Opioid and benzodiazepine prescribing in cancer: Current practices and future opportunities for mitigating potential risks.

299 Background: After a cancer diagnosis, the potential for overlap in opioid and benzodiazepine prescriptions is substantial. When prescribed in combination, these medications can have the unintended consequence of compromising patient safety. There is a dearth of information about cancer care providers’ current practices for co-prescribing and mitigating associated harms. Methods: We conducted interviews with oncology and palliative care providers from 2 major medical centers (March – September 2023). Interviews focused on attitudes about and current practices for co-prescribing opioids and benzodiazepines. Interviews continued until the team determined that thematic saturation had been reached. We analyzed interview transcripts using a staged approach to thematic analysis including double coding of all transcripts. Results: 20 providers (10 oncology, 10 palliative care) participated. Most providers were white (80%) and self-identified as female (55%). Most (85%) were physicians vs. advanced practice providers, and most (70%) had 10+ years in practice. We identified 3 key themes. (1) Reluctance to prescribe benzodiazepines. Providers reported rarely co-prescribing, with benzodiazepines viewed as an effective treatment for chemotherapy-related nausea, a less effective treatment for anxiety, and having a poor safety profile. Some were comfortable prescribing benzodiazepines for anxiety in select circumstances (e.g., short-term, as a bridge to more effective treatments). (2) Medication safety precautions. These included, for each medication, starting at a low dose and titrating up slowly; consolidating prescriptions under one provider; and patient education around side effects, overdose, and naloxone. However, several oncology providers expressed hesitation about providing naloxone due to stigma. (3) Risk assessment and monitoring. These strategies can be objective (e.g. urine drug screens [UDS]) or subjective (e.g. trustworthiness).Before prescribing opioids and/or benzodiazepines, most providers mentioned checking state Prescription Drug Monitoring Program (PDMP) databases and conducting a chart review. Some palliative care providers described using UDS to assess adherence and diversion. Several oncologists expressed uncertainty about how to obtain information about past or present substance misuse and tended to avoid such assessments entirely as to not make patients feel stigmatized. Providers described relying on their own perception of a patient’s trustworthiness, with some acknowledging the resulting potential for bias. Conclusions: Providers’ experiences with assessing and mitigating risks associated with opioids and benzodiazepines highlight important opportunities for training to address stigma and implicit bias, especially as they relate to providing naloxone and screening for substance misuse and use disorder.