Opioid Use Assessments and Palliative Care

Throughout the past 10 years, Canada had been facing an on-going public health epidemic characterized by the problematic use of opioids. During this period, Ontario has seen a drastic increase in opioid related deaths and overdoses1. Opioids are a category of medications with varying strengths that relieve pain by interacting with the body’s nervous system. Within this category are prescription opioids that are tightly controlled and designed for therapeutic use in a clinical setting and illegal opioids or street drugs that are illegally produced and distributed in an unregulated manner.

Although there are numerous adverse effects to opioid use, these medications are often necessary in palliative and end-of-life care to provide pain management and other benefits for patients. Previous studies have estimated that one in five palliative patients is at risk for opioid misuse2. A US-based study noted that nearly 25% of the hospices surveyed had discharged a patient in the past year due to concerns about misuse of medications3. Given the addictive nature of opioids, Canadian healthcare providers are required to use numerous tools to identify and monitor patients who require opioid treatment to identify problematic opioid use.

Current opioid assessment tools identified in the literature include questionaries such as CAGE/ CAGE-AID, SOAPP/SOAPP-R/SOAPP-SF, and OTR. These questionnaires generally consist of three to five questions intended to indicate to clinicians whether patients are at-risk for problematic opioid use. The exception is the SOAPP-R, which is an expansion of SOAPP that includes a total of 24 questions. Generally, all three assessment tools are easily integrated into practice due to their succinct format and ease of use5. However, because these assessments are condensed, they generally only provide surface-level assessments.

A recent review found that all three questionnaires and their variants had limited evidence to support their effectiveness in a palliative care setting5. In fact, these questionnaires that are often used to assess problematic opioid use in palliative care were not created with the unique needs of palliative patients in mind nor have they been assessed from a palliative care perspective2,5.

Another frequently used opioid use assessment tool is a urine drug test. There are two categories of urine drug tests are screening via immunoassay and confirmatory gas chromatography or mass spectroscopy tests6. Urine drug tests can be used independently or in conjunction with opioid-use questionnaires. There is a large amount of variability associated with urine testing as the sensitivity can vary depending on the method used as well as the interpretation of the results.

The same review noted that the use of urine drug tests ranged from routine use to targeted testing for certain patients based on certain signs and factors observed by providers5. The authors suggest that routine urine drug tests be used on all patients because of observations that targeted testing often disproportionately affects marginalized populations. Further, as with the questionnaires, there is limited knowledge about the practicality of urine detection tests for monitoring opioid use in palliative care2,5.

Opioid treatment in palliative care is often necessary as the medications provide necessary treatment to patients. As such, recent research suggests that assessment of current strategies may be needed to better address the needs of patients receiving opioid therapy5.

Citations

  1. Ontario Drug Policy Research Network; Office of the Chief Coroner for Ontario/Ontario Forensic Pathology Service; Ontario Agency for Health Protection and Promotion (Public Health Ontario); Centre on Drug Policy Evaluation. Preliminary Patterns in Circumstances Surrounding Opioid-Related Deaths in Ontario during the COVID-19 Pandemic. Toronto, ON: Ontario Drug Policy Research Network; 2020.https://www.publichealthontario.ca/-/media/documents/o/2020/opioid-mortality-covid-surveillance-report.pdf?la=en

  2. Carmichael, A. N., Morgan, L., & Del Fabbro, E. (2016). Identifying and assessing the risk of opioid abuse in patients with cancer: an integrative review. Substance abuse and rehabilitation, 7, 71–79. https://doi.org/10.2147/SAR.S85409

  3. Cagle, J. G., McPherson, M. L., Frey, J. J., Sacco, P., Ware, O. D., Hoffmann, D., & Guralnik, J. M. (2021). A National Survey of Challenges Faced by Hospices During the Opioid Crisis: Estimates of Pain Medication Shortages, Missing Medications, and Opioids Left in the Home Post-Death. Journal of Pain and Symptom Management.

  4. Vranken, M. J., Linge-Dahl, L., Mantel-Teeuwisse, A. K., Radbruch, L., Schutjens, M. H. D., Scholten, W., … & Jünger, S. (2020). The perception of barriers concerning opioid medicines: A survey examining differences between policy makers, healthcare professionals and other stakeholders. Palliative medicine, 34(4), 493-503.

  5. 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.

  6. Reisfield, G. M., Salazar, E., & Bertholf, R. L. (2007). Rational use and interpretation of urine drug testing in chronic opioid therapy. Annals of Clinical & Laboratory Science, 37(4), 301-314.