The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Adult Cancer Pain provide recommendations for the comprehensive management of pain in patients with cancer. This article will focus on methods for screening for pain, safe and appropriate prescription of opioid and miscellaneous analgesics, and the optimization of nonpharmacologic interventions including integrative and interventional strategies for treatment of cancer-related pain. Additionally, the NCCN Guidelines discuss methods for the safe reduction of opioids when appropriate, as well as techniques for encouraging the judicious use of opioids. The complete version of the NCCN Guidelines for Adult Cancer Pain addresses additional issues that are not covered here, including management of pain during a pain crisis, management of procedure-related pain and anxiety, pain management for cancer survivors, and the use of nonopioid and adjuvant analgesics for cancer-related pain.

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Purpose To describe one strategy for dispensing of methadone at emergency department (ED) and hospital discharge implemented within 2 urban academic medical centers. Summary Expanding access to medications for opioid use disorder (OUD) is a national priority. ED visits and hospitalizations offer an opportunity to initiate or continue these lifesaving medications, including methadone and buprenorphine. However, federal regulations governing methadone treatment and significant gaps in treatment availability have made continuing methadone upon ED or hospital discharge challenging. To address this issue, the Drug Enforcement Administration (DEA) granted an exception allowing hospitals, clinics, and EDs to dispense a 72-hour supply of methadone while continued treatment is arranged. Though this exception addresses a critical unmet need, guidance for operationalizing this service is limited. To facilitate expanded patient access to methadone on ED or hospital discharge at 2 Baltimore hospitals, key stakeholders within the parent health system were identified, and a workgroup was formed. Processes were established for requesting, approving, preparing, and dispensing the methadone supply using an electronic health record order set. Multidisciplinary educational materials were created to support end users of the workflow. In the first 3 months of implementation, 42 requests were entered, of which 36 were approved, resulting in 79 dispensed methadone doses. Conclusion This project demonstrates feasibility of methadone dispensing at hospital and ED discharge. Further work is needed to evaluate impact on patient outcomes, such as hospital and ED utilization, length of stay, linkage to treatment, and retention in treatment.

INTRODUCTION In clinical practice, sublingual (SL) buprenorphine-naloxone is prescribed as once daily or split daily dosing for the management of opioid use disorder (OUD). Evidence is lacking that assesses how split daily buprenorphine-naloxone affects OUD outcomes. This study aims to evaluate how the dosing frequency of SL buprenorphine-naloxone impacts therapy effectiveness when treating patients with OUD. METHODS This retrospective analysis included adult outpatients prescribed treatment with SL buprenorphine-naloxone for OUD between July 1, 2016, and March 1, 2020. The study excluded patients with sickle cell disease, recent methadone treatment, or pregnancy. We characterized study groups by dosing frequency, either once daily or split dosing. The study compared retention in treatment, medication adherence, adherence to treatment program, and hospital encounters between groups. RESULTS The study screened eight-hundred and seven patients, and included 250 patients newly prescribed SL buprenorphine-naloxone. Fifty-seven patients (22.8 %) were prescribed once daily dosing and 193 patients (77.2 %) were prescribed split daily dosing. The study found no significant differences noted in 12-month rates of treatment retention (52.6 % vs. 45.6 %, p = .35). These outcomes remained similar when assessed at three and six months. Within a year of buprenorphine-naloxone initiation, the study found no differences in the percentage of patients with hospitalizations (26.3 % vs. 38.3 %, p = .10), median number of hospitalizations (2 vs. 2), or proportion of days covered by a prescription ≥80 % (93.3 % vs. 92.0 %, p = .82). CONCLUSIONS In this study, patients receiving once daily buprenorphine-naloxone had similar treatment outcomes to patients receiving split dosing. Further controlled studies are necessary to evaluate which patients are more likely to benefit from split dosing.

Background: This study aims to characterize patients with patient-directed discharge (PDD) and substance use disorders (SUD) and to summarize involvement of an Addiction Consult Service (ACS) in encounters resulting in PDD in an urban academic medical center. Methods: This single-center, retrospective, pre-and post-implementation study included patient encounters for hospitalized adults with at least one documented SUD and a PDD. The pre-and post-implementation periods were defined as July 2018–June 2019 and July 2020–June 2022, respectively. The primary outcome was a comparison of PDD rates between cohorts. Secondary outcomes were hospital length of stay (LOS) and 30-day read-mission rates. In the post-implementation cohort, ordering of and completion of an ACS consult and time to order and time to completion of the consult were assessed. For the subgroup with OUD, severity of withdrawal symptoms, utilization of methadone and/or buprenorphine in the first 24 h of admission, and rate of buprenorphine discharge prescribing were described. Differences in categorical variables between cohorts were analyzed using Chi-square or Fisher’s exact test and continuous variables were analyzed using the Student T -test or the Wilcoxon Rank Sum, as appropriate. Results: A total of 346 encounters (pre n = 101 and post n = 245) comprised of 252 unique patients were included. Patients were median 41 years old (IQR 33–54), 65.9% male, and 49.1% white. OUD (57.5%) was the most common SUD diagnosis among encounters and 40.8% were associated with more

Corticosteroids are used for a multitude of indications in palliative patients. In this narrative review, we aim to review literature on the treatment and prevention of neuropsychiatric complications of steroids. For prevention, only lamotrigine had a positive effect in a small number of studies. For treatment, olanzapine appears to be nearly universally effective at low doses, but randomized trial evidence is lacking. Further randomized clinical trials are necessary to elucidate data-driven guidelines for prevention and treatment of corticosteroid-induced neuropsychiatric symptoms. Until further data are available, it is reasonable to consider low dose olanzapine for any patient taking 40 mg of prednisone or its equivalent, especially those with a history of depression or neuropsychiatric symptoms.

JACCP: JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACYVolume 5, Issue 2 p. 114-117 EDITORIAL Call to action: Clinical pharmacy and addressing the opioid crisis Stephanie Abel Pharm.D., Stephanie Abel Pharm.D. orcid.org/0000-0003-4715-2688 Office of Opioid Safety, University of Kentucky HealthCare, Lexington, Kentucky, USASearch for more papers by this authorAmanda R. M. Winans Pharm.D., Amanda R. M. Winans Pharm.D. orcid.org/0000-0003-3835-7227 Department of Pharmaceutical Care Services, Bassett Healthcare, Cooperstown, New York, USASearch for more papers by this authorNadia Jubran Pharm.D., Corresponding Author Nadia Jubran Pharm.D. [email protected] orcid.org/0000-0001-7036-190X U.S. Department of Veterans Affairs, Veterans Integrated Services Networks (VISN) 5 Academic Detailing, Washington, District of Columbia, USA Correspondence Nadia Jubran, U.S. Department of Veterans Affairs, Veterans Integrated Services Networks (VISN) 5 Academic Detailing, Washington, DC 20422. Email: [email protected]Search for more papers by this authorSuzanne Nesbit Pharm.D., FCCP, Suzanne Nesbit Pharm.D., FCCP orcid.org/0000-0001-6205-1936 Departments of Pharmacy and Oncology, Center for Drug Safety and Effectiveness, The Johns Hopkins Hospital, Baltimore, Maryland, USASearch for more papers by this author Stephanie Abel Pharm.D., Stephanie Abel Pharm.D. orcid.org/0000-0003-4715-2688 Office of Opioid Safety, University of Kentucky HealthCare, Lexington, Kentucky, USASearch for more papers by this authorAmanda R. M. Winans Pharm.D., Amanda R. M. Winans Pharm.D. orcid.org/0000-0003-3835-7227 Department of Pharmaceutical Care Services, Bassett Healthcare, Cooperstown, New York, USASearch for more papers by this authorNadia Jubran Pharm.D., Corresponding Author Nadia Jubran Pharm.D. [email protected] orcid.org/0000-0001-7036-190X U.S. Department of Veterans Affairs, Veterans Integrated Services Networks (VISN) 5 Academic Detailing, Washington, District of Columbia, USA Correspondence Nadia Jubran, U.S. Department of Veterans Affairs, Veterans Integrated Services Networks (VISN) 5 Academic Detailing, Washington, DC 20422. Email: [email protected]Search for more papers by this authorSuzanne Nesbit Pharm.D., FCCP, Suzanne Nesbit Pharm.D., FCCP orcid.org/0000-0001-6205-1936 Departments of Pharmacy and Oncology, Center for Drug Safety and Effectiveness, The Johns Hopkins Hospital, Baltimore, Maryland, USASearch for more papers by this author First published: 03 February 2022 https://doi.org/10.1002/jac5.1592Citations: 1Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinkedInRedditWechat REFERENCES 1Mackey K, Veazie S, Anderson J, Bourne D, Peterson K. Evidence Brief: barriers and facilitators to use of medications for opioid use disorder. Hsrd.research.va.gov. August 2019. Accessed December 8, 2021. Available from: https://www.hsrd.research.va.gov/publications/esp/barriers-facilitators-oud.pdf. 2 National Academies of Sciences, Engineering, and Medicine. Medications for opioid use disorder save lives. Washington, DC: The National Academies Press, 2019. 3Atkins J, Dopp AL, Temaner EB. Combatting the stigma of addiction—The need for a comprehensive health system approach. NAM Perspectives. 2020; 1–3. Accessed December 8, 2021. https://doi.org/10.31478/202011d. 4 Shatterproof Addiction Stigma Index in collaboration with The Hartford. Shatterproof.org. Accessed December 8, 2021. Available from: https://www.shatterproof.org/our-work/ending-addiction-stigma/shatterproof-addiction-stigma-Index. 5 Trends in the Rate of Opioid-Related Hospitalizations. Ahrq.gov. Published May 2019. Accessed December 8, 2021. Available from: https://www.ahrq.gov/opioids/map/index.html. 6 Report shows decreases in opioid prescribing, increase in overdoses. Ama-assn.gov. September 21, 2021. Accessed December 8, 2021. Available from: https://www.ama-assn.org/press-center/press-releases/report-shows-decreases-opioid-prescribing-increase-overdoses. 7 Addressing the Opioid Crisis in the United States. IHI.org. April 2016. Accessed December 8, 2021. Available from: http://www.ihi.org/resources/Pages/Publications/Addressing-Opioid-Crisis-US.aspx. 8 The Stem the Tide: Addressing the Opioid Epidemic. AHA.org. Accessed December 8, 2021. Available from: https://www.aha.org/guidesreports/2017-11-07-stem-tide-addressing-opioid-epidemic-taking-action. 9 National Dialogue for Healthcare Innovation’s Opioid Crisis Solutions Summit: A Roadmap for Action. NDHI.org. Accessed December 8, 2021. Available from: https://www.ndhi.org/files/7415/2907/4391/Opioid_Roadmap_FINAL.pdf. 10 National Quality Forum Playbook: Opioid stewardship. Qualityforum.org. March 2018. Accessed December 8, 2018 Available from: https://store.qualityforum.org/collections/opioid-stewardship. Citing Literature Volume5, Issue2Special Issue: The Opioid Crisis: Opportunities for Clinical Pharmacy PracticeFebruary 2022Pages 114-117 ReferencesRelatedInformation

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

OBJECTIVE:To determine how passively providing informational handouts and/or drug disposal kits affects rates of leftover prescription opioid disposal.DESIGN:A multi-arm parallel-group randomized controlled trial with masked outcome assessment and computer-guided randomization.SETTING:Johns Hopkins Health System outpatient pharmacies.SUBJECTS:Individuals who filled ≥1 short-term prescription for an immediate-release opioid for themselves or a family member.METHODS:In June 2019, 499 individuals were randomized to receive an informational handout detailing U.S. Food and Drug Administration-recommended ways to properly dispose of leftover opioids (n = 188), the informational handout and a drug disposal kit with instructions on its use (n = 170), or no intervention (n = 141) at prescription pickup. Subjects were subsequently contacted by telephone, and outcomes were assessed by a standardized survey. The primary outcome was the use of a safe opioid disposal method.RESULTS:By 6 weeks after prescription pickup, 227 eligible individuals reported they had stopped taking prescription opioids to treat pain and had leftover medication. No difference in safe disposal was observed between the non-intervention group (10% [6/63]) and the group that received disposal kits (14% [10/73]) (risk ratio = 1.44; 95% confidence interval: 0.55 to 3.74) or the group that received a fact sheet (11% [10/91]) (risk ratio = 1.15; 95% confidence interval: 0.44 to 3.01).CONCLUSIONS:These findings suggest that passive provision of a drug disposal kit at prescription pickup did not increase rates of leftover opioid disposal when compared with provision of a fact sheet alone or no intervention. Active interventions may deserve further investigation.

OBJECTIVE:Over 80 percent of surgery patients experience acute post-operative pain and less than half feel their pain is adequately controlled. Patients receiving chronic opioids, including methadone, are at the highest risk of inadequate pain control. Guidelines do not provide specific recommendations for analgesia management in this population. The purpose of this study was to evaluate the association between post-operative methadone use and respiratory depression.DESIGN:This study was a single center, retrospective, cohort study of adult patients.SETTING:Patients included were admitted to a single academic medical center from July 2016 to September 2018.PARTICIPANTS:Medical records of adult inpatients with an operative procedure who received perioperative methadone were reviewed.MAIN OUTCOME MEASURES:Preoperative methadone use was evaluated for all patients. Post-operative methadone dosing was compared to preoperative methadone dosing. Post-operative respiratory depression was evaluated. Logistic regression was performed to identify risk factors for respiratory depression.RESULTS:Two hundred ninety-eight patients were included in the study. Patients were divided into groups based on pre-operative methadone use. Over 90 percent of patients were on preoperative methadone. There were no significant differences in baseline characteristics between groups. In the initial seven post-operative days, 14.8 percent of patients had documented respiratory depression. Respiratory depression was more common among patients who were newly initiated on methadone post-operatively. Factors associated with respiratory depression included male sex, increased age, and new post-operative methadone initiation.CONCLUSIONS:Most patients who were administered post-operative methadone were on preoperative methadone. New post-operative methadone initiation was a risk factor for respiratory depression.

Purpose. The opioid epidemic continues to result in significant morbidity and mortality even within hospitals where opioids are the second most common cause of adverse events. Opioid stewardship represents one model for hospitals to promote safe and rational prescribing of opioids to mitigate preventable adverse events in alliance with new Joint Commission standards. The purpose of this study was to identify the prevalence of current hospital practices to improve opioid use. Methods. A cross-sectional survey of hospital best practices for opioid use was electronically distributed via electronic listservs in March 2018 to examine the presence of an opioid stewardship program and related practices, including formulary restrictions, specialist involvement for high-risk patients, types of risk factors screened, and educational activities. Results. Among 133 included hospitals, 23% reported a stewardship program and 14% reported a prospective screening process to identify patients at high risk of opioid-related adverse events (ORAEs). Among those with a prospective screening process, there was variability in ORAE risk factor screening. Formulary restrictions were dependent on specific opioids and formulations. Patient-controlled analgesia was restricted at 45% of hospitals. Most hospitals reported having a pain management service (90%) and a palliative care service providing pain management (67%). Conclusion. The absence of opioid stewardship and prospectively screening ORAEs represents a gap in current practice at surveyed hospitals. Hospitals have an opportunity to implement and refine best practices such as access to pain management specialists, use of formulary restrictions, and retrospective and prospective monitoring of adverse events to improve opioid use.

PURPOSEMillions of Americans who undergo surgical procedures receive opioid prescriptions as they return home. While some derive great benefit from these medicines, others experience adverse events, convert to chronic opioid use, or have unused medicines that serve as a reservoir for potential nonmedical use. Our aim was to investigate concepts and methods relevant to optimal opioid prescribing and pain treatment in the perioperative period.METHODSWe reviewed existing literature for trials on factors that influence opioid prescribing and optimization of pain treatment for surgical procedures and generated a conceptual framework to guide future quality, safety, and research efforts.RESULTSOpioid prescribing and pain treatment after discharge from surgery broadly consist of 3 key interacting perspectives, including those of the patient, the perioperative team, and, serving in an essential role for all patients, the pharmacist. Systems-based factors, ranging from the organizational environment's ability to provide multimodal analgesia and participation in enhanced recovery after surgery programs to other healthcare system and macro-level trends, shape these interactions and influence opioid-related safety outcomes.CONCLUSIONSThe severity and persistence of the opioid crisis underscore the urgent need for interventions to improve postoperative prescription opioid use in the United States. Such interventions are likely to be most effective, with the fewest unintended consequences, if based on sound evidence and built on multidisciplinary efforts that include pharmacists, nurses, surgeons, anesthesiologists, and the patient. Future studies have the potential to identify the optimal amount to prescribe, improve patient-focused safety and quality outcomes, and help curb the oversupply of opioids that contributes to the most pressing public health crisis of our time.

In recent years, the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Adult Cancer Pain have undergone substantial revisions focusing on the appropriate and safe prescription of opioid analgesics, optimization of nonopioid analgesics and adjuvant medications, and integration of nonpharmacologic methods of cancer pain management. This selection highlights some of these changes, covering topics on management of adult cancer pain including pharmacologic interventions, nonpharmacologic interventions, and treatment of specific cancer pain syndromes. The complete version of the NCCN Guidelines for Adult Cancer Pain addresses additional aspects of this topic, including pathophysiologic classification of cancer pain syndromes, comprehensive pain assessment, management of pain crisis, ongoing care for cancer pain, pain in cancer survivors, and specialty consultations.

# Foreword {#article-title-2} The ASHP Research and Education Foundation (“the Foundation”) is pleased to present the seventh edition of the annual Pharmacy Forecast . We are again pleased to disseminate the Pharmacy Forecast through AJHP, providing readers with easy access to the report. The

•Explain the mechanism of action of immunotherapy in cancer treatment.•Describe the effect of immunotherapy on cancer response patterns and its impact on expectations of patients and providers.•Discuss effective management of immune-mediated side effects. Recent advances in immunotherapy, such as immune checkpoint inhibitors, have drastically changed the oncology landscape, including occasional dramatic responses. They have also created new challenges for hospice and palliative care providers. Through interactive lectures, case-based examples, role play and “pop quiz”-style questions, this concurrent session will review the available evidence for immunotherapy in cancer care focusing on the key issues palliative care and hospice providers should know when caring for patients currently or previously treated with immunotherapy. Two pharmacists with extensive experience in oncology palliative care will list commonly used immunotherapy agents, explain mechanisms of action and clarify the complex nomenclature of immunotherapy agents. Common side effects as well as less common, but potentially life-threatening side effects with specific strategies for how to manage side effects will be described. The panel will explain important considerations in the pharmacologic approach to managing symptoms in patients receiving immunotherapy, such as caution in the use of steroids. A palliative oncologist with four years of experience providing palliative care to patients treated almost exclusively with targeted and immunotherapy will review available data on immunotherapy's impact on clinical outcomes, including alteration in measuring response to treatment, impact on life expectancy and the growing list of cancers successfully treated with these regimens. The success of these agents raises important questions for exactly how and when to integrate palliative care into the care of patients on immunotherapy. Through an illustrative case, a clinical oncology palliative care nurse with expertise in caring for patients on immunotherapy, will describe how immunotherapy can dramatically alter patient prognostic perceptions and their approach to decision-making about cancer-directed therapy. The success of these new agents heightens the role of palliative care specialists in helping patients and oncologists navigate decisions about continuing cancer-directed therapy versus enrolling on hospice while living with incurable cancer.

Purpose. An interprofessional initiative to operationalize outpatient naloxone prescribing at a large academic medical center is described. Summary. The initiative was carried out by a work group of clinical pharmacists and pharmacy administrators in collaboration with physicians and nursing staff leaders from multiple practice settings. An opioid overdose risk-assessment guide was developed on the basis of literature review and expert opinion. An institutional policy to guide identification of high-risk patient populations and facilitate naloxone prescribing and dispensing was developed and vetted by multiple expert committees. Patient education materials were created, and patients at high risk for opioid overdose were educated about overdose risk factors and naloxone use by a pharmacist and/or nurse before discharge or, in some cases, by outpatient pharmacists; when feasible, patients' friends, family members, and/or caregivers were included in education sessions. Interventions included distribution of a pamphlet emphasizing the importance of contacting emergency medical services personnel immediately in the event of an overdose, depicting the process for administration of injectable and nasal spray formulations of naloxone, and providing information on other first-response steps. Collaboration with outpatient pharmacies allowed for successful dispensing of naloxone prescriptions. Conclusion. The implementation of an outpatient naloxone prescribing policy at a large academic medical center created a streamlined approach for the interprofessional healthcare team to use in providing naloxone education and improved naloxone access to patients at high risk for opioid overdose.

Objective: Despite the prevalence of pain in clinical practice, pain is under represented in medical school curricula. Neurologists are often engaged in teaching about pain neurobiology, pain-associated conditions and treatments, as well as caring for patients with chronic pain. Chronic opioid exposure is one factor that increases chronic pain and prevention of unnecessary opioid exposure is a key clinical objective. Background: As an NIH Pain Consortium Center of Excellence in Pain Education, we are creating online learning modules grounded in interprofessional competencies in pain. Our goal is comprehensive, opioid-sparing, patient-centered pain care: incorporating pharmacological and non-pharmacological therapies. Members of our interprofessional team, headed by a neurologist, collaborate to create learning modules highlighting clinical skills in pain assessment, neurobiology, pharmacological and non-pharmacological treatments. Design/Methods: Our first case is a pregnant patient with anterior pelvic pain, a highly prevalent condition. Case variations including “occasional” and “daily” opioid use, are situated at the end of the learning flow so that opioids do not distract from the primary focus of the module. Including videos demonstrating patient-provider interactions, as well as interactive slides, the module is delivered such that learners are able to choose their own path through the content. After extensive peer feedback during development, we piloted our module to neurology clerkship students and others at multiple training levels. Results: Narrative analysis showed the module was highly satisfactory to students who appreciated the interdisciplinary and interprofessional aspects, as well as the ability to pace and shape their own learning. Students expressed eagerness to access additional modules covering further conditions of pain. Our results show that module based learning is well-received and advances stated learning objectives. Conclusions: Additional research is needed to identify those aspects of online learning most strongly associated with learner satisfaction and attainment of pain-associated educational objectives in neurology with a goal of reducing opioid exposure and dependence. Study Supported by: Funding Body : National Institute on Drug Abuse Grant Title : NIH Pain Consortium Center of Excellence in Pain Education Project Number/Project Number Application ID : 271201500066C-0-0-1 Disclosure: Dr. Nugent has nothing to disclose. Dr. Buenaver has nothing to disclose. Dr. Gonzalez-Fernandez has nothing to disclose. Dr. Kozachik has nothing to disclose. Dr. Nesbit has nothing to disclose. Dr. Hogans has received personal compensation in an editorial capacity for Pain Medicine.

End-of-life decision making in cancer can be a complicated process. Patients and families encounter multiple providers throughout their cancer care. When the efforts of these providers are not well coordinated in teams, opportunities for high-quality, longitudinal goals of care discussions can be missed. This article reviews the case of a 55-year-old man with lung cancer, illustrating the barriers and missed opportunities for end-of-life decision making in his care through the lens of team leadership, a key principle in the science of teams. The challenges demonstrated in this case reflect the importance of the four functions of team leadership: information search and structuring, information use in problem solving, managing personnel resources, and managing material resources. Engaging in shared leadership of these four functions can help care providers improve their interactions with patients and families concerning end-of-life care decision making. This shared leadership can also produce a cohesive care plan that benefits from the expertise of the range of available providers while reflecting patient needs and preferences. Clinicians and researchers should consider the roles of team leadership functions and shared leadership in improving patient care when developing and studying models of cancer care delivery.