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52 A New York State program that mandates prescribers consult the PDMP registry before prescribing a controlled substance found a significant reduction (Plearn more of the mandatory PDMP.53 Several other states recommend or encourage prescribers or dispensers to access their PDMP database. A recent survey found pharmacists frequently use the PDMP to screen for opioid misuse and doctor-shopping, but overall safe use of opioids did not improve, and PDMP users were less likely to discuss their concerns directly with the patient.54 Universal precautions UPs in pain medicine were developed in 2005, and are a ten-step approach to the assessment and KU-55933 nmr management of chronic noncancer pain, including but not limited to opioid therapy.55 Adaptations of UPs have been advocated by several narrative reviews for the treatment of cancer-related pain.56�C57 Other than narrative reviews, there is no evidence in the literature that UPs improve outcomes in patients with cancer. Discussion In the past, oncologists and palliative care clinicians may have been reluctant to implement opioid-abuse screening, because they underappreciated the risks of addiction, diversion, and opioid-induced neurotoxicity. However, if clinicians are to alleviate the suffering of patients with cancer, manage pain, and improve quality of life, a comprehensive risk assessment for opioid abuse is essential. Opioid-use disorder in cancer is especially difficult to identify, in part because the problem may be framed in terms of ��overtreatment�� rather than abuse.58 Paradoxically, despite concerns about abuse and overtreatment, many cancer patients are still not receiving opioids for severe pain, particularly in developing countries, but also in the US among minorities.59 In the absence of any standardized screening, the opioid-abuse risk is likely to be underappreciated. In 1990, only 3% of inpatient and outpatient CYTH4 consultations by the psychiatry service at Memorial Sloan Kettering Cancer Center were related to drug abuse.60 Our review suggests the prevalence of opioid use-disorder risk is substantially higher among patients with cancer. Screening questionnaires and UDSs from five different National Cancer Institute Centers indicate at least one in five patients may be at risk of opioid-use disorder. Patients with specific tumor types related to tobacco and alcohol abuse, such as lung, esophageal, and head and neck cancers are at even greater risk, although the overall prevalence is still unclear.61 Several studies using screening questionnaires demonstrated associations between high-risk patients and important clinical outcomes, such as aberrant behavior, prolonged opioid use, higher morphine-equivalent daily dose, greater health care utilization, and symptom burden.