Study Description

Study Title: A transatlantic study to explore the attitudes of palliative care physicians regarding the identification of problematic opioid use among patients with advanced cancer.

Study Team: Dr Fiona Kiely, Dr Jenny Lau, Dr Aoife Lowney, Dr Breffni Hannon, Dr Mary Miller, Dr Joseph Arthur and Dr Jessica Lee.

You are being invited to participate in a research study as a consultant palliative care physician who cares for patients with advanced cancer. The purpose of this study is to gain an understanding of how palliative care physicians evaluate patients who may be at risk of having or developing problematic opioid use.

Physicians working in Ireland, the United Kingdom, Canada and the United States of America will be invited to participate.
 
If you agree to participate you will be asked to proceed with this short online survey. This survey should take approximately 10 minutes to complete. Your participation in this study is completely voluntary. You may choose not to participate or to withdraw participation at any time. 

Please see the Participant Information Leaflet attached in the invitation email for additional information. If you have any questions or concerns regarding the study, please write to Dr. Jessica Lee at jessicanicanlaoi@gmail.com.

We thank you for your time and participation.

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* 1. I have read the participant information, as above, and consent to proceed with this survey.

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* 2. I am a consultant or staff physician in palliative medicine who prescribes and/or gives advice on the prescribing of opioids for patients with advanced cancer

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* 3. In what country do you currently practice?

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* 4. Gender

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* 5. Years working in palliative care

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* 6. Primary clinical setting of work

Please imagine that you are reviewing these patients in your usual day-to-day clinical work setting and ensure that you answer all vignettes based on your current practice.

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* 7. Case 1: 23 year old patient with a background of Stage 3 cervical cancer currently receiving chemoradiotherapy. Her past medical history is not significant for any other conditions. Referred to palliative care services by oncology for support in symptom management. Currently tolerating treatment well with good response demonstrated on most recent imaging.   Shares that she was previously working as an apprentice hairdresser but has been unable to work throughout her treatment and is currently receiving unemployment benefit. Admits to binge-drinking with her friends most weekends and occasional social cocaine use.

Based on the information provided, in your current practice, how likely would you be to consider this patient having, or being at high risk for developing, problematic opioid use?

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* 8. Case 2:  48 year old patient referred to community palliative care services for support in symptom management by their family doctor. Noted to have been referred twice previously and did not engage with the service at those times. History of intermediate stage hepatocellular carcinoma on background of alcohol related liver disease. Has received chemoembolisation treatment with good response and has stable liver function tests on most recent blood work-up. He continues to drink alcohol and smokes cannabis regularly. Previous history of illegal drug uses noted. Service has struggled to make contact and it transpires that he is not living at his recorded address following the breakup of his relationship. Issues on review include constipation, nausea and intermittent right upper quadrant pain.

Based on the information provided, in your current practice, how likely would you be to consider this patient having, or being at high risk for developing, problematic opioid use?

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* 9. Case 3: 69 year old patient with background of metastatic squamous cell carcinoma of the pharynx admitted to inpatient hospice unit for care with a prognosis of likely short days. Noted rapid decline at home over previous weeks with increasing somnolence, reduced appetite and difficulty managing oral intake including medications. Had been cared for by niece, estranged from ex-wife and son. Significant history of alcohol use until recent days. No known history of illegal drug use. Past medical history including osteoarthritis and hypertension. Agitated on admission with evidence of aspiration pneumonia and possible alcohol withdrawal.

Based on the information provided, in your current practice, how likely would you be to consider this patient having, or being at high risk for developing, problematic opioid use?

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* 10. Case 4:  60 year old patient with background of metastatic colorectal cancer with liver metastases is referred to the out-patient palliative care service for symptom management and supportive care. Continues on chemotherapy which he is tolerating well. Single man who lives in own home. Currently working in the local post office. Independent and active, and continues to golf twice a week. Enjoys 3 bottles of beer in the evening time. Reports to drinking more at the weekends with friends and is aware that he is drinking above the recommended weekly intake. No history of illegal drug use. He has a history of depression for which he attends his general practitioner/family doctor. He reports mood has been generally good and that he has an excellent network of friends who are very supportive. Symptom burden low presently but appreciative of ongoing palliative care involvement. 

Based on the information provided, in your current practice, how likely would you be to consider this patient having, or being at high risk for developing, problematic opioid use?

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* 11. Case 5:  68 year old patient with background of metastatic renal cell cancer to lymph nodes maintained on immunotherapy with stable disease on most recent imaging. Referred to Palliative Medicine outpatient clinic for symptom assessment and supportive management with estimated prognosis of months - years. Lives with wife in their own home. 3 supportive adult children with 4 grandchildren. Enjoys fishing and hiking. Retired session musician. Describes issues with lower back pain with recent imaging confirming retroperitoneal nodal mass. When discussing a proposed management plan of commencing low dose regular opioid the patient shares that he is concerned regarding opioid addiction. Following exploration he shares that he previously had a cocaine problem in his 40s and is worried that he has “an addictive personality”. Does not drink alcohol and is a non-smoker.

Based on the information provided, in your current practice, how likely would you be to consider this patient having, or being at high risk for developing, problematic opioid use?

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* 12. Case 6: 48 year old patient with metastatic breast cancer maintained on hormonal treatment with stable disease on most recent imaging. She is referred to out-patient palliative care services and reviewed in clinic. She has a background of generalised anxiety disorder and agoraphobia and attends mental health services for management of this. During conversation she shares that she has previously used illegal drugs as a coping mechanism to manage social anxiety in day to day life. She has not taken cocaine in over a year now and attends Narcotics Anonymous. No history of alcohol use disorder. She describes a supportive family and continues to work in part-time in administration from home. She is experiencing some pain in her left hip and describes fatigue. She is very open to ongoing follow-up. 

Based on the information provided, in your current practice, how likely would you be to consider this patient having, or being at high risk for developing, problematic opioid use?

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* 13. Case 7: 22 year old patient with Metastatic Ewings Sarcoma admitted to the inpatient hospice unit from home. He has been known to oncology services since diagnosis aged 16 and has recently had significant progression of metastatic disease to lung and liver with a prognosis estimated as less than 3 months. He is symptomatic on review with breathlessness, pain and profound fatigue. He lives with his parents and sister and until recently attended an online software development course. He has a background of anxiety which was diagnosed 3 years previously and is under the care of community mental health services. He does not drink alcohol or smoke and has no history of illegal drug use. On admission investigations reveal hypercalcaemia and anaemia and appropriate treatment is initiated. Family meeting is arranged to discuss guarded prognosis. 

Based on the information provided, in your current practice, how likely would you be to consider this patient having, or being at high risk for developing, problematic opioid use?

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* 14. Case 8: 60 year old patient reviewed in out-patient palliative care clinic. Background of metastatic prostate cancer to bone maintained on androgen deprivation therapy. Recent imaging showing stable disease and bloods showing haemoglobin, platelets and renal function within normal ranges. Single gentleman with no children. Does not smoke or drink alcohol. No history of illegal drug use. Previously worked as a self-employed carpenter. Shared financial concerns as no entitlement to sick pay and has had recent issues with making mortgage repayments. Pain currently controlled on a regimen of opioids and neuropathic agents.

Based on the information provided, in your current practice, how likely would you be to consider this patient having, or being at high risk for developing, problematic opioid use?

You have reached the end of this survey. Many thanks for your participation.

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