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: 72 year old patient with a background of locally advanced carcinoma of pharynx receiving radical radiation therapy and adjuvant chemotherapy for management of same. Admitted to hospital with severe pain and difficulty swallowing and receiving treatment for severe mucositis. Imaging and nasendoscopy suggest excellent response to treatment. Referred by radiation oncology to palliative care for support in treatment related symptom management. Background history of Chronic Obstructive Pulmonary Disease, lifelong smoker and alcohol use disorder. Previous cocaine use. Lives with husband and their two dogs. Worked successfully as an artist. No financial concerns expressed.

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: 55 year old patient with background of metastatic non-small cell lung cancer to lung, lymph nodes and liver admitted to the hospice in-patient unit for ongoing care. Prognosis estimated as weeks to short months. When discussing trialing a low dose opioid for pain management patient shares hesitancy to do so in the context of a family and personal history of illegal drug use and concern regarding addiction. Reports previous admissions to rehabilitation facilities for treatment of alcohol and cocaine addiction. Has been abstinent for the previous 2 years. Patient shares with you that his behaviour during this period resulted in the breakdown of his relationship and loss of his job. Receives disability allowance currently and is struggling financially. Being supported by your social work colleagues in this regard. Background of anxiety and depression and is taking regular antidepressant and anxiolytics.

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:  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: 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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