Do Palliative Care Clinics Screen for Substance Abuse and Diversion? Results of a National Survey

Abstract

Background:

Opioids are the mainstay of treatment of cancer pain. With increased use there have been concerns about rising rates of prescription drug abuse and diversion. Although there has been an increase in research and practice guidelines about the scope of the problem for chronic, nonmalignant pain, less information is available about both the frequency of the problem and current practices regarding screening for substance abuse and diversion in patients and family members seen in palliative care clinics.

Objective:

The aim of this study was to evaluate the degree to which palliative programs felt that substance abuse and diversion was an issue, and to identify practices regarding care of patients with potential substance misuse issues.

Methods:

We sent a survey regarding substance abuse perception, policies, training, and screening to 94 accredited palliative medicine fellowship program directors as obtained by the Accreditation Council for Graduate Medical Education (ACGME) directory.

Results:

We received usable responses from 38 (40.4%) programs. Policies for screening patients (40.5%) or family members (16.2%), dealing with diversion (27%), and use of a screening tool (32.4%) were reported infrequently. Despite this, one-half of respondents indicated that substance abuse and diversion was an issue for their clinics, with only 25% indicating substance abuse was not an issue. Additionally, the majority of fellows (83%) and about half (47%) of staff received mandatory training for dealing with substance misuse. All programs provided some screening of patients, with 48.7% screening all patients for abuse. Screening of family members was relatively rare, as was routine use of the urine drug screen (UDS).

Conclusion:

Despite increased concerns about substance abuse, the majority of programs did not have substance abuse and diversion policies or report screening all patients, with screening of caregivers rarely reported. Consensus guidelines addressing substance abuse and diversion for palliative patients are needed to address this growing problem.

Introduction

Pain is one of the most common symptoms associated with the diagnosis of cancer, with more than half of all cancer patients reporting pain.¹ The use of opioids and other controlled substances is often required for symptom management.² However, there is increasing concern about the misuse of prescribed opioids due to increasing deaths from overdoses. Opioid misuse includes the deliberate use of opioid medications in ways other than prescribed because of addiction or for nonmedical purposes, use by those without a prescription, and diversion of prescribed drugs. In 2012, 4.9 million people admitted to the misuse of pain relievers, making it the second most commonly used illicit substance (after marijuana). Of those initiating illicit drug use during 2012, more than 1 in 4 respondents have admitted to use of prescription drugs for nonmedical purposes (26%), with 17% comprising inappropriate use of pain relievers, 4.1% tranquilizers, 3.6% stimulants, and 1.3% sedatives. Of nonmedical users of psychotherapeutic drugs, more than half received these drugs from a friend or relative.³

Whereas concerns about misuse of prescribed opioids have mainly been focused on patients with nonmalignant pain, similar problems have been found in cancer patients and others with life-limiting illnesses. Data about substance abuse in cancer patients and those seen in palliative care clinics have been scarce, but one study found more than 40% of patients seen were moderate to high risk for opioid abuse as measured by the Opioid Risk Tool; 62% of these at risk patients with a urine drug screen (UDS) ordered had at least one abnormal result.⁴ A recent survey of palliative care fellows demonstrated significant encounters with patients with substance abuse issues, with 77% of fellows having seen at least one such patient, and 29% more than two within the past 2 weeks. The majority of fellows did not feel comfortable dealing with issues such as lost or stolen medications or distinguishing between addiction versus undertreated pain.⁵

Guidelines for using opioids in chronic nonmalignant pain recommend assessment of the patient's relative risk for medication misuse or abuse using a validated screening tool at the initiation of opioid therapy.^6,7 Review of the prescription monitoring program (PMP) (where available) and UDS are recommended dependent on level of risk. Similar protocols specifically addressing the needs of cancer patients or others commonly seen by hospice and palliative care providers are less common. For example, a recent study of Virginia hospices showed that few had policies and procedures for dealing with substance misuse.⁸

As the number and scope of palliative care programs increase, the need to address the issue of substance abuse is increasing. The aim of this study is to determine the practices of palliative care programs with regard to treatment of patients and family members at risk for substance abuse and diversion.

Methods

We developed a survey to assess prescribing practices and screening methods for substance abuse and diversion in palliative care fellowship programs nationwide (designed and adapted with permission from a study by Blackhall et al.⁸). Institutional Review Board (IRB) approval was obtained by the IRB for Behavioral Sciences, University of Virginia.

Ninety-four adult palliative care fellowship programs were identified through the Accreditation Council for Graduate Medical Education (ACGME) website. Beginning in March 2014, invitations were sent to fellowship program directors to take part in an online survey or to forward the survey to an appropriate individual who was most familiar with the program's practice and policies. Successive follow-up e-mails were sent for nonresponders until May 2014.

The survey included questions about the program itself (numbers of fellows in training, number of patients seen in the inpatient and outpatient setting), policies and procedures regarding substance abuse and diversion, and training related to substance abuse. The full survey is available online in Appendix 1 (www.liebertpub.com/jpm) and includes questions regarding screening for substance abuse and diversion among patient and caregivers, as well as the use of UDS and PMPs if available. Questions regarding screening could be answered “routinely,” “only when provider feels appropriate,” and “never.” Questions about their impression of whether substance abuse and prescription drug diversion is a problem were answered using a Likert scale of 1 to 5 (“strongly agree,” “somewhat agree,” “neither agree nor disagree,” “somewhat disagree,” and “strongly disagree”).

Statistical analysis

We used χ² tests to evaluate the association of the perception of substance abuse or diversion being a problem and a program creating screening policies or practices. For this analysis, we dichotomized the result of the questions about substance abuse and diversion being a problem as “agree” versus all other answers. Additionally, for the question regarding a written policy for screening tools, we dichotomized this answer as use of a screening tool versus not. For questions regarding the frequency of screening, answers were dichotomized to any screening versus never. All statistical analysis were performed using SAS version 9.2 (SAS Institute, Inc., Cary, NC).

Results

An invitation to participate was sent to 94 palliative care fellowship programs according to the ACGME database directory. Forty-two responses were received from the ninety-four programs that were sent the survey. However, two programs sent two responses, and their responses were omitted, resulting in the final number of respondents of 38 (40.4%). Demographic details about the survey programs are listed in Table 1.

Table 1.

Demographics of Programs

Characteristic	Number (%)
Number of fellows
1–2	23 (60.5%)
3–4	11 (29%)
5 or more	4 (10.5%)
Average inpatient daily census
1–10	1 (4%)
11–20	2 (8%)
21–30	8 (32%)
31 or more	14 (56%)
Program characteristic
Write prescriptions	7 (19.4%)
Write only recommendations (no prescriptions)	4 (11.1%)
Both	25 (69.5%)
Presence of outpatient palliative clinic
Yes	31 (81.6%)
No	7 (18.4%)
Average outpatient clinic weekly census
No outpatient clinic	6 (19.35%)
20 or less	9 (29.03%)
21–40	9 (29.03%)
41–60	5 (16.13%)
61–80	1 (3.23%)
81–100	0
101 or more	1 (3.23%)

The most commonly reported number of fellows per program was two. The most commonly reported average daily census for palliative inpatient services was 31 or more. For outpatient clinics, providers most often saw 20 to 40 patients per week. Half of responding programs agreed that substance abuse and diversion were issues for their clinic, with less than one-third of palliative care programs indicating that substance abuse (25%) and diversion (30.5%) were not a problem for them (see Table 2).

Table 2.

Evaluation of Substance Abuse and Diversion Responses

	Agree	Neither agree nor disagree	Disagree
Substance abuse is a problem for our program	50% (strongly agree 25%, agree 25.0%)	25%	25.0% (strongly disagree 5.56%, disagree 19.44%)
Diversion is a problem for our program	50% (strongly agree 19.44%, agree 30.56%)	19.44%	30.5% (strongly disagree 8.33%, disagree 22.22%)

Written policies regarding substance abuse and diversion

Table 3 shows the data regarding written policies. Less than half of responding palliative care programs had a written policy concerning screening for past or active substance abuse (including alcohol), and only 16.2% had a policy for screening family caregivers. Written policies regarding diversion of prescription drugs were also uncommon—only 27% of programs reported a written policy regarding drug diversion in patients and 10.8% had a policy regarding diversion by family members.

Table 3.

Policy and Training Responses

	Yes	No
Have a written policy regarding screening patients for substance abuse in patients	40.5%	59.5%
Have a written policy regarding screening family members for substance abuse	16.22	83.78%
Have a written policy regarding screening patients for drug diversion	27.03%	72.97%
Have a written policy regarding screening family members for drug diversion	10.8%	89.2%
Have a written policy requiring the use of a screening tool regarding substance abuse and diversion	32.4%	67.6%
	• 18.9% – requires routine screening • 13.5% – screening per provider discretion
Have mandatory training for staff	47.2%	52.8%
Have mandatory training for fellows	83.33%	16.67%

The majority of the responding palliative care programs did not have a written policy regarding use of a screening tool for substance abuse (67.6%). Of those with a policy, 18.9% answered that a screening tool is required on all patients, and 13.5% said a screening tool is to be used when provider feels appropriate. The most commonly used screening tool was the Opioid Risk Tool, and few programs reported using the Screener and Opioid Assessment for Patients with Pain (SOAPP), Screener and Opioid Assessment for Patients with Pain Revised (SOAPP-R), and the Diagnosis, Intractability, Risk, and Efficacy (DIRE) tool. Mandatory training regarding substance abuse and diversion was required for most fellows (83.3%), and about half of other staff members (47.2%).

Practices of palliative care programs regarding substance abuse and diversion

Table 4 shows data regarding frequency of screening by responding programs. With or without written policies, slightly less than half reported screening all patients (48.7%), whereas the remainder reported screening patients “when indicated/when provider feels appropriate” (51.3%). Only 13.9% routinely screened family members, whereas 72.2% screened “when indicated/when provider feels appropriate” and 13.9% never screened family members.

Table 4.

Screening Responses

	All patients	Provider discretion	Never
How often are patients screened for substance abuse?	48.7%	51.3%	0
How often are family members screened for substance abuse?	13.89%	72.22%	13.89%
How often are patients screened for drug diversion?	32.43%	64.86%	2.7%
How often are family members screened for drug diversion?	10.8%	72.97%	16.2%
How often do you do urine drug screens?	11.1%	75.0%	13.9%
How often do you use the prescription monitoring program?^a	36.11%	41.67%	8.33%

13.9% of programs from states without a prescription monitoring program.

With or without specific policies, only 32.4% reported routine screening for drug diversion; 64.9% reporting screening “when indicated,” and 2.7% said they never screened for diversion. Screening family caregivers for prescription drug diversion was even more uncommon, with routine screening present in 10.8% of programs, “when indicated” for the majority (73%), and “never” for 16.2%.

Routine use of UDS was uncommon (11.1%). Whereas 75% of programs reported using them when indicated, 13.9% of programs reported never using a UDS. Approximately one-third of programs reported routine use of the PMP (36.1%), with 41.7% reporting using it “when indicated.” However, 8.3% reported not using it and 13.9% reported that their state did not have a PMP.

To evaluate the effect of having the perception that substance abuse and diversion is an issue in a program's practice, we evaluated the association of agreement with these statements on screening and policy creation. Programs that indicated that substance abuse was a problem were more likely to have a written policy for screening patients for substance abuse (p=0.04) and a policy requiring the use of a screening tool (p=0.03). Additionally, they were more likely to screen all patients for substance abuse (p=0.008), and to use UDS (p=0.016). However, the perception that substance abuse was a problem was not associated with a written policy for screening family members (p=0.37), mandatory staff (p=0.74) or fellow (p=0.70) training, increased screening of family members for substance abuse (p=0.58), or use of the PMP with all patients (p=0.26).

The perception that drug diversion was a problem was associated with having a written policy regarding the screening for drug diversion in patients (p=0.003) and family members (p=0.03), as well as a policy regarding the use of a screening tool for substance abuse and diversion (p=0.03). However, the perception that drug diversion was a problem was not associated with routine screening of patients (p=0.192) or families (p=0.282) for drug diversion (p=0.192).

Discussion

Because of rapidly increasing problems related to the misuse of prescription medications, including overdoses and deaths,⁹ new guidelines for nonmalignant pain have stressed the importance of screening and monitoring patients for aberrant use.^6,7 These guidelines suggest routine screening of all patients receiving opioids (including use of a standardized tool) to risk-stratify for substance misuse. This should be followed by monitoring for aberrant behaviors with routine PMP review (which identifies patients having multiple providers) and the use of UDS looking for unprescribed medications, illicit substances, or failure to take prescribed opioids. This is especially true for higher risk or long-term patients. Concerns about opioid prescribing have been focused on those with nonmalignant pain, for a variety of reasons, including evidence that opioids are more effective in cancer-related pain, concerns about under-treatment, and the feeling that substance abuse in not problematic if the patient is close to the end of life. Recently, recognition that patients with cancer and other life-limiting illnesses may have problematic substance abuse disorders has surfaced.^4,10–14

In this survey, half of responding palliative care programs agreed that substance misuse was a concern in their clinical setting. Identifying this as a concern was associated with having policies for screening, although it is not clear if the policies raise the level of concern or if concerns lead to a written policy. Nevertheless, less than half of all programs had policies mandating routine screening of patients or their family members for substance misuse, and even smaller numbers routinely used monitoring techniques such as the PMP (where available) or UDS, instead using them at provider discretion. Identifying problems with family members was even less common than attention to patient-related concerns. Narrative comments revealed confusion about the need for such policies, and what they should contain.

This study is limited by the response rate of 40.4%. Furthermore, we do not have data on the type of patients seen in these clinics and the number of patients who are prescribed opioids. Aside from our data concerning the UDS and PMP use, we do not have data on other safety measures taken by these programs. Nevertheless, this survey suggests that there is a need for a national conversation regarding this issue in palliative care and oncology.

We would argue that patients seen in outpatient palliative care (and oncology) clinics are at risk for substance misuse, and should undergo similar screening and monitoring to those in other settings, although decisions about the use of opioids in high-risk patients may differ somewhat from those with nonmalignant disease. Our reasons for suggesting this step are as follows:

1. Substance misuse is common, and therefore may occur in all patients or their caregivers, including those seen by palliative care physicians.

The 2013 National Survey on Drug Use and Health estimates that 9.1% of employed adults and 18.2% of unemployed adults had problems with substance abuse or dependence.¹⁵ Aside from alcohol and marijuana, pain relievers are the most commonly abused substance. Even if patients do not have a substance abuse disorder, they may have a family member who is struggling with this problem and is at risk of relapse or overdose due to exposure to their family member's medications. When this at-risk caregiver is the only person available to care for the patient and provide medications when they are too weak to take them independently, this concern is magnified.

2. Patients with cancer and others cared for by palliative care and hospice providers are the group most commonly treated with high-dose opioids, and therefore are a likely source of diversion of these medications into the community.

Many primary care physicians are now hesitant to provide opioids for the treatment of nonmalignant pain. In our institution, the cancer center (including our palliative care clinic) is one of the few clinical areas where chronic opioids are prescribed. Because studies suggest that many of the opioids used in a nonmedical setting are obtained from family members or friends,^16–18 physicians who work in these settings have a special responsibility to ensure that these medications are not misused or diverted into the community. Diversion can be difficult to detect, but the UDS can provide information about this problem. If a patient is getting a month's supply of extended release morphine each month, but has a UDS which does not show morphine, this should alert the provider to ask further questions about how this medication is being used.

3. Increasing life expectancies for patients with cancer and other chronic conditions and a focus on survivorship means a decreasing distinction between cancer and nonmalignant pain.

As palliative care programs move more into the outpatient setting, treatment of chronic pain will be a more common part of the job description. One estimate of the prevalence of chronic pain in cancer patients with no evidence of ongoing malignancy followed in the palliative care clinic was high at 56%.¹⁹

4. Routine monitoring and screening are important because clinicians cannot reliably discern those patients at risk for misuse.

Both routine risk stratification and ongoing monitoring using PMP and UDS are important in detecting problematic and unsafe behaviors. Illicit drug use is found to be present in approximately 15% of patients without prior history of substance abuse.^20,21 Chronic pain patients whose behaviors do not raise red flags often have problems uncovered by the UDS.²² We suggest broaching this topic with patients and their family members in a matter of fact manner as part of a discussion about opioid safety.

5. The risks-benefit ratio for opioid use in situations where there is risk of abuse will vary with the clinical situation.

The patient with very severe pain from incurable cancer has a high need for opioids and efforts to continue prescribing while working to minimize risk should be the focus. Patients with substance abuse disorders do not deserve to die in pain because they have this problem. However, in other settings, such as the patient who has no evidence of active cancer and has a pain syndrome that is less likely to respond to opioids, risks of narcotics may outweigh benefits, especially when there is documented misuse despite education and risk reduction strategies.

6. Patients with substance abuse disorders, or whose family members are affected can usually be treated for their cancer-related pain with close monitoring and limit-setting even when they require opioids.

In our experience, risk reduction can be achieved by techniques that include: limiting the amounts prescribed at one time (a few days or weeks rather than a month); and doing UDS and PMP monitoring at each visit. Further research is needed on this topic to determine the role of other strategies (such as abuse deterrent opioids) in this setting.

7. Uncontrolled substance abuse is a form of suffering, and creates suffering for everyone close to the patient with this problem.

Those who argue that it is unnecessary to be concerned about substance abuse in patients with terminal illnesses must posit that the actively abusing person is happy and fulfilled by indulging in their addiction. We disagree. The patient who is using a month supply of medication in a week to treat their addiction rather than their pain is not enjoying themselves. We would argue that active substance abuse is a form of misery that rivals that of cancer pain and for this reason should not be ignored by palliative care clinicians whose focus is the treatment of suffering.

8. Addressing the issue of substance abuse in the family members of our patients is an ethical obligation.

As mentioned above, in the setting of palliative medicine and hospice care family members are often expected to provide caregiving, which may include administering opioid medications. Part of teaching patients to use opioids safely should include teaching them to avoid exposing family members with substance abuse disorders to these medications. Failure to discuss this may result in serious harm to the at-risk family member, who now has regular access to these drugs. The Opioid Risk Tool includes questions about family history of substance abuse, which can be used as a springboard for this conversation.

9. Given the increasing regulatory concern about opioid prescribing, failure of palliative care and oncology programs to develop best practice guidelines and follow them voluntarily is likely to result in regulations being developed by outside agencies such as the Drug Enforcement Administration (DEA), which do not fit the patient populations we care for.

Conclusion

The majority of the palliative care fellowship programs felt substance abuse and diversion presented problematic issues in their population. However, most do not have policies regarding substance abuse and prescription drug diversion. There is a need for national policies, guidelines, and training for substance abuse in palliative care fellowship programs.

Footnotes

Acknowledgments

American Academy of Hospice and Palliative Medicine Annual Assembly 2015, Philadelphia, PA, poster presented February 25–28, 2015 (poster hung for these dates, no formal presentation). Abstract published: Tan PD, Blackhall LJ, Barclay JS: Screening for substance abuse and drug diversion in palliative care fellowship programs. J Pain Symptom Manage 2015;49(2):456.

Author Disclosure Statement

No competing financial interests exist.

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