title: Patterns of analgesic adherence predict health care utilization among outpatients with cancer pain.
abstract: BACKGROUND
  Studies in chronic noncancer pain settings have found that opioid use increases health care utilization. Despite the key role of analgesics, specifically opioids, in the setting of cancer pain, there is no literature to our knowledge about the relationship between adherence to prescribed around-the-clock (ATC) analgesics and acute health care utilization (hospitalization) among patients with cancer pain.
  
  
  OBJECTIVE
  To identify adherence patterns over time for cancer patients taking ATC analgesics for pain, cluster these patterns into adherence types, combine the types into an adherence risk factor for hospitalization, identify other risk factors for hospitalization, and identify risk factors for inconsistent analgesic adherence.
  
  
  METHODS
  Data from a 3-month prospective observational study of patients diagnosed with solid tumors or multiple myeloma, having cancer-related pain, and having at least one prescription of oral ATC analgesics were collected. Adherence data were collected electronically using the medication event-monitoring system. Analyses were conducted using adaptive modeling methods based on heuristic search through alternative models controlled by likelihood cross-validation scores.
  
  
  RESULTS
  Six adherence types were identified and combined into the risk factor for hospitalization of inconsistent versus consistent adherence over time. Twenty other individually significant risk factors for hospitalization were identified, but inconsistent analgesic adherence was the strongest of these predictors (ie, generating the largest likelihood cross-validation score). These risk factors were adaptively combined into a model for hospitalization based on six pairwise interaction risk factors with exceptional discrimination (ie, area under the receiver-operating-characteristic curve of 0.91). Patients had from zero to five of these risk factors, with an odds ratio of 5.44 (95% confidence interval 3.09-9.58) for hospitalization, with a unit increase in the number of such risk factors.
  
  
  CONCLUSIONS
  Inconsistent adherence to prescribed ATC analgesics, specifically the interaction of strong opioids and inconsistent adherence, is a strong risk factor for hospitalization among cancer outpatients with pain.
authors: Department of Biobehavioral Health Sciences, NewCourtland Center of Transitions and Health, School of Nursing, University of Pennsylvania, Philadelphia, PA, USA.
authors: Salimah H
authors: SH
authors: Meghani
authors: School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
authors: George J
authors: GJ
authors: Knafl
keywords: MEMS; analgesics; cancer pain; hospitalization; medication adherence; opioids