Assessment tools for problematic opioid use in palliative care

Study Authors: Jenny Lau1,2,3 , Paolo Mazzotta2,4, Rouhi Fazelzad5, Suzanne Ryan3,6, Alissa Tedesco4, Andrew J. Smith7,  Abhimanyu Sud2,8, Andrea D. Furlan9,10,11, Camilla Zimmermann3,6,12

 

Affiliations: 

1 Division of Palliative Care, University of Toronto, Toronto, ON, Canada; 2 Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada; 3 Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada; 4 Temmy Latner Centre for Palliative Care, Sinai Health System, Toronto, ON, Canada; 5 UHN Library and Information Services, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada; 6 Division of Palliative Medicine, University of Toronto, Toronto, ON, Canada; 7 Addictions Division, Centre for Addiction and Mental Health, Toronto, ON, Canada; 8 Medical Psychiatry Alliance, Toronto, ON, Canada

9 Division of Physical Medicine and Rehabilitation, Department of Medicine, University of Toronto, Toronto, ON, Canada; 10 Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada; 11 Institute for Work and Health, Toronto, ON, Canada; 12 Division of Medical Oncology, University of Toronto, Toronto, ON, Canada

 

Source: Lau, J., Mazzotta, P., Fazelzad, R., Ryan, S., Tedesco, A., Smith, A. J., ... & Zimmermann, C. (2021). Assessment tools for problematic opioid use in palliative care: A scoping review. Palliative Medicine, 02692163211015567.

 

What we did: Our research team conducted a scoping review to identify tools that can be used to assess for the presence or risk of problematic opioid use in palliative care.

 

Why we did this: Prescription opioids are essential medicines in palliative care to relieve suffering from pain, dyspnea and cough. However, opioids are also associated with significant harms. In 2017, Canada and the US declared that both countries are experiencing public health crises related opioid poisoning and death. The COVID-19 pandemic is worsening this crisis: opioid-related hospitalizations and deaths have increased by 27% and 65%, respectively.¹ Between January 2016 and March 2021, over 26,000 Canadians were hospitalized and over 22,000 Canadians died due to opioids.¹ Though fentanyl and fentanyl analogues are the main drivers of the current opioid crisis, 10% of deaths are related to prescription opioids.¹ In response to these concerns about opioid-related harms, palliative care experts and organizations are recommending the use of tools to screen for problematic opioid use. ^2,3

 

How we did this: We conducted a comprehensive scoping review of bibliographic databases (inception to January 31, 2020), reference lists and grey literature to identify primary studies that reported on tools used to assess for problematic opioid use among adults receiving  prescription opioids to manage symptoms from advanced cancer, neurodegenerative diseases or end-stage organ disease. Our search strategy had no restrictions based on study design, location or language.

 

What we found: We identified 42 observational studies (total 14,431 participants) published between 2009 and 2020 that used questionnaires (n = 32) and urine drug tests (n = 21) to assess for problematic opioid use in palliative care. These studies were conducted primarily in the US (n = 38) and outpatient palliative care settings (n = 36). The questionnaires were Cut down, Annoyed, Guilty, and Eye-opener (CAGE, n = 8), CAGE-Adapted to Include Drugs (CAGE-AID, n = 6), Opioid Risk Tool (n = 9), Screener and Opioid Assessment for Patients with Pain (SOAPP; n = 3), SOAPP-Revised (n = 2), and SOAPP-Short Form (n = 5). Only two studies’ primary objectives were to evaluate a questionnaire’s psychometric properties in patients receiving palliative care. With regards to urine drug tests, there was wide variation in how they were incorporated into palliative care. The reported frequency of abnormal urine drug test results ranged from 8.6% to 70%.

 

Why might this study matter: Our review identified studies that examined use of tools developed for chronic pain and addiction populations, and none adequately evaluated the effectiveness of these tools to assess for problematic opioid use in palliative care. Despite the paucity of evidence, palliative care experts and organizations are recommending the use of these tools.^2,3 Our findings suggest that these recommendations are premature as the purpose, administration and impact of these tools on clinical care and outcomes are unclear.

 

What are our next steps: The duration of palliative care involvement can now range from hours to years, given the increasing and earlier integration of palliative care in life-limiting non-malignant and malignant conditions. Patients receiving palliative care may be at risk of opioid-related harms. Identification and management strategies may differ from those of chronic pain populations, and may vary according to country, palliative care setting and stage of illness. The development and validation of tools to assess for problematic opioid use in palliative care are important next steps to measure the extent of opioid-related harms and to inform prevention and management strategies.

 

Exchange author information: Dr. Jenny Lau. Medical Director, Harold and Shirley Lederman Palliative Care Centre, Princess Margaret Cancer Centre, University Health Network. 12-270, 620 University Ave, Toronto, ON, M5G 2C1. Jenny.Lau@uhn.ca

 

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