Opioid safety recommendations in adult palliative medicine: a North American Delphi expert consensus.

OBJECTIVES: Despite the escalating public health emergency related to opioid-related deaths in Canada and the USA, opioids are essential for palliative care (PC) symptom management.Opioid safety is the prevention, identification and management of opioid-related harms. The Delphi technique was used to develop expert consensus recommendations about how to promote opioid safety in adults receiving PC in Canada and the USA. METHODS: Through a Delphi process comprised of two rounds, USA and Canadian panellists in PC, addiction and pain medicine developed expert consensus recommendations. Elected Canadian Society of Palliative Care Physicians (CSPCP) board members then rated how important it is for PC physicians to be aware of each consensus recommendation.They also identified high-priority research areas from the topics that did not achieve consensus in Round 2. RESULTS: The panellists (Round 1, n=23; Round 2, n=22) developed a total of 130 recommendations from the two rounds about the following six opioid-safety related domains: (1) General principles; (2) Measures for healthcare institution and PC training and clinical programmes; (3) Patient and caregiver assessments; (4) Prescribing practices; (5) Monitoring; and (6) Patients and caregiver education. Fifty-nine topics did not achieve consensus and were deemed potential areas of research. From these results, CSPCP identified 43 high-priority recommendations and 8 high-priority research areas. CONCLUSIONS: Urgent guidance about opioid safety is needed to address the opioid crisis. These consensus recommendations can promote safer opioid use, while recognising the importance of these medications for PC symptom management.

Deprescribing in the Home Palliative Setting.

Background: When patients' goals of care have shifted toward comfort, treatment should focus on alleviating symptoms rather than prolonging life at the expense of comfort. Objective: To determine whether the number of noncomfort medications is associated with deprescribing in patients seen by a home-visiting palliative care physician. Design: Single-centre retrospective chart review of patients cared for in the home setting by a specialty palliative care program to determine factors associated with deprescribing. All medications on initial consult were classified as comfort, possibly for comfort, and definitely not for comfort (DNC). Patients were stratified depending on whether intentional deprescribing occurred. Data were analyzed for associations between deprescribing and other variables: number and proportion of DNC medications, diagnosis, palliative performance scale (PPS), number of encounters, code status, preferred place of death, and time to death. Setting: Study population included 80 patients followed by specialist home-visiting palliative physicians in a tertiary center. Inclusion criteria were adult patients with PPS ≤60%, initially seen by a home-visiting palliative physician between 2016 and 2018 and followed for at least 60 days or until death. Results: Deprescribing occurred in 44% of study patients within 60 days. Median number of DNC medications was 3 in the deprescribed group and 0 in the nondeprescribed group (p < 0.001). Proportion of DNC medications was 29% in the deprescribed group and 15% in the nondeprescribed group (p < 0.01). Conclusions: Deprescribing is associated with an increased number and proportion of DNC medications at the time of initial in-home palliative assessment. Deprescribing rates varied greatly between different home-visiting palliative providers.

Why do homeless people use a mobile health unit in a country with universal health care?

Mobile health units (MHUs) are an important source of health care for the uninsured; however, it is unclear what role these units play in Canada, where a universal health insurance system exists. The purpose of this study was to understand why individuals who live in a country with universal health insurance seek care at an MHU and to determine whether MHUs are used in addition to or in place of the client's usual source of care. This study investigated the use of the Rotary Club of Toronto Health Bus among 150 homeless and marginally housed adults in Toronto, Ontario, over a 3-month period. Data were collected on demographic characteristics, current and lifetime homelessness, health care use, and reasons for using the Health Bus. The majority of participants (94.6%) had a regular health care source, primarily doctor's offices (41.6%) and community health centers (16.1%); 18 (12.1%) stated that the Health Bus was their usual source of care. Participants were frequent users of the Health Bus, reporting a median of 7.0 visits (interquartile range, 3.5-12.0 visits) in the past 3 months. Most clients (86.0%) reported using the Health Bus to obtain basic supplies (eg, vitamins, socks); health problems were cited as reasons for using the Health Bus for 55 (36.7%) participants. The findings suggest that in a country with universal health insurance, MHUs supplement other sources of health care, providing essential supplies and offering important outreach services to a high-needs population.