Screening for Substance Abuse and Diversion in Virginia Hospices

Abstract

Background:

Although inadequate treatment of pain is a problem for hospice patients, increases in the medical use of opioids have been accompanied by increasing levels of abuse and diversion in the community. Balancing pain relief with concerns about abuse and diversion is a difficult issue for hospices.

Objectives:

The aim of this study was to determine policies and practices in Virginia hospices regarding substance abuse and diversion in patients and their families.

Methods:

A survey was conducted of Virginia hospices about policies, perceptions, and training regarding substance abuse and diversion.

Results:

Twenty-three of 63 hospice agencies responded (36.5%). Less than half (43.8%) required mandatory substance abuse training. Only 43.5% had policies regarding screening for substance abuse in patients; 30.4% had a policy regarding screening for substance abuse in family members. Policies regarding screening for diversion in patients (21.7%), and families (17.4%) were rare. Policies regarding opioid use in patients with a history of substance abuse or diversion were uncommon (33.3%, 30.4%, respectively); 30.4% had policies regarding use of opioids in patients whose family members had a history of diversion or abuse. Thirty-eight percent of hospices agreed that substance abuse and diversion was a problem for their agency, and these agencies were more likely to have written policies or mandatory training.

Conclusion:

Most Virginia hospices lack mandatory training and policies regarding substance abuse and diversion in patients and family members. More than one-third felt that abuse and diversion were problems in their agencies. A national conversation regarding policies toward substance abuse and diversion in hospice agencies is needed.

Introduction

Under-treatment of pain in patients with cancer and other life-threatening illnesses has been widely identified as a public health problem. During the late 1980s and 1990s research documenting the inadequacy of cancer pain treatment¹ and barriers to improved care led to new guidelines for cancer pain treatment and changes in the regulation of opioid medications, which are the cornerstone of management of cancer-related pain.² Partly as a result of these efforts, prescribing of opioid medications has increased significantly over the past 10 years.^3,4_ENREF_1 Increased utilization of hospice services over this time frame may also have impacted opioid prescribing.⁵ Hospice enrollment has seen steady yearly increases, with 1.58 million patients receiving hospice services, providing care for approximately 42% of all deaths in the United States.⁶ Cancer is the admission diagnosis for approximately 36% of hospice patients,⁶ many of whom require significant doses of opioid therapy to control cancer-related pain.⁷ Additionally, more than one-half of all hospice patients and palliative care patients use opioids during their care.^8,9

Unfortunately, concurrent with this increased rate of prescribing has been a tremendous rise in the rates of abuse of prescription opioids and opioid-related drug overdoses and deaths. Evidence suggests a direct correlation between these adverse effects and rates of prescribing as well as doses prescribed.^10–12 In rural Virginia, drug overdose deaths increased 300% between 1997 and 2003; most of these involved prescription opioids.¹³ Nationally, by 2007 deaths from prescription opioids had increased by almost four-fold.⁴

The literature on the prevalence of substance abuse in hospice patients is limited; however, the National Survey on Drug Use and Health estimates that 8.4% of fully employed adults and 17.5% of unemployed adults are using illicit drugs.¹⁴ Estimates on the prevalence of alcoholism among patients with advanced illnesses such as cancer range between 17% and 28%,^9,15–17and patients with a history of alcohol abuse are more likely to use other illicit substances.¹⁷ Approximately 25% of palliative care patients have a substance use disorder, and current palliative care fellows report frequently treating patients with substance abuse issues.^16,18 Additionally, although patients may not have substance abuse issues, caregivers often have issues with illicit drug use and may be at risk due to significant exposure to these medications while providing care.¹³ These data on the high prevalence of substance abuse in the general population and in those with advanced illness provide evidence that hospice providers are certain to encounter substance abuse issues among patients and family caregivers.

There is currently no literature documenting how agencies address substance abuse among hospice patients or their family caregivers. The purpose of this study was to evaluate the frequency of such policies and practices in Virginia hospices and to determine the degree to which providers felt that substance abuse and diversion are problems in their clinical practice.

Methods

We developed a survey to assess substance abuse and diversion practices in Virginia hospices. We identified hospices in Virginia through national and state databases including the National Hospice and Palliative Care Organization Membership Directory. An invitation to participate in an online survey was sent via e-mail to hospice administrators and medical directors of the 63Virginia hospices identified. E-mail addresses were identified through the databases if available and by contacting hospices by phone if necessary. We requested that the survey be completed by the individual at the hospice who was most familiar with the hospice's policies and procedures, and each agency was free to choose who that person was, either by forwarding the survey to that person or supplying us with the person's contact information. Invitations were sent out and collected from October 2009 to January 2010. Follow-up e-mails were sent to nonrespondents.

The survey was designed by an iterative process through discussions with palliative care practitioners with experience in care of patients with a substance abuse history and review of practice guidelines. (The survey is available in the Appendix.) Hospice administrators or medical directors were asked if substance abuse or drug diversion was felt to be a problem and if the hospice team received any mandatory training dealing with these issues. We evaluated whether or not each hospice had policies regarding screening for substance abuse and drug diversion in patients or caregivers, and if they had policies for the use of opioids in these populations. Additionally, we ascertained whether or not hospices screened for substance abuse or drug diversion in patients or caregivers, including the use of urine drug screens and the Virginia Prescription Monitoring Service.

To ascertain the hospice size, we asked for an estimate of the average daily census. In the situation where hospices operated from multiple locations, we asked for the total census at all locations. Responses to questions about policies were answered “yes” or “no.” Questions regarding screening could be answered “never,” “only when indicated or when the provider feels it is appropriate,” or “routinely.” Questions regarding substance abuse and drug diversion being a problem were answered using a Likert scale of 1 to 5 (“strongly disagree,” “somewhat disagree,” “neither agree nor disagree,” “somewhat agree,” or “strongly agree”).

Statistical analysis

We used χ² tests to evaluate the effect of creation of policies, mandatory staff training, and use of screening tests. We used analysis of variance (ANOVA) to determine predictors for the perception that substance abuse and drug diversion are problems with hospices. All statistical analysis was performed using SPSS version 18 (IBM Statistics, Armonk, NY).

Results

Twenty-three out of the sixty-three hospice agencies contacted (36.5%) completed the survey. Most hospices did not feel that substance abuse was a problem in their hospice (strongly disagree 18.8%, somewhat disagree 37.5%, neither agree nor disagree 6.3%, somewhat agree 31.3%, strongly agree 6.3%). Most did not feel that drug diversion was a problem (strongly disagree 25%, somewhat disagree 31.3%, neither agree nor disagree 6.3%, somewhat agree 31.3%, strongly agree 6.3%). The mean average daily census was 71 patients.

More than one-half of all hospices did not have a written policy regarding screening for active or historic substance abuse disorders among patients (56.5%) or family caregivers (69.6%). Despite this, most hospices report either routine (56.5%) or “when appropriate” (39.1%) screening of hospice patients for substance abuse disorders. Family member screening is similar, with 43.5% reporting routine and 52.2% reporting “as appropriate” evaluations. In regards to prescription drug diversion, most hospices do not have a policy for screening for drug diversion in patients (77.3%) or family caregivers (81.8%). However, most hospices do report screening patients either routinely (40.9%) or “when indicated” (54.5%) and family members routinely (36.4%) or “when indicated” (63.6%).

Most hospices do not have a policy regarding the use of opioids when there is a history of substance abuse disorders by patients (66.7%) or family caretakers (66.7%). Similarly, most do not have a policy regarding the use of opioids when there is a history of drug diversion by either the patient (66.7%) or family caretakers (66.7%). In terms of monitoring, most hospices report either never performing urine drug testing (61.9%) or only as indicated (33.3%). Most report using the Virginia Prescription Monitoring Program either never (90%) or only when it is indicated (5%). Most hospices do not report mandatory training (56.3%) for their staff regarding substance abuse disorders or prescription drug diversion.

Policy and training

To evaluate the effect of having written policies, we evaluated the association between the presence of different types of policies concurrently and screening practices. Most hospices that had a policy regarding screening for substance abuse in patients also had a policy for screening for substance abuse in caretakers (p<0.002) and for drug diversion (p=0.005). Additionally, most hospices that had policies for screening for drug diversion in family caretakers also had policies for screening for a history of substance abuse in family caretakers (p=0.040) and drug diversion in patients (p<0.001). Those hospices that had written policies about screening for substance abuse disorders in patients (p=0.017) or caretakers (p=0.001), or drug diversion in patients (p=0.009) or caretakers (p=0.003) were more likely to engage in screening practices.

Those hospices that had written policies regarding screening for drug diversion in patients (p=0.009) and family members (p=0.03), or use of opiates in situations of substance abuse disorders in patients (p=0.013) and family members (p=0.013), or use of opiates in situations where patients (p=0.013) or family members (p=0.013) have a history of drug diversion were more likely to have mandatory staff training regarding substance abuse disorders and prescription drug diversion. However, written policies for screening for substance abuse in patients or caretakers were not associated with mandatory training. Those hospices that screen for drug diversion were more likely to have mandatory staff training (p=0.049). However, mandatory training was not associated with frequency of screening for substance abuse in patients or caretakers, drug diversion in caretakers, use of urine drug screen, or use of the Virginia Prescription Monitoring Service.

Multivariate analysis

To evaluate predictors of the perception that substance abuse and drug diversion are problems, we performed two separate ANOVA analyses (see Tables 1 and 2). In both analyses, the only significant predictor of a hospice stating that substance abuse was a problem or drug diversion was a problem was the presence of a written policy regarding screening for drug diversion in patients. The R-squared value for “Substance abuse is a problem” was 0.699, and for “Prescription drug diversion is a problem” it was 0.634.

Table 1.

Multivariate Model for Prediction of the Perception That “Substance Abuse Is a Problem in Our Hospice”

Variable	Beta	95% CI
Written policy regarding screening for history of drug diversion in patients	3.060	0.341 to 5.780
Written policy regarding screening for history of drug diversion in family caretakers	−1.208	−4.205 to 1.790
Written policy regarding screening for substance abuse in family caretakers	−0.954	−2.515 to 0.606
Written policy regarding use of opioids in patients with family history of substance abuse	−0.230	−2.093 to 1.633
Mandatory staff training	−1.018	−2.872 to 0.836
Average daily census	0.010	−0.001 to 0.021

CI, confidence interval.

Table 2.

Multivariate Model for Prediction of the Perception That “Prescription Drug Diversion Is a Problem in Our Hospice”

Variable	Beta	95% CI
Written policy regarding screening for substance abuse in family caretakers	−0.932	−2.609 to 0.745
Written policy regarding screening for diversion in patients	2.144	0.125 to 4.162
Written policy regarding opioid use when family caretakers have a history of substance abuse	−0.588	−2.331 to 1.155
Mandatory staff training	−0.687	−2.634 to 1.260
Average daily census	0.010	−0.001 to 0.022

CI, confidence interval.

Discussion

In our study, more than half of hospices in Virginia did not have policies regarding any aspect of the care for patients and family members at risk for substance abuse and diversion, and most did not train their clinical staff about this topic. In most of the written comments, however, hospice providers indicated genuine concern about ensuring that patients are provided with safe and effective pain control, while limiting abuse and diversion. They expressed interest in learning about the work of their peers, evidence-based practices, and model policies. Although one significant limitation to this study is that responses were received from only 37% of the hospices within the state of Virginia, representing a lower response rate than expected, these responses came from a broad range of locations and types of hospices.

Why should hospice agencies address this issue? At present, health care professionals are not uniform in their feelings concerning substance abuse in hospice patients, often stating that drug abuse is less of a concern for patients at the end of life.^19,20 However, the well-documented evidence for increasing levels of drug abuse and diversion in this country, along with associated, alarming increases in opioid-related deaths make this a concern for all health care professionals.^10–12 Although the focus of hospice care is to reduce suffering and improve the quality of life for patients with terminal illnesses and their families, management of substance abuse should not be seen as opposed to symptom management. On the contrary, substance abuse is a significant and treatable contributor to the suffering of patients and their families, making this well within the mission of hospice care.¹⁹ Substance abuse (defined as ongoing misuse of substances despite adverse consequences²¹) makes safe and effective management of symptoms at the end of life more difficult by increasing the risk of serious drug-related adverse effects and interfering with the relationship between clinicians and patients.²² Furthermore, these behaviors damage social and family relationships, and may prevent completion of emotional work at the end of life.¹⁹

How should hospices address these issues? Current guidelines exist for prescribing opiates in patients with chronic, nonmalignant pain, but fewer guidelines exist for managing substance abuse and pain at the end of life.²³ Several tools have been developed to screen for active substance abuse²⁴ and to assess the potential for abuse.^25,26_ENREF_26 The Opioid Risk Tool (ORT) provides an easy to use assessment of the risk of future substance abuse based on factors such as the presence or absence of personal and family history of abuse.²⁷ The Revised Screener and Opioid Assessment for Patients with Pain (SOAPP-R) is another widely used screening tool that has shown to be helpful in predicting risk of opioid misuse.^28–30 Although simple to use, especially the ORT, these tools have not been validated for use with cancer patients or those enrolled in hospice care.

In addition to routine screening, guidelines for the treatment of nonmalignant pain suggest written pain contracts, urine drug screen monitoring, frequent visits, and state prescription drug monitoring programs especially for at-risk individuals.^23,31,32 The data concerning the efficacy of these measures are not robust, although a recent systematic review does note a modest reduction in opioid misuse with treatment agreements and urine drug screening,³¹ and reduction in prescription drug misuse has been seen in areas where prescription monitoring programs are in place.^33–35 Detection and management of situations in which a family caregiver is suspected of diversion or abuse is a topic on which there is virtually no literature, but in the hospice setting, where these caregivers must often administer medications to frail patients unable to care for themselves, the potential for this problem is very real.

Research into the best methods of safely and effectively treating pain and other symptoms in the at-risk hospice population, while reducing risk of diversion and adverse effects, is desperately needed. At present, expert opinion regarding the care for end-of-life patients with substance abuse recommends an approach similar to that for nonmalignant pain including a multidisciplinary approach to care, treatment of comorbid psychiatric illnesses, 12-step programs,³⁶ and written agreements for all patients.^36,37 The treatment of these patients should be nonjudgmental and focused on safety and the reduction of suffering. Therefore, whereas violation of agreements, abnormal urine drug screen, or aberrations noted in physician monitoring programs often result in termination of services for patients with nonmalignant pain, violations in those with terminal illnesses should be seen as an opportunity for risk mitigation, with more frequent visits, smaller dispensed quantities, and psychological evaluation.³⁶ Training of clinicians on this topic is recommended as well, and has been associated with increased clinical confidence and willingness to work with substance abusing patients.^{18
38}

Although only intended to ascertain current attitudes and practices in Virginia, this study has led to a statewide task force led by the Virginia Association of Hospice and Palliative Care intended to develop model policies and procedures regarding substance abuse and diversion in hospice patients.³⁹ Efforts such as these, in association with ongoing research, are essential not only to improve patient care, but also to prevent burdensome and perhaps counterproductive regulatory changes that may be externally imposed if we fail to define best practices in this area.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

Appendix. Substance Abuse Hospice Questionnaire

1. Does your hospice have a written policy regarding screening for a history of current/past substance abuse (including alcohol) in:

Patients

Yes

Family caregivers

Yes

2. Whether or not your hospice has a written policy, how often does your staff screen for substance abuse (including alcohol) in:

Patients

Routinely; all are screened

When indicated/when provider feels it is appropriate

Never

Family caregivers

Routinely; all are screened

When indicated/when provider feels it is appropriate

Never

3. Does your hospice have a written policy regarding screening for a history of prescription drug diversion in:

Patients

Yes

Family caregivers

Yes

4. Whether or not your hospice has a written policy, how often does your staff screen for a history of prescription drug diversion in:

Patients

Routinely; all are screened

When indicated/when provider feels it is appropriate

Never

Family caregivers

Routinely; all are screened

When indicated/when provider feels it is appropriate

Never

5. Does your hospice have a written policy regarding the use of opioids in:

Patients whose family caregivers have a known or suspected history of substance abuse?

Yes

Patients whose family caregivers have a known or suspected history of prescription drug diversion?

Yes

6. Whether or not your hospice has a written policy, do your patients routinely undergo urine drug tests?

Yes; all patients undergo routine urine drug tests.

Only when indicated or when the provider feels it is appropriate.

7. Whether or not your hospice has a written policy, do you ask patients to allow you to use the Virginia prescription monitoring program?

Yes; all patients are asked.

Only when indicated or when the provider feels it is appropriate.

8. Does your staff receive any mandatory training regarding issues related to substance abuse and/or prescription drug diversion?

Yes

9. Substance abuse is a problem in our hospice.

Strongly agree

Somewhat agree

Neither agree nor disagree

Somewhat disagree

Strongly disagree

10. Prescription drug diversion is a problem in our hospice.

Strongly agree

Somewhat agree

Neither agree nor disagree

Somewhat disagree

Strongly disagree

Please estimate your hospice's average daily census.

Comments:

References

Cleeland

, Gonin

, Hatfield

, Edmonson

, Blum

, Stewart

, Pandya

. Pain and its treatment in outpatients with metastatic cancer. N Engl J Med, 1994; 330:592–596.

Jacox A

, Payne

et al. Management of Cancer Pain. Clinical Practice Guideline, 9. Rockville, MD: Agency for Health Care Policy and Research, U.S. Department of Health and Human Services, 1994.

Kuehn

. Opioid prescriptions soar: Increase in legitimate use as well as abuse. JAMA, 2007; 297:249–251.

Boudreau

, Von Korff

, Rutter

, Saunders

, Ray

, Sullivan

, Campbell

, Merrill

, Silverberg

, Banta-Green

, Weisner

. Trends in long-term opioid therapy for chronic non-cancer pain. Pharmacoepidemiol Drug Saf, 2009; 18:1166–1175.

Temel

, Greer

, Muzikansky

, Gallagher

, Admane

, Jackson

, Dahlin

, Blinderman

, Jacobsen

, Pirl

, Billings

, Lynch

. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med, 2010; 363:733–742.

Organization NHaPC: NHPCO Facts and Figures. 2011. www.nhpco.org/files/public/statistics_research/2011_facts_figures.pdf. 2012 April 19.

Setoguchi

, Glynn

, Stedman

, Flavell

, Levin

, Stevenson

. Hospice, opiates, and acute care service use among the elderly before death from heart failure or cancer. Am Heart J, 2010; 160:139–144.

Portenoy

, Sibirceva

, Smout

, Horn

, Connor

, Blum

, Spence

, Fine

. Opioid use and survival at the end of life: A survey of a hospice population. J Pain Symptom Manage, 2006; 32:532–540.

Jenkins

, Schulz

, Hanson

, Bruera

. Demographic, symptom, and medication profiles of cancer patients seen by a palliative care consult team in a tertiary referral hospital. J Pain Symptom Manage, 2000; 19:174–184.

10.

Okie

. A flood of opioids, a rising tide of deaths. N Engl J Med, 2010; 363:1981–1985.

11.

Paulozzi

, Ryan

. Opioid analgesics and rates of fatal drug poisoning in the United States. Am J Prev Med, 2006; 31:506–511.

12.

Bohnert

, Valenstein

, Bair

, Ganoczy

, McCarthy

, Ilgen

, Blow

. Association between opioid prescribing patterns and opioid overdose-related deaths. JAMA, 2011; 305:1315–1321.

13.

Wunsch

, Nakamoto

, Behonick

, Massello

. Opioid deaths in rural Virginia: A description of the high prevalence of accidental fatalities involving prescribed medications. Am J Addict, 2009; 18:5–14.

14.

Substance Abuse and Mental Health Services Administration. Results from the 2010 National Survey on Drug Use and Health: Summary of National Findings. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2011

15.

Parsons

, Delgado-Guay

, El Osta

, Chacko

, Poulter

, Palmer

, Bruera

. Alcoholism screening in patients with advanced cancer: Impact on symptom burden and opioid use. J Palliat Med, 2008; 11:964–968.

16.

Bruera

, Moyano

, Seifert

, Fainsinger

, Hanson

, Suarez-Almazor

. The frequency of alcoholism among patients with pain due to terminal cancer. J Pain Symptom Manage, 1995; 10:599–603.

17.

Dev

, Parsons

, Palla

, Palmer

, Del Fabbro

, Bruera

. Undocumented alcoholism and its correlation with tobacco and illegal drug use in advanced cancer patients. Cancer, 2011; 117:4551–4556.

18.

Childers

, Arnold

. “I feel uncomfortable 'calling a patient out'”: Educational needs of palliative medicine fellows in managing opioid misuse. J Pain Symptom Manage, 2012; 43:253–260.

19.

Passik

, Theobald

. Managing addiction in advanced cancer patients: Why bother? J Pain Symptom Manage, 2000; 19:229–234.

20.

Ballantyne

. Opioid misuse in oncology pain patients. Curr Pain headache Rep, 2007; 11:276–282.

21.

American Psychiatric Association. Diagnostic and Statistical Manual for Mental Disorders, 4th. Washington, DC: APA, 1994.

22.

Gonzales

, Coyle

. Treatment of cancer pain in a former opioid abuser: Fears of the patient and staff and their influence on care. J Pain Symptom Manage, 1992; 7:246–249.

23.

Chou

. 2009 Clinical Guidelines from the American Pain Society and the American Academy of Pain Medicine on the use of chronic opioid therapy in chronic noncancer pain: What are the key messages for clinical practice? Polskie Archiwum Medycyny Wewnetrznej, 2009; 119:469–477.

24.

Fleming

, Davis

, Passik

. Reported lifetime aberrant drug-taking behaviors are predictive of current substance use and mental health problems in primary care patients. Pain Med, 2008; 9:1098–1106.

25.

Michna

, Ross

, Hynes

, Nedeljkovic

, Soumekh

, Janfaza

, Palombi

, Jamison

. Predicting aberrant drug behavior in patients treated for chronic pain: Importance of abuse history. J Pain Symptom Manage, 2004; 28:250–258.

26.

Chou

, Fanciullo

, Fine

, Miaskowski

, Passik

, Portenoy

. Opioids for chronic noncancer pain: Prediction and identification of aberrant drug-related behaviors: A review of the evidence for an American Pain Society and American Academy of Pain Medicine clinical practice guideline. J Pain, 2009; 10:131–146.

27.

Webster

, Webster

. Predicting aberrant behaviors in opioid-treated patients: Preliminary validation of the Opioid Risk Tool. Pain Med, 2005; 6:432–442.

28.

Butler

, Fernandez

, Benoit

, Budman

, Jamison

. Validation of the revised Screener and Opioid Assessment for Patients with Pain (SOAPP-R) J pain, 2008; 9:360–372.

29.

Akbik

, Butler

, Budman

, Fernandez

, Katz

, Jamison

. Validation and clinical application of the Screener and Opioid Assessment for Patients with Pain (SOAPP) J Pain Symptom Manage, 2006; 32:287–293.

30.

Butler

, Budman

, Fernandez

, Jamison

. Validation of a screener and opioid assessment measure for patients with chronic pain. Pain, 2004; 112:65–75.

31.

Starrels

, Becker

, Alford

, Kapoor

, Williams

, Turner

. Systematic review: Treatment agreements and urine drug testing to reduce opioid misuse in patients with chronic pain. Ann Intern Med, 2010; 152:712–720.

32.

Passik

, Kirsh

. Assessing aberrant drug-taking behaviors in the patient with chronic pain. Curr Pain Headache Rep, 2004; 8:289–294.

33.

Worley

. Prescription drug monitoring programs, a response to doctor shopping: Purpose, effectiveness, and directions for future research. Issues Ment Health Nurs, 2012; 33:319–328.

34.

Gugelmann

, Perrone

. Can prescription drug monitoring programs help limit opioid abuse? JAMA, 2011; 306:2258–2259.

35.

Reifler

, Droz

, Bailey

, Schnoll

, Fant

, Dart

, Bucher Bartelson

. Do prescription monitoring programs impact state trends in opioid abuse/misuse? Pain Med, 2012; 13:434–442.

36.

Kirsh

, Passik

. Palliative care of the terminally ill drug addict. Cancer Invest, 2006; 24:425–431.

37.

Chou

, Fanciullo

, Fine

, Adler

, Ballantyne

, Davies

, Donovan

, Fishbain

, Foley

, Fudin

, Gilson

, Kelter

, Mauskop

, O'Connor

, Passik

, Pasternak

, Portenoy

, Rich

, Roberts

, Todd

, Miaskowski

. American Pain Society-American Academy of Pain Medicine Opioids Guidelines Panel. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain, 2009; 10:113–130.

38.

Amodeo

. The therapeutic attitudes and behavior of social work clinicians with and without substance abuse training. Subst Use Misuse, 2000; 35:1507–1536.

39.

Virginia Association for Hospice and Palliative Care Risk Evaluation & Mitigation Tool-Kit: Strategies to Promote the Safe Use of Opioids. info@virginiahospices.org