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:  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: 71 year old patient with background of non-small cell lung cancer with contralateral lung metastases. Currently maintained on targeted therapies (tyrosine kinase inhibitor) under the care of Oncology services and has had partial response to treatment on most recent imaging. Referred to Palliative Care services for symptom management and support. No additional medical history of note. On review in out-patient clinic he shares that the past month has been particularly challenging following his separation from his partner. He has been drinking alcohol more heavily than previous as a result and this is causing relationship issues with his son who he is temporarily living with. No history of illegal drug use. He is maintained on low dose opioid and adjuvants and describes pain as controlled presently. 

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:  59 year old patient with a background of metastatic oesophageal cancer to liver and lymph nodes. Admitted under the care of acute oncology services with nausea, vomiting and general deterioration. Investigations reveal rapid disease progression with peritoneal carcinomatosis and significant ascites. No further systemic treatment options deemed appropriate by his primary team. Referred to Palliative Care Services for consideration of hospice transfer for ongoing care with estimated prognosis of short weeks. Background of alcohol use disorder, anxiety and depression. No history of illegal drug use. Psychiatry services consulted regarding alternative route for oral antidepressants and anxiolytics. On review, complex abdominal pain, nausea and anxiety are the most distressing symptoms for the patient. Lives with his wife and 2 teenage children and describes a very supportive family. Both he and family are agreeable to being listed for transfer to the inpatient palliative care unit. 

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: 54 year old patient with background of non-small cell lung cancer with small volume lung metastases admitted to hospital with a lower respiratory tract infection. Referred to Palliative Care services for support in symptom management.  Precarious social situation on review - living in a homeless shelter intermittently and spending most nights sleeping on the streets. Actively smoking heroin. No history of alcohol use disorder. Background medical history of COPD. Not taking any regular prescribed medications. Predominant issues on admission include chest wall pain, shortness of breath and cough.

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: 93 year old patient is admitted to the hospice inpatient unit. She has a background of radiologically diagnosed widely metastatic lung cancer and has been deemed an unsuitable candidate for systemic anti cancer treatment. Past medical history significant for vascular dementia and osteoarthritis. No history alcohol use disorder or of illegal drug use. Widowed lady with 5 adult children. Previously worked as a nurse. Predominant symptoms of fatigue and breathlessness on admission to the hospice. Low functional baseline requiring full nursing care with prognosis estimated as short weeks.

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: 47 year old lady with metastatic non-small cell lung cancer to bone. Admitted to Hospice in-patient unit for period of assessment and pain management with plan to discharge home post same. Continues on efgr inhibitor with stable disease on recent imaging. Previous radiotherapy to vertebral disease at T12. Significant issues with radicular back pain requiring complex medication regimen and recent insertion of an intrathecal pump. Background history of depression and anxiety and is followed by community mental health services. Married with 2 children with a supportive extended family. Drinks the occasional beer. No history of illegal drug 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?

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

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