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: 70 year old patient with hormone sensitive metastatic prostate cancer to bone currently managed with androgen deprivation therapy. Stable disease and tolerating treatment well. Referred to palliative care services for pain management. History of depression and hypertension. Pain predominantly affecting the right hip consistent with known metastatic bone disease located in right iliac crest. Prescribed regular opioid and neuropathic agents for the management of same. Drinks four pints of beer per day and shares that he has used cocaine occasionally in the past but denies any recent use. Currently living with son, from whom he was previously estranged, and awaiting allocation of suitable social housing accommodation. 

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: 38 year old patient with metastatic lung cancer to liver, bone  and brain (EGFR negative, PDL <1%). No additional medical history of note. Referred to the Community Palliative Care Team for symptom management. Lives with his partner and 1 adult son. Financially stable with illness benefits being paid by his employer. History of alcohol use disorder. Smokes cannabis weekly and uses cocaine occasionally. Recent imaging confirms significant progression of disease with systemic treatment discontinued by oncology. Prognosis estimated as 3-6 months. 

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: 77 year old patient admitted to the in-patient hospice unit for end of life care with a background of acute leukemia following transformation from long standing chronic myeloid leukaemia. Has been transfusion dependent with most recent red cell transfusion 10 days prior. Decision made by primary team in line with patient wishes not to pursue further blood product transfusion. Background history of anxiety, osteoporosis, hypertension and congestive cardiac failure. Lives with husband and has two adult children now living locally with their own families. Enjoys a gin and tonic now in the evenings having been abstinent from alcohol for the past ten years. Describes previous alcohol use disorder but shares that in the context of her likely short prognosis she is not concerned about “addiction” being an issue now. No reported 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?

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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:  23 year old patient with metastatic anaplastic thyroid cancer referred to community palliative care services. Noted to have recent progression of disease with metastases to lungs, liver and right adrenal gland. Systemic anticancer treatment recently discontinued. Prognosis estimated as < 3 months. Known background of anxiety and anorexia. Issues including breathlessness, exacerbation of anxiety and fatigue. Living with parents. Had been training as a hairdresser but ceased apprenticeship three months previously due to deteriorating condition. Drinks alcohol occasionally and does share that she has previously used amphetamines and cocaine, particularly during the most challenging period of her illness related to anorexia nervosa. She denies any recent substance 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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* 12. Case 6: 45 year old with a background of metastatic colorectal cancer to retroperitoneal lymph nodes referred to out-patient palliative care services. Noted on referral that this patient is currently living in a homeless shelter awaiting allocation of social housing with previous history of significant drug use (crack cocaine and methamphetamine). No history consistent with alcohol use disorder described. Noted background of anxiety and depression with recurrent episodes of deliberate self harm. He attends for review to the clinic alone and describes symptoms including intermittent nausea and lower back pain. He continues on chemotherapy and has been engaged with treatment and follow-up.  Stable disease noted on most recent restaging imaging. Recent blood workup unremarkable. He demonstrates reasonable insight into disease and goals of treatment and is agreeable to ongoing palliative care input. 

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:  60 year old patient with metastatic pancreatic cancer to liver and lung. Admitted to the Hospice for ongoing care with prognosis estimated as weeks. Issues including nausea, vomiting and complex abdominal pain. Background medical history of hypertension and dyslipidaemia. Married with 2 adult children. Retired solicitor who previously enjoyed golf and sailing. Consumes alcohol socially on occasion. No history of illegal drug use. Main hope is for good care and comfort, aware of guarded prognosis. Financial and legal affairs have all been arranged through his previous law practice. 

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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