摘要
介绍：阿片类药物和苯二氮卓类药物是治疗癌症症状的常用处方药。这两种药物合用会增加不良事件的风险，尤其是对大多数癌症患者中的多病老年人而言。我们旨在了解癌症护理提供者在阿片类药物和苯二氮卓类药物联合处方及减轻潜在危害方面的做法：我们采访了来自两个医疗系统的肿瘤和姑息治疗提供者。访谈的重点是对阿片类药物和苯二氮卓类药物联合处方的态度和当前做法。我们采用分阶段的主题分析方法对访谈记录进行了分析：20 名医疗服务提供者（10 名肿瘤科，10 名姑息治疗科）参加了访谈。我们确定了三个关键主题。(1）不愿处方苯二氮卓类药物：医疗服务提供者报告称，他们很少共同处方苯二氮卓类药物，因为他们不经常处方苯二氮卓类药物，认为其安全性较差。(2) 用药安全预防措施：这些措施包括从小剂量开始，缓慢增加剂量，尽可能将处方集中在一个医疗服务提供者处，并就副作用、用药过量和纳洛酮等问题向患者和护理者提供教育。与肿瘤科医生相比，姑息关怀医疗服务提供者更经常描述向患者和护理人员提供纳洛酮的情况。(3) 风险评估和监控：大多数医疗服务提供者都提到要检查州处方药监控计划数据库并进行病历审查，以确定药物滥用史的证据。有几位肿瘤专家表示，由于担心污名化，他们不便询问药物滥用史。医疗服务提供者有时会依赖于他们对患者可信度的看法，其中一些人承认这可能会产生偏见：讨论：我们强调了改善肿瘤科药物审查与调和实践、提高纳洛酮在肿瘤科实践中的使用率、系统化筛查患者药物滥用以及加强将成瘾和精神病学服务整合到肿瘤科和姑息治疗中的机会。在肿瘤治疗中定期使用老年病学评估也能解决我们观察到的许多安全问题。Introduction: Opioids and benzodiazepines are commonly prescribed for cancer symptoms. In combination, they can increase the risk of adverse events, particularly for older adults with multimorbidity, who represent most patients with cancer. We aimed to understand cancer care providers' practices for opioid and benzodiazepine coprescribing and mitigating potential harms.
Materials and methods: We interviewed oncology and palliative care providers from two health systems. Interviews focused on attitudes about and current practices for coprescribing opioids and benzodiazepines. We analyzed interview transcripts using a staged approach to thematic analysis.
Results: Twenty providers (10 oncology, 10 palliative care) participated. We identified three key themes. (1) Reluctance to prescribe benzodiazepines: providers reported rarely coprescribing because they do not routinely prescribe benzodiazepines, which were viewed as having a poor safety profile. (2) Medication safety precautions: these included starting at a low dose and titrating up slowly, consolidating prescriptions under one provider whenever possible, and providing patient and caregiver education around side effects, overdose, and naloxone. Compared to oncologists, palliative care providers more often described providing naloxone to patients and caregivers. (3) Risk assessment and monitoring: most providers mentioned checking state Prescription Drug Monitoring Program databases and conducting chart reviews to identify evidence of substance misuse history. Several oncologists expressed discomfort in asking about substance misuse history due to concerns about stigma. Providers described sometimes relying on their perception of a patient's trustworthiness, with some acknowledging the potential for bias.
Discussion: We highlight opportunities to improve medication review and reconciliation practices in oncology, increase uptake of naloxone in oncology practice, systematize efforts to screen patients for substance misuse, and strengthen integration of addiction and psychiatry services into oncology and palliative care settings. Regular use of geriatric assessment in oncology would also address many of the safety concerns we observed.
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