curable. The median age was 58, 55% were female, 59% were married or had a partner, 48% were Catholic, and 35% were college educated. Sixty-eight percent perceived that the goal of therapy was “to get rid of their cancer,” and 47% perceived themselves as “seriously ill.” Multicovariate logistic regression analysis shows that accurate perception of curability was associated with female gender (odds ratio [OR] 0.73, p = .027), higher education (OR 0.37, p Conclusion Inaccurate perception of curability in advanced cancer patients is 55% and significantly differs by gender, education, performance status, employment status, and country of origin. Further studies are needed to develop strategies to reduce this misperception of curability in advanced cancer patients. Implications for Practice The findings of this study indicate that inaccurate perception of curability among advanced cancer patients is 55%. Inaccurate perception of curability significantly differs by gender, education, performance status, employment status, and country of origin. There is great need to facilitate improved patient–physician communication so as to improve health care outcomes and patient satisfaction.

Background: Despite the high frequency, severity, and effects of cancer-related fatigue (CRF) on the quality of life (QoL) of patients with cancer, limited treatment options are available. The primary objective of this study was to compare the effects of oral Panax ginseng extract (PG) and placebo on CRF. Secondary objectives were to determine the effects of PG on QoL, mood, and function. Methods: In this randomized, double-blind, placebo-controlled study, patients with CRF ≥4/10 on the Edmonton Symptom Assessment System (ESAS) were eligible. Based on a pilot study, we randomized patients to receive either 400 mg of standardized PG twice daily or a matching placebo for 28 days. The primary end point was change in the Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F) subscale from baseline to day 29. Results: Of 127 patients, 112 (88.2%) were evaluable. The mean (SD) FACIT-F subscale scores at baseline, day 15, and day 29 were 22.4 (10.1), 29.9 (10.6), and 30.1 (11.6) for PG (P

PURPOSE There is limited access to quality palliative care (PC) for patients with advanced cancer in sub-Saharan Africa. Our aim was to describe the development of the Project Extension for Community Healthcare Outcomes-Palliative Care in Africa (ECHO-PACA) program and describe a preliminary evaluation of attitudes and knowledge of participants regarding the ability of the program to deliver quality PC. METHODS An interdisciplinary team at the MD Anderson Cancer Center, guided by experts in PC in sub-Saharan Africa, adapted a standardized curriculum based on PC needs in the region. Participants were then recruited, and monthly telementoring sessions were held for 16 months. The monthly telementoring sessions consisted of case presentations, discussions, and didactic lectures. Program participants came from 14 clinics and teaching hospitals in Ghana, Kenya, Nigeria, South Africa, and Zambia. Participants were surveyed at the beginning, midpoint, and end of the 16-month program to evaluate changes in attitudes and knowledge of PC. RESULTS The median number of participants per session was 30. Thirty-three (83%) of 40 initial participants completed the feedback survey. Health care providers’ self-reported confidence in providing PC increased with participation in the Project ECHO-PACA clinic. There was significant improvement in the participants’ attitudes and knowledge, especially in titrating opioids for pain control ( P = .042), appropriate use of non-opioid analgesics ( P = .012), and identifying and addressing communication issues related to end-of-life care ( P = .014). CONCLUSION Project ECHO-PACA was a successful approach for disseminating knowledge about PC. The participants were adherent to ECHO PACA clinics and the completion of feedback surveys. Future studies should evaluate the impact of Project ECHO-PACA on changes in provider practice as well as patient outcomes.

IMPORTANCE: The recent parenteral opioid shortage (POS) has potential implications for cancer-related pain management in hospitalized patients. OBJECTIVE: This study compared changes in opioid prescriptions and clinically improved pain (CIP) among patients treated by an inpatient palliative care (PC) team before and after our institution first reported the POS. DESIGN, SETTING, AND PARTICIPANTS: A cohort study of 386 eligible patients with cancer treated at a comprehensive cancer center 1 month before and after the announcement of the POS. We reviewed data from electronic health records, including patient demographics, opioid type, route of administration, and dose. Board-certified palliative care specialists assessed CIP at follow-up day 1. EXPOSURES: The announcement of the POS by the institution’s pharmacy and therapeutics committee on February 8, 2018. MAIN OUTCOMES AND MEASURES: The primary outcome was to measure the change in opioid prescription patterns of physicians, and the secondary outcome was to measure the proportion of patients who achieved CIP before and after announcement of the POS. RESULTS: Of 386 eligible patients, 196 were men (51%), 270 were white (70%), and the median age was 58 years (interquartile range, 46-67 years). Parenteral opioids were prescribed less frequently by the referring oncology teams after the POS (56 of 314 [18%]) vs before the POS (109 of 311 [35%]) (P

IMPORTANCE: One of the main aims of research on nonmedical opioid use (NMOU) is to reduce the frequency of NMOU behaviors through interventions such as universal screening, reduced opioid exposure, and more intense follow-up of patients with elevated risk. The absence of data on the frequency of NMOU behavior is the major barrier to conducting research on NMOU. OBJECTIVE: To determine the overall frequency of and the independent predictors for NMOU behavior. DESIGN, SETTING, AND PARTICIPANTS: In this prognostic study, 3615 patients with cancer were referred to the supportive care center at MD Anderson Cancer Center from March 18, 2016, to June 6, 2018. Patients were eligible for inclusion if they had cancer and were taking opioids for cancer pain for at least 1 week. Patients were excluded if they had no follow-up within 3 months of initial consultation, did not complete the appropriate questionnaire, or did not have scheduled opioid treatments. After exclusion, a total of 1554 consecutive patients were assessed for NMOU behavior using established diagnostic criteria. All patients were assessed using the Edmonton Symptom Assessment Scale, the Screener and Opioid Assessment for Patients with Pain (SOAPP), and the Cut Down, Annoyed, Guilty, Eye Opener–Adapted to Include Drugs (CAGE-AID) survey. Data were analyzed from January 6 to September 25, 2020. RESULTS: A total of 1554 patients (median [interquartile range (IQR)] age, 61 [IQR, 52-69] years; 816 women [52.5%]; 1124 White patients [72.3%]) were evaluable for the study, and 299 patients (19.2%) had 1 or more NMOU behaviors. The median (IQR) number of NMOU behaviors per patient was 1 (IQR, 1-3). A total of 576 of 745 NMOU behaviors (77%) occurred by the first 2 follow-up visits. The most frequent NMOU behavior was unscheduled clinic visits for inappropriate refills (218 of 745 [29%]). Eighty-eight of 299 patients (29.4%) scored 7 or higher on SOAPP, and 48 (16.6%) scored at least 2 out of 4 points on the CAGE-AID survey. Results from the multivariate model suggest that marital status (single, hazard ratio [HR], 1.58; 95% CI, 1.15-2.18; P = .005; divorced, HR, 1.43; 95% CI, 1.01-2.03; P = .04), SOAPP score (positive vs negative, HR, 1.35; 95% CI, 1.04-1.74; P = .02), morphine equivalent daily dose (MEDD) (HR, 1.003; 95% CI, 1.002-1.004; P

Context Health care provider education is an effective strategy to improve knowledge and competencies in opioid-prescribing practices. However, there are very few studies regarding this among providers of patients with cancer pain and nonmedical opioid use (NMOU). The aim of our study was to assess participants' attitudes, beliefs, and self-perceived confidence in caring for patients with cancer pain and NMOU before and after attending an opioid educational seminar on the use and nonmedical use of opioids in patients with cancer. Methods An anonymous cross-sectional survey was conducted among health care providers who attended an opioid educational event in April 2018 and May 2019. Results The overall response rate was 63% (129 of 206). Approximately 72% of participants had concerns about NMOU in patients with cancer, 69% felt that such patients are frequently underdetected, and 63% felt that cancer pain is frequently undertreated. At baseline, only 23% reported adequate knowledge and 35% reported confidence in caring for patients with cancer with NMOU-related issues. Among those who completed both the preseminar and postseminar surveys, these numbers improved significantly at the end of the seminar (26% vs. 71% and 43% vs. 84%, respectively; all P Conclusion Most health care providers expressed concerns about underdetection of NMOU and undertreatment of pain among patients with cancer. Many self-reported knowledge and confidence deficits in caring for patients with cancer with NMOU. Seminar participation was associated with an increase in the number of participants with self-perceived knowledge and confidence. Future studies are needed to ascertain the impact of such opioid educational events on patient care practices.

BACKGROUND Data are limited on the use and outcomes of urine drug tests (UDTs) among patients with advanced cancer. The main objective of this study was to determine the factors associated with UDT ordering and results in outpatients with advanced cancer. METHODS A retrospective chart review was conducted of 1058 patients who attended an outpatient supportive care clinic from March 2014 to November 2015. Sixty-one patients who were receiving chronic opioid therapy and underwent UDTs were identified. A control group of 120 patients who did not undergo UDTs was selected for comparison. RESULTS Sixty-one of 1058 patients (6%) underwent UDTs, and 33 of 61 patients (54%) had abnormal results. Multivariate analysis indicated that the odds ratio for UDT ordering was 3.9 in patients who had positive Cut Down, Annoyed, Guilty, and Eye Opener (CAGE) questionnaire results (P = .002), 4.41 in patients aged

This cohort study assesses the frequency of abnormal urine drug test findings among patients with cancer pain treated with long-term opioid therapy who underwent random and targeted testing.

To determine the timing of palliative care (PC) access, symptoms, and end-of-life (EOL) quality care outcomes of patients with advanced nonsmall cell lung cancer (NSCLC) referred to outpatients embedded palliative care consults (EPC) compared with those of outpatients palliative care consults (OPC).There are no studies comparing the outcomes of outpatients EPC consults with those of stand-alone OPC consults among patients with NSCLC.The design consists of a random sample of OPC consults (January 2009 to July 2012) and EPC consults (August 2012 to June 2013) at MD Anderson Cancer Center. After the initial consult, all EPC follow-ups occurred at the OPC clinic.Patients' characteristics, symptoms (assessed by Edmonton Symptom Assessment Scale), time from referral to first consult, overall survival from consult to death, and EOL quality care outcomes (ICU admissions, emergency center visits, hospitalizations within last 30 days, cancer treatments within last 14 days, hospice referrals, advanced care planning [ACP] discussions, and completion of advanced directives) were reviewed.A total of 340 consults were included (EPC consults = 147). Baseline Eastern Cooperative Oncology Group status (2.2 vs. 1.9, p 0.001) and median pain (6 vs. 5, p = 0.038) were higher among EPC consults. In EPC consults, time from referral to first consult was shorter (median: 0 day vs. 7 days, p 0.001), and ACP discussions occurred more frequently (90% vs. 77%, p = 0.026), and earlier (median: 2 month vs. 1 month before death, p = 0.018). No other significant differences in symptoms, EOL outcomes, or survival were observed.EPC consults plus OPC follow-ups accessed PC earlier, and had more frequent and earlier ACP discussions as compared with OPC consults. Embedded palliative cancer care might not be the ideal model for an initial PC consultation. Further research is necessary.

9 Background: Increasing total opioid dose is the standard approach for managing uncontrolled cancer pain. Other than simply increasing the opioid dose, palliative care interventions are multidimensional and may improve pain control in the absence of opioid dose increase. The purpose of this study was to determine the proportion of patients referred to our inpatient palliative care (IPC) team who achieved clinically improved pain (CIP) without opioid dose increase. Methods: We reviewed consecutive patients referred to our IPC team. Eligibility criteria included: 1) taking opioid medication; 2) having ≥ 2 consecutive visits with the IPC team; 3) Edmonton Symptom Assessment Scale (ESAS) pain score ≥ 4 at consultation. We assessed patient demographics and clinical variables, including cancer type, opioid prescription data (type, route, oral morphine equivalent daily dose [MEDD]), presence of opioid rotation, psychological consultation, changes in adjuvant medications (e.g., corticosteroids, benzodiazepines, and neuroleptics), and achievement of CIP. Results: Of the 300 patients enrolled, CIP was achieved in 196 (65%) patients. Of CIP patients, 85 (43%) achieved CIP without an increase in MEDD. CIP without MEDD increase was associated with more adjuvant medication changes (P = 0.003), less opioid rotation (P = 0.005), and lower symptom distress scale of ESAS (P = 0.04). Conclusions: Nearly half of patients achieved CIP without MEDD increase, suggesting that multidimensional palliative care intervention is effective in improving pain control in many opioid-tolerant patients without the need to increase the opioid dose.

11602 Background: Non-Medical opioid use is a growing crisis. Cancer patients at risk of harmful use of prescribed opioids are frequently underdiagnosed. The aim was to develop a nomogram to predict the probability of occurrence of Inappropriate opioid use that is, presence of SOAPP ≥ 7) among patients receiving outpatient supportive care consultation at a comprehensive cancer center. Methods: 3588 consecutive cancer patients referred to a supportive care clinic from March 1, 2016 to July 15, 2018 were reviewed. Patients were eligible if they had diagnosis of cancer, and were on opioids for pain for at least a week. All patients were assessed using Edmonton Symptom Assessment Scale with spiritual pain and financial distress (ESAS-FS), MEDD (morphine equivalent daily dose), SOAPP-14 (validated questionnaire for assessment of risk of inappropriate opioid use, and CAGE-AID (screening questionnaire for alcoholism/substance use disorder). Patients at with SOAPP+ were defined by SOAPP score ≥7. A nomogram was devised based on the risk factors determined in the multivariate logistic regression model and it can be used to estimate the probability of inappropriate opioid use. Results: Median age was 62yrs. Median ESAS pain item score on consultation was 5, Median ECOG was 2.20.4% were SOAPP+ and 10.1% were CAGE-AID+. SOAPP+ was significantly associated with gender, race, marital status, smoking status, depression, anxiety, financial distress, MEDD and CAGE score. The C-index is 0.8(CI 0.78, 0.82). A nomogram was developed. For example, for a male Hispanic patient, who is married, never smoked, with the following ESAS scores: (depression = 3, anxiety = 3, financial distress = 8), CAGE score of 0, and MEDD of 20, the total score is 9+9+0+0+6+10+26+0+1 = 61. In the nomogram a score of 58 indicates the probability of inappropriate opioid use being 0.1 and a score of 88 indicates the probability of 0.2. Based on the patient’s total score of 61, the probability of his aberrant behavior is between 10% to 20% (close to 10%). Conclusions: A nomogram can predict the risk of inappropriate opioid use in cancer patients.

221 Background: Although urine drug testing (UDT) is an effective risk monitoring tool for patients on chronic opioid therapy, there is currently no evidence to guide physicians in identifying who should have UDT, or when and how often it should be ordered. The main objective of our study was to describe the characteristics of patients who underwent random UDT and a similar cohort who underwent targeted UDT. Methods: Demographic and clinical information of 212 patients who underwent random UDT was retrospectively reviewed and compared with 88 patients who underwent targeted UDT. Targeted UDT was ordered based on the physician’s estimation of patient risk for nonmedical opioid use. All patients were eligible for random UDT regardless of their risk potential for nonmedical opioid use. Results: 212/231 (92%) eligible patients underwent random UDT. Of these 59 (28%) had abnormal results. Among 64 abnormalities detected, 14 (20%) were prescribed opioids that were absent from the urine, 19 (30%) were unprescribed opioids that were present, and 32 (50%) were illicit drugs (91% marijuana). 38/88(43%) of targeted patients had abnormal results. Among 49 abnormalities detected, 13 (27%) were prescribed opioids that were absent from the urine, 15 (31%) were unprescribed opioids that were absent, and 21 (43%) were illicit drugs (71% marijuana). UDT abnormalities were significantly higher in the targeted group than the random group (43.2% vs. 27.8%, p=0.01). There were no significant differences in demographic and clinical characteristics between random and targeted patients with abnormal UDT findings. UDT abnormality was independently associated with age (OR= 0.97 per year, 95% CI: 0.95-0.99, p=0.012), female gender (OR=0.47, 95% CI: 0.28-0.81, p=0.006), anxiety (OR=1.11per point, 95% CI: 1.01-1.22, p=0.039), and appetite (OR= 1.14 per point, 95% CI: 1.04-1.26, p=0.006). Conclusions: More than 1 in 4 cancer patients who underwent random UDT had abnormal results. UDT abnormality in randomly selected patients were no different from targeted patients. Further studies are needed to guide clinical practice regarding standardization of UDT ordering among patients with cancer.

226 Background: Opioid misuse is a growing crisis. Cancer patients at risk of aberrant drug behaviors are frequently underdiagnosed. Primary aim was to determine the association between current tobacco smoking, daily opioid use, pain response, and risk for aberrant opioid use behaviors (AOB) among patients receiving outpatient supportive care consultation at a comprehensive cancer center. Methods: 1,501 consecutive cancer patients referred to a supportive care clinic from March 1, 2016 to June 6, 2018 were reviewed. Patients were eligible if they had diagnosis of cancer, and were on opioids for pain for at least a week. All patients were assessed using Edmonton Symptom Assessment Scale (ESAS), SOAPP-14 (validated questionnaire for assessment of risk for aberrant opioid use behaviors), and CAGE-AID. Patients with AOB (SOAPP+) were defined by SOAPP score ≥7. Results: Median age was 61yrs. Median ESAS pain item score on consultation was 5. Median ECOG was 2. Never smokers, previous smokers, and current smokers were 54%, 40%, and 6.6% respectively. 16.8% were AOB+ and 10.1% were CAGE-AID+. There was no significant difference in ESAS pain response at first follow-up between AOB+ versus AOB negative. Morphine Equivalent Daily Dose (MEDD) in AOB+ never smokers versus previous smokers versus current smokers was 45 mg versus 60 mg versus 75mg respectively (P=0.03). Table 1 shows that male pts and those with current or previous smoking history, anxiety, and prior alcoholism/illicit drug use are at increased risk of AOB. Conclusions: Male patients and those with history of current or previous smoking history, anxiety, and prior alcoholism/illicit drug use are at increased risk of AOB. [Table: see text]

Objective:There is a limited number of pragmatic studies to evaluate the criteria for referral to outpatient palliative care. The aim of our study was to compare the characteristics, symptoms, and survival of patients with advanced non-small-cell lung cancer (NSCLC) referred (RF) versus not referred (NRF) to a novel embedded same-day rapid-access supportive care clinic (RASCC) and to compare the subgroups among referred patients.Method:We reviewed the medical records of all patients who received treatment at the thoracic oncology clinic for advanced non-small-cell lung cancer between August 1, 2012, and June 30, 2013, who were referred to the RASCC and those who were not referred. An oncology-estimated prognosis of ≤6 months and/or severe symptom distress was employed as criteria for referral to the RASCC.Results:Of 410 eligible patients, 155 (37.8%) were referred to the RASCC. RF patients had significantly higher patient-reported scores for pain, fatigue, lack of appetite, and symptom distress, as well as worse performance status and shorter survival than NRF patients. Among the RF patients, those who were referred early (≤3 months) had significantly worse symptom distress and shorter overall survival than patients who were referred later on. The patients treated by thoracic oncologists who referred a smaller proportion of their patients to the RASCC had significantly worse anxiety, well-being, spiritual pain, and symptom distress than patients treated by those who referred a larger proportion of their patients to the RASCC.Significance of Results:We found that patients who were referred to the RASCC had higher reported symptom distress and worse survival ratings. Further studies are needed to evaluate the optimal criteria for timely integration of palliative care and oncology care.

228 Background: Opioid misuse is a growing crisis among patients with chronic pain. Cancer patients at risk of aberrant drug behaviors (ADB) are frequently underdiagnosed in routine cancer care. The aim of this study was to determine the frequency and factors predicting risk for Aberrant Opioid and Drug use among Patients receiving Outpatient Supportive Care Consultation at a Comprehensive Cancer Center Methods: In this retrospective study, 690 consecutive patients referred to a supportive care clinic were reviewed. Patients were eligible if they were ≥18 years, had a diagnosis of cancer, and were on opioids for pain for atleast a week. All patients were assessed with the Edmonton Symptom Assessment Scale (ESAS), SOAPP-14, and CAGE-AID. At risk patients with aberrant opioid behavior (+Risk) was defined as SOAPP-14 score ≥7. Descriptive statistics, spearman correlation coefficient, multivariate analysis were performed. Results: 690/752 consults were eligible. A total of 135(20%)were +risk. 69(11%) were CAGE-AID +.SOAPP-14 scores were positively associated with CAGE-AID p < 0.001; male gender p = 0.007; ESAS pain p = < 0.006; ESAS depression p < 0.001; ESAS anxiety, p < 0.001, and ESAS financial distress p = < 0.001. Multivariate analysis indicated that the odds ratio for +Risk was 2.47 in patients with CAGE-AID+ (p < 0.001), 1.95 for male gender (p = 0.005), 1.11 per point for ESAS anxiety (p = 0.019), and 1.1 per point. for ESAS financial distress (p = 0.02). Conclusions: 20% of cancer patients on opioids presenting to supportive care center are at risk of aberrant drug behavior. Male patients with anxiety, financial distress, and prior alcoholism/illicit drug use are significant predictors of +Risk. Further research to effectively manage these patients is needed.

Context Cranial electrotherapy stimulation (CES) is a safe modulation of brain activity for treating depression, anxiety, insomnia, and pain. However, there are no published studies in patients with advanced cancer (ACPs). Objectives The aim of the study was to determine the feasibility and preliminary efficacy of a four-week CES intervention on depression, anxiety, sleep disturbance, and pain scores. Concurrent salivary biomarker studies were conducted. Methods In this one group open label pre- and post-intervention study with a four-week CES intervention, ACPs with one or more of four moderate intensity (≥3/10) Edmonton Symptom Assessment Scale (ESAS) symptoms (depression, anxiety, sleep disturbance, and pain) were eligible. Adherence (0%–100%), satisfaction rates (0–10), and safety were assessed. ESAS, Hospital Anxiety and Depression Scale (HADS), Pittsburgh Sleep Quality Index, Brief Pain Inventory, and salivary levels (cortisol, alpha amylase, C-reactive protein, and interleukin-1β, and interleukin-6) were assessed from baseline to Week 4. Results Thirty-three of 36 patients (92%) completed the CES. Median (interquartile range) adherence CES use and satisfaction scores were 93% (89–100) and 10% (9–10), respectively, and the adherence criteria was met in the study. CES use was safe (no Grade 3 or higher adverse events). HADS anxiety ( P P = 0.024), ESAS anxiety ( P = 0.001), ESAS depression ( P = 0.025), Brief Pain Inventory pain ( P = 0.013), Pittsburgh Sleep Quality Index daytime dysfunction ( P = 0.002), and medication use ( P = 0.006) scores improved after four-week CES treatment. Conclusion In this preliminary study, we found that the use of CES was safe and feasible in ACP. The use of CES was associated with significant improvement of depression, anxiety, pain, and sleep scores. These findings support further studies of CES in ACP for symptom control.

10118 Background: Opioid misuse is a growing crisis in cancer patients. Cancer patients at risk of aberrant drug behaviors (ADB) are frequently underdiagnosed in routine cancer care. The aim of this study was to determine the frequency and factors associated with ADB using the “Screener and Opioid Assessment for Patients tool” (SOAPP-14) in cancer patients seen at the outpatient supportive care center. We also examined the screening performance of Cut Down, Annoyed, Guilty, and Eye Opener (CAGE-AID) as compared to The SOAPP-14 as a gold standard. Methods: In this retrospective study, 1108 consecutive patients referred to supportive care clinic were reviewed. Patients were eligible if they were ≥18 yrs, have a diagnosis of cancer, and were on opioids for pain for atleast a week. Patients’ demographics, the Edmonton Symptom Assessment Scale (ESAS), SOAPP-14, and CAGE-AID scores were analyzed. ADB+ was defined as SOAPP-14 score ≥7. Descriptive statistics, spearman correlation coefficient, multivariate, and ROC analysis were performed. Results: 703/1108 consults were eligible. A total of 153/703 (22%) were ADB +ve. SOAPP-14 scores were positively correlated with CAGE-AID r = .38, p < 0.001; male gender r = 0.11, p = 0.003; ESAS pain r = 0.11, p = 0.005; ESAS depression r = 0.22, p < 0.001; ESAS anxiety r = 0.22, p < 0.001, and ESAS financial distress r = 0.23, p < 0.001. Multivariate analysis indicated that the odds ratio for ADB +ve was 6.18 in patients with CAGE-AID+ (p < 0.001), 1.8 for male gender (p = 0.007), 1.1/pt. for ESAS anxiety (p = 0.044), and 1.1/pt. for ESAS financial distress (p = 0.007). A CAGE-AID score of 1/4 has a sensitivity of 47%, specificity of 89% positive predictive value 63.6% and negative predictive value 69.2%. Conclusions: Our study suggests that 22% of cancer patients on opioids presenting to supportive care center are at risk of aberrant drug behavior (ADB). Male patients with anxiety, financial distress, and prior alcoholism/illicit drug use are significant predictors of ADB’s. A cut off score of ≥1 out 4 on CAGE-AID questionnaire allows better screening of ADB in outpatient advanced cancer patients. Further research to effectively manage these patients is needed.

210 Background: There is limited literature on specific patient characteristics associated with response to placebo. The aim of this study was to identify frequency, and predictors of response to placebo. Methods: We conducted pooled analysis of the placebo arm in six randomized, double-blind, placebo-controlled clinical trials for cancer related fatigue. Baseline patient characteristics, symptoms (FACIT-F, and ESAS), Global Symptom Evaluation (GSE, rated as better, same and worse). Response was defined as an increase (D FACIT-F score) ≥ 3.5 points from baseline or change in ESAS of ≤ 1. Baseline patient characteristics and symptoms (as assessed by ESAS) were analyzed to determine their association with response to placebo using logistic regression analysis. ROC was calculated for GSE “better” of “4” or more (i.e., moderately better to very great deal better) and FACIT-F change. Results: Total of 306 patients with advanced cancer received placebo. The median age was 59, 54% were female, 76% were white, 51% were had college education or higher, the most common cancer type was genitourinary 24%. 55% had Zubrod performance ≤ 2. Median FACIF-F subscale score was 21. Placebo response was 176/306 (58%) with FACIT-F subscale ≥ 3.5 points and 185 (60%) with ESAS fatigue ≤ 1. Mean change in fatigue using FACIT- F subscale score was 7.18 (11.68) and ESAS was -2.21 (2.82). Change in FACIT-F and ESAS were significantly correlated (r = 0.56, P ≤ 0.001). 99/306 (32%) reported that their fatigue was “better” by GSE. Female gender (OR 2.72, P = 0.04), and anxiety (OR 1.39, P = 0.046) were significantly associated with placebo response. ROC with cut-off of GSE ≥ 4 and change in FACIT-F score was 11.5 and placebo response rate based on cut-off of 7.5 was 84/306 (27%). Conclusions: Our results confirm that placebo response is substantial in fatigue treatment trials in palliative patients. Placebo response rate varies based on the methods used to estimate response (from 27% to 60%). Female patients and higher anxiety at baseline were significantly associated with placebo response. More research is needed to accurately benchmark placebo response.

209 Background: Cancer related fatigue (CRF) is the most common and disabling symptom in cancer.Panax ginseng extract (PG) is frequently used as a nutraceutical treatment for fatigue. There are no well-powered placebo-controlled trials that used validated CRF outcome measures to investigate of PG effects in cancer patients. The primary objective of this trial was to evaluate the effects oral PG versus Placebo (PL) for CRF. Methods: Patients with cancer fatigue ≥ 4/10 on Edmonton Symptom Assessment Scale (ESAS) were eligible. Patients were randomized to either 400mg of standardized PG or matching PL orally twice a day for 28 days. The primary endpoint was change in the Functional Assessment of Chronic Illness-Fatigue (FACIT-F) fatigue subscale from baseline to Day 28. Secondary outcomes were Functional Assessment of Cancer Therapy-General (FACT-G), Hospital Anxiety and Depression Scale (HADS), and ESAS. Results: Total evaluable patients were 112 (56 for PG and PL groups). No significant differences in baseline characteristics between the two groups except cancer type (p = 0.002). There was significant improvement in FACIT fatigue and ESAS fatigue scores in PG and PL groups at Day 15 and Day 29. The mean (SD) of FACIT-F fatigue scores at baseline, Day 15, and Day 29 were 22.6 (10.4), 29.8(10.7), 30.1 (11.6) and 23.8 (9.1), 30.0 (10.1), 30.4 (11.6) for PG and PL respectively. Mean (SD) improvement in the FACIT-F subscale at Day 29 was not significantly different in PG than in the PL group [7.5 (12.7) vs 6.5 (9.9), P = 0.67]. Mean (SD) improvement in the ESAS fatigue, FACT-G, and HADS at Day 29 were also not significantly different in PG than in the PL group. In a multiple linear model analysis, the change in FACIT-F fatigue from Day 0 to Day 29 was negatively correlated with baseline FACIT-F fatigue (p = 0.0005), baseline HADS score (p = 0.032), and male gender (p = 0.023). There were a significantly higher number of any grade of toxicities in PL group than in PG group (33/62 vs. 28/64, p = 0.024). Conclusions: Both PG and Placebo result in a significant improvement in CRF at Day 15 and Day 29. PG was not significantly superior to placebo after 4 weeks of treatment. Further studies are needed. Clinical trial information: NCT01375114.