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. (Required.)

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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 (Required.)

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3. In what country do you currently practice? (Required.)

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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: 24 year old patient with diagnosis of Ewings Sarcoma and estimated prognosis of 6-12 months. Background of depression and anxiety. Reports excessive alcohol consumption and shares that he has used cocaine socially in the past. Living with parents and his teenage sister. Working part-time as a cashier in a local supermarket. 

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: 53 year old patient with metastatic pancreatic cancer is admitted to hospice for end of life care with a prognosis of days to short weeks. Background of generalised anxiety disorder. She has become increasingly agitated following admission with hallucinations and altered mental status. Reversible factors addressed including opioid rotation. Following further assessment, she reveals that she has been drinking approximately half a bottle of vodka per night at home over recent months. Also reveals she smokes cannabis regularly and has previously used cocaine. Lives with her husband who works night shifts. Describes a very supportive family. Shares that she has concealed her drinking from family members including her husband and asks that this information remains confidential. 

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: 71 year old patient with a background of metastatic prostate cancer with undetectable PSA and testosterone. He was referred to palliative care services for pain management. History notable for ischaemic heart disease, diabetes and depression. Recently separated from partner and has moved out of the family home. Temporarily staying with a friend. Consumes four cans of beer most evenings to aid with sleep. Does not have any history of illegal drug use. Prognosis estimated to be years. Predominant issue on assessment is lower back pain. Imaging has been arranged by oncology to further investigate same. 

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: 51 year old patient with advanced metastatic ovarian cancer admitted to the hospice for symptom management of bowel obstruction and end of life care. Issues including abdominal pain, nausea and vomiting. Maintained on subcutaneous infusion of morphine, haloperidol and hyoscine butylbromide. Single lady with no children. Previously worked in the service industry but was made redundant during the covid-19 pandemic and has been unable to return to work since due to illness. Unfortunately she has no sick pay entitlements. Known and supported by homelessness services in this time period.  Drinks alcohol to help get to sleep at night. Has been less able to tolerate recently secondary to nausea and is receiving chlordiazepoxide to manage potential withdrawal features. No history of illegal drug use. No other significant medical history of note. 

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:  66 year old patient with background of hormone sensitive metastatic prostate cancer with bone metastases admitted to inpatient hospice unit for symptom assessment on a background of complex social situation. Continues on androgen deprivation therapy with stable PSA. Living with his wife who has dementia with recent cognitive decline and significant behavioural disturbance. Their daughter had temporarily moved in to provide care and support prior to admission. Patient reports increasing fatigue and pain affecting the right hip. Drinks alcohol occasionally at family celebrations or holidays and reports history of drug use (including cannabis and cocaine) in his 30’s and 40’s. 

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: 59 year old patient with a background of metastatic prostate cancer is referred to palliative care services for symptom support.  He lives with his wife and 4 children and works as chief financial officer in a large multinational company. He has recently modified his job role at work and is currently planning early retirement. He has no financial concerns. On review in clinic he reports occasional right hip pain with correlation of bone disease in this region on recent imaging. When discussing any previous alcohol or drug use on his assessment he shares that he took cocaine regularly for approximately 15 years. He has no history of alcohol use disorder and last used cocaine prior to his diagnosis 12 months ago. He has requested that this information remain confidential as his wife and family are unaware. He describes low appetite, early satiety and abdominal discomfort. 

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: 62 year old patient with widely metastatic rectal carcinoma with fistulating disease from the primary lesion to the genitourinary tract. Background of recurrent urinary tract infections requiring hospitalisation with recent decision to forgo further hospital admission and manage symptomatically at home. Reviewed by the community palliative care team. Lives alone in council accommodation. Divorced and describes a complex relationship with his only daughter who he has recently reached out to following a period of prolonged estrangement. Occasionally drinks alcohol. No history of illegal drug use. No history of mental health illness. Appears unwell on assessment with tenesmus, intermittent fevers and rapid weight loss. Possibility of hospice inpatient admission outlined in the context of deteriorating condition, rapidly rising care needs and limited home supports. 

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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