Opioid safety is the prevention, identification, and management of opioid-related problems.

Opioids are essential for palliative care (PC) symptom management, mainly for the control of pain, dyspnea, and cough.
Internationally, approximately 115,000 people died in 2017 from opioid-related overdoses. Multiple factors contribute to the opioid crisis, including increase in substance use as a coping mechanism, and restricted access to mental health and addiction services. Unfortunately, though prescription opioids are essential in PC, 27%-38% of deaths are from prescription opioids used by patients or diverted to others.

Most knowledge about opioid safety is from chronic noncancer pain and addiction medicine, but treatment cannot be applied directly to PC patients. To generate knowledge on opioid risk-lessening strategies in PC a Delphi technique was used to develop expert recommendations.

Results of the Delphi process

General principles to guide opioid prescribing and identification, and management of opioid use disorders (OUDs) in PC. High-priority recommendations:
1. Opioids should not only be prescribed by PC specialists to patients with life-limiting illnesses.
2. Opioid prescribing should be a practice of all clinicians caring for patients with life-limiting illnesses, such as family physicians and oncologists.
3. PC physicians could mentor non-PC physicians on opioid use for individuals with life-limiting illnesses.
4. Identifying whether a patient has OUD does not depend on a patient’s diagnosis or prognosis.
5. Management of a patient’s OUD does not depend on their diagnosis.
6. Identifying a caregiver’s OUD does not depend on the patient’s prognosis.

Measures that health care institutions and PC programs can implement to promote opioid safety. High-priority recommendations:
1. Health care institutions should collect data about opioid-related overdoses of patients receiving PC.
2. Health care institutions should provide access to pharmacological OUD treatments (i.e., methadone, buprenorphine-naloxone).
3. PC clinical programs should provide education about:
• specific opioid safety topics (i.e., urine drug tests).
• addiction medicine, psychiatry, and pain medicine.
• joint management of patients at high risk of any use of prescription opioids in a manner other than intended by the prescribing physician and pharmaceutical manufacturer, including aberrant opioid medication-taking behaviors (AMTB), OUD, and opioid-related overdose.

Patient with life-limiting illnesses and caregiver assessments for opioid-related harms. High-priority recommendations:
1. Before receiving opioid prescriptions, every patient should receive assessments that include asking about their caregiver’s substance use history.
2. Theft or borrowing of opioids, and route altercation of prescribed opioids are the most important AMTBs that PC clinicians should be aware of.
3. PC physicians should know that histories of post-traumatic stress and sexual abuse are two of the identified risk factors for AMTB.
4. The CAGE questionnaire, Opioid Risk Tool, and urine drug testing (UDT) are recommended tools that can be used to identify patients who are at high risk of AMTB or OUD.
5. PC physicians should use clinical assessments, rather than specific tools or tests, to identify patients with life-limiting illnesses who have OUD, i.e., using the Diagnostic and Statistical Manual of Mental Disorders, 5th Ed. (DSM-5) OUD criteria.
6. PC physicians should be aware that one of the risk factors for opioid-related overdose is when a patient receives opioid prescriptions from two or more physicians.

Prescribing practices that can prevent and manage opioid-related harms. High-priority recommendations:
1. Physicians should have access to regional prescription monitoring programs to track previously dispensed prescriptions.
2. If a patient’s primary prescriber for their opioids will be away, covering clinicians should have access to detailed pain management plans and documentation.
3. Patients who are at high risk of AMTB, OUD, and/or opioid-related overdose should receive daily to weekly dispensing of their opioids.
4. For patients with active AMTB, OUD, and/or history of opioid-related overdose, joint management with addiction medicine specialists should be considered.

Practices that can be implemented to monitor for opioid-related harms. High-priority recommendations:
1. Patients receiving PC who are at high risk or have active AMTB, OUD, and opioid-related overdose should be assessed more frequently than low-risk individuals.
2. PC physicians are recommended to assess for and document the universal precautions after initiating or adjusting opioids (analgesia, activity level, adverse effects, AMTB) and adherence to instructions.
3. Pill counts by nurses were recommended for patients at home and in clinics.

Patient and caregiver education. High-priority recommendations about the topics to be included in education.
• Patient education: Differentiating between physical dependence and OUD, chemical coping with opioids, opioid-related overdose signs and symptoms, safe disposal of opioids, opioid withdrawal symptoms, and driving/operating machinery.
• Caregiver education: Differentiating between physical dependence and OUDs, indications for opioid use, opioid adverse effects, opioid-related overdose signs and symptoms, and safe storage and disposal of opioids—they should receive instructions (written and verbal) to return unused medications to pharmacies.

See reference for more information.

Adapted from Lau J et al. Opioid Safety Recommendations in Adult Palliative Medicine: A North American Delphi expert consensus. BMJ Support Palliat Care 2021; bmjspcare-2021-003178.