Marital Status and Pain Severity Predict Nonmedical Opioid Use in Patients With Cancer

cancer patient, medication
Senior female patient discusses concerns about her medication with an unrecognizable home healthcare nurse.
The researchers’ objective was to determine the overall frequency of and the independent predictors for nonmedical opioid use behavior.

Patients with cancer who receive opioids to manage pain may be more likely to participate in nonmedical opioid use (NMOU) behavior if they are single or divorced, score higher on the Screener and Opioid Assessment for Patients with Pain (SOAPP) tool, or report higher pain severity levels, a study in JAMA Oncology suggests.

The study included a total of 1554 patients with cancer (median age, 61 years) who were referred to a cancer center for supportive care from 2016 to 2018. All patients had received opioid medications for 1 week or longer to help manage cancer pain. The investigators assessed patients using the Edmonton Symptom Assessment Scale, SOAPP, and Cut Down, Annoyed, Guilty, Eye Opener-Adapted to Include Drugs (CAGE-AID) survey.

Approximately 19.2% (n=299) of patients demonstrated 1 or more NMOU behaviors (median per patient, 1). The majority of the NMOU behaviors (77%) were reported by the first 2 follow-up visits. Unscheduled clinic visits for inappropriate refills represented the most frequent NMOU behavior (29%).

Up to 29.4% (n=88) of these patients scored at least 7 on SOAPP, indicating that these patients had an increased risk of NMOU. Additionally, 16.6% (n=48) of patients scored at least 2 out of 4 points on the CAGE-AID survey, which is considered an indicator for increased risk of potential NMOU behavior in patients with cancer.

Factors that were independently associated with the presence of NMOU behavior in the multivariate analysis included being single (hazard ratio [HR], 1.58; 95% CI, 1.15-2.18; P =.005) or divorced (HR, 1.43; 95% CI, 1.01-2.03; P =.04), having a positive vs negative SOAPP score (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 <.001), and Edmonton Symptom Assessment Scale pain level (HR, 1.11; 95% CI, 1.06-1.16; P <.001).

Single marital status, MEDD greater than 50 mg, and SOAPP scores above 7 were factors that were also associated with a 56% higher risk of NMOU behavior in recursive partition analysis.

Limitations of the study include its retrospective nature and the inclusion of predictive variables that were present in only the electronic health record.

The investigators concluded that these findings highlight “the need for continuous vigilance and careful use of these opioids in this population,” adding that the prognostic variables identified in the study could “assist clinicians and investigators designing clinical and research programs in this important field.”

Disclosure: Some study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.


Yennurajalingam S, Arthur J, Reddy S, et al. Frequency of and factors associated with nonmedical opioid use behavior among patients with cancer receiving opioids for cancer pain. JAMA Oncol. 2021;7(3):404-411. doi:10.1001/jamaoncol.2020.6789