Managing Opioids, Including Misuse and Addiction, in Patients With Serious Illness in Ambulatory Palliative Care: A Qualitative Study

Abstract

Background: Pain and opioid management are core ambulatory palliative care skills. Existing literature on how to manage opioid misuse/use disorder excludes patients found in palliative care settings, such as individuals with serious illness or those at the end of life. Objectives: We conducted an exploratory study to: (1) Identify the challenges palliative care clinicians face when prescribing opioids in ambulatory settings and (2) explore factors that affect opioid decision-making. Methods: We recruited palliative care clinicians who prescribe opioids in ambulatory settings, which included open-ended questions and was conducted online. Results were analyzed qualitatively using a content analysis-based approach. Results: Eighty-three palliative care clinicians (mostly MDs/DOs) participated. Challenges faced when prescribing opioids included clinician differences in approach to care (eg, transitioning from another clinician with more permissive opioid prescribing), medication access (eg, inadequate pharmacy supply), resource constraints (eg, access to mental health and addiction expertise), managing problems outside the typical palliative care scope (eg addiction). Participants also discussed factors that influenced their opioid prescribing decisions, such as opioid-related harms and risks that they need to weigh; they also spoke about the necessity of considering other factors like the patient’s environment, disease, treatment, and prognosis. Conclusion: This study highlights the challenge of opioid management in patients with serious illness, particularly when misuse or substance use disorder is present, and suggests areas for future research focus. Our next step will be to establish consensus on approaches to opioid prescribing decision-making and policy in seriously ill patients presenting to ambulatory palliative care.

Risk of opioid misuse in people with cancer and pain and related clinical considerations: a qualitative study of the perspectives of Australian general practitioners

“…Participants’ emphasis on the goal of comfort care as a justification for liberally prescribing opioids towards the end of life should also be interpreted within the context of research suggesting that doctors sometimes overestimate patients’ desire to be pain free at the expense of mental clarity 70. GPs in our study also seemed to have lower levels of concern regarding addiction and misuse in the palliative context than has been reported for palliative care physicians 71…”

Palliative care for patients with substance use disorder and multiple problems: a qualitative study on experiences of healthcare professionals, volunteers and experts-by-experience

“…HCP/VE stated that they need more specific education and a mobile team for both consultation and care provision tailored to the patient's needs. Recent research shows similar results [49][50][51][52]. The resources to provide optimal palliative care for patients with SUD+ appear insufficient.…”

Consensus-based approach to managing opioids, including opioid misuse and opioid use disorder, in patients with serious illness: protocol for a modified Delphi process

“…Our team previously conducted two studies that provided insight into how to design cases and responses (clinical management strategies). 16 17 In a recent qualitative study, we asked palliative care clinicians to describe challenges they face when caring for patients with serious illness prescribed opioid therapy. Clinical management challenges identified included managing opioids in patients with a history of substance use disorders and addressing opioid-related harms, including misuse behaviours such as concurrent use of cocaine or medications that were not prescribed such as benzodiazepines.…”

“…Clinical management challenges identified included managing opioids in patients with a history of substance use disorders and addressing opioid-related harms, including misuse behaviours such as concurrent use of cocaine or medications that were not prescribed such as benzodiazepines. 16 In addition to substance use, other prior work has identified several common and challenging misuse behaviours that may arise in patients prescribed opioid therapy such as taking more opioids than prescribed or aggressive behaviour. 17 Importantly, our qualitative study consistently identified prognosis for life expectancy (referred to in this article as prognosis) as an important factor that influences opioid decision-making in individuals with serious illness.…”