1
|
Hadler RA, Klinedinst R, Jones CA, Bao Y, Pathak R, Zarrabi AJ, Rosa WE. Dangerous Variation or Patient-Centered Care? Palliative Care and Pain Providers' Comfort, Experiences, and Approaches when Treating Cancer Pain With Coexisting Aberrant Behaviors. Am J Hosp Palliat Care 2024:10499091241259034. [PMID: 38830349 DOI: 10.1177/10499091241259034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024] Open
Abstract
BACKGROUND Patients with cancer-related pain are at high risk for aberrant drug use behaviors (ADB), including self-escalation, diversion and concurrent illicit substance or opioid misuse; however, limited evidence is available to guide opioid prescribing for patients with life-limiting illness and concurrent or suspected ADB. We sought to characterize how specialists evaluate for and manage these high-risk behaviors in patients with cancer-related pain. METHODS We conducted telephonic semi-structured interviews with palliative care and pain medicine providers. Participants discussed their own comfort and experience level with identifying and managing ADB in patients with life-limiting illness. They were subsequently presented with a series of standardized scenarios and asked to describe their concerns and management strategies. RESULTS 95 interdisciplinary pain and palliative care specialists were contacted; 37 agreed to participate (38.9%). Analysis of interview contents revealed several central themes: (1) widespread discomfort and anxiety regarding safe and compassionate opioid prescribing for high-risk patients, (2) belief that widely used risk-mitigation tools such as opioid contracts and urine drug screens provided inadequate support for decision-making, and (3) lack of institutional and organizational support and guidance for safe prescribing strategies. Most clinicians reported self-education regarding addiction and alternative prescribing/pain management strategies. Providers varied widely in their willingness to discontinue opioid prescribing in a patient with aberrant behavior and pain associated with life-limiting illness. CONCLUSION Providers caring for patients demonstrating ADB and cancer-related pain struggle to balance safe prescribing with symptom management. Increased guidance is needed regarding opioid prescribing, monitoring, and discontinuation in high-risk patients.
Collapse
Affiliation(s)
- Rachel A Hadler
- Department of Anesthesiology, Emory University, Atlanta, GA, USA
- Emory Critical Care Center, Emory University, Atlanta, GA, USA
| | - Rachel Klinedinst
- Palliative Care Alliance, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Christopher A Jones
- Palliative Care Program, Department of Medicine, Duke University, Durham, NC, USA
| | - Yuhua Bao
- Department of Population Health Sciences, Weill-Cornell Medicine, New York, NY, USA
| | - Ravi Pathak
- Department of Anesthesiology, Emory University, Atlanta, GA, USA
- Division of Palliative Medicine, Department of Family and Preventive Medicine, Emory University, Atlanta, GA, USA
| | - Ali J Zarrabi
- Division of Palliative Medicine, Department of Family and Preventive Medicine, Emory University, Atlanta, GA, USA
| | - William E Rosa
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| |
Collapse
|
2
|
Rudy L, Lacroix E. Substance use disorders in hospice palliative care: A narrative review of challenges and a case for physician intervention. Palliat Support Care 2024:1-9. [PMID: 38420710 DOI: 10.1017/s1478951523001402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
OBJECTIVES Substance use disorders (SUDs) are frequently encountered in hospice palliative care (HPC) and pose substantial quality-of-life issues for patients. However, most HPC physicians do not directly treat their patients' SUDs due to several institutional and personal barriers. This review will expand upon arguments for the integration of SUD treatment into HPC, will elucidate challenges for HPC providers, and will provide recommendations that address these challenges. METHODS A thorough review of the literature was conducted. Arguments for the treatment of SUDs and recommendations for physicians have been synthesized and expanded upon. RESULTS Treating SUD in HPC has the potential to improve adherence to care, access to social support, and outcomes for pain, mental health, and physical health. Barriers to SUD treatment in HPC include difficulties with accurate assessment, insufficient training, attitudes and stigma, and compromised pain management regimens. Recommendations for physicians and training environments to address these challenges include developing familiarity with standardized SUD assessment tools and pain management practice guidelines, creating and disseminating visual campaigns to combat stigma, including SUD assessment and intervention as fellowship competencies, and obtaining additional training in psychosocial interventions. SIGNIFICANCE OF RESULTS By following these recommendations, HPC physicians can improve their competence and confidence in working with individuals with SUDs, which will help meet the pressing needs of this population.
Collapse
Affiliation(s)
- Lauren Rudy
- Department of Psychology, University of New Brunswick, Fredericton, NB, Canada
| | - Emilie Lacroix
- Department of Psychology, University of New Brunswick, Fredericton, NB, Canada
| |
Collapse
|
3
|
Andraka-Christou B, McAvoy E, Gordon AJ, Ohama M, Brach M, Taylor EA, Vaiana M, Saloner B, Stein BD. Urine drug testing in the context of opioid analgesic prescribing for chronic pain: a content analysis of U.S. state laws in 2022. PAIN MEDICINE (MALDEN, MASS.) 2023; 24:1306-1317. [PMID: 37551941 PMCID: PMC10690857 DOI: 10.1093/pm/pnad103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 07/07/2023] [Accepted: 07/28/2023] [Indexed: 08/09/2023]
Abstract
BACKGROUND In response to the opioid crisis, U.S. states have passed laws requiring urine drug testing (UDT) when opioid analgesics are prescribed for chronic pain. We sought to identify state law UDT requirements. METHODS We searched NexisUni legal database using terms related to UDT, chronic pain, and opioids. We included laws effective during spring 2022 that required UDT when opioids were prescribed for chronic pain. We performed deductive content analysis, coding laws for mandated UDT frequency, type of clinician and type of payer to whom the law applied, and circumstances under which UDT was mandated. RESULTS We found 32 laws across 13 states that met our inclusion criteria. UDT requirements varied substantially by state, including with regard to the type of clinician to whom the law applied, the mandated frequency of UDT (eg, at initiation/assessment, at least annually, more than once per year), and the circumstances in which UDT was mandated (eg, patient had substance use disorder; dosage/day threshold). DISCUSSION Relatively few states have UDT mandates associated with prescribing opioids as chronic pain treatment. When developing policy indicators for empirical studies, researchers evaluating how UDT policy affects health outcomes must consider the complexity and lack of uniformity of UDT requirements. In addition, even if states mandate UDT, it is unclear whether clinicians understand the best way to use the test results.
Collapse
Affiliation(s)
- Barbara Andraka-Christou
- School of Global Health Management & Informatics, University of Central Florida, Orlando, FL 32801, United States
- Department of Internal Medicine (Secondary Joint Appointment), University of Central Florida, Orlando, FL 32827, United States
| | - Elizabeth McAvoy
- O'Neill School of Public and Environmental Affairs, Indiana University, Bloomington, IN 47405, United States
| | - Adam J Gordon
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT 84108, United States
- Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT 84108, United States
| | - Maggie Ohama
- The Cardiac and Vascular Institute, Gainesville, FL 32605, United States
| | | | - Erin A Taylor
- RAND Corporation, Santa Monica, CA 90401, United States
| | - Mary Vaiana
- RAND Corporation, Santa Monica, CA 90401, United States
| | - Brendan Saloner
- Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, United States
| | | |
Collapse
|
4
|
Lee CY, Good P, Huggett G, Greer R, Hardy J. Drug dependence epidemiology in palliative care medicinal cannabis trials. BMJ Support Palliat Care 2023:spcare-2023-004583. [PMID: 37748856 DOI: 10.1136/spcare-2023-004583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 09/06/2023] [Indexed: 09/27/2023]
Abstract
OBJECTIVES Drug dependence is becoming increasingly common and meeting palliative care patients with substance use disorders is inevitable. However, data on substance use in these patients are lacking. This study aims to evaluate the prevalence of drug dependence in palliative care patients with advanced cancer and correlate with symptom distress and opioid use. METHODS Palliative care patients with advanced cancer interested in participation in a medicinal cannabis trial were required to complete Alcohol, Smoking and Substance Involvement Screening Test (ASSIST), Edmonton Symptom Assessment Scale (ESAS) and record of concomitant medications including baseline opioid use as part of the eligibility screen. RESULTS Of the 182 participants, 167 (92%) reported lifetime alcohol and 132/182 (73%) lifetime tobacco use. No participant reached the threshold criteria for high risk of drug dependence with majority being low risk. There was no correlation between ASSIST score, ESAS and oral morphine equivalent. CONCLUSION This study identified alcohol and tobacco as the main substances used in this group of patients and that most were of very low risk for drug dependence. This suggests routine drug screening for palliative care patient may not be justified, but the high possibility of questionnaire bias is acknowledged.
Collapse
Affiliation(s)
- Chee Yen Lee
- Palliative Medicine, Ipswich Hospital, Ipswich, Queensland, Australia
- Palliative Medicine, Mater Misericordiae Ltd Brisbane, South Brisbane, Queensland, Australia
| | - Phillip Good
- UQ, Saint Lucia, Queensland, Australia
- Supportive and Palliative Care, Mater Health Services, Brisbane, Queensland, Australia
- Mater Research Institute The University of Queensland, South Brisbane, Queensland, Australia
| | - Georgie Huggett
- Mater Research Institute The University of Queensland, South Brisbane, Queensland, Australia
| | | | - Janet Hardy
- Supportive and Palliative Care, Mater Health Services, Brisbane, Queensland, Australia
| |
Collapse
|
5
|
Edwards T, Arthur J, Joy M, Lu Z, Dibaj S, Bruera E, Zhukovsky D. Assessing risk for nonmedical opioid use among patients with cancer: Stability of the CAGE-AID questionnaire across clinical care settings. Palliat Support Care 2023:1-5. [PMID: 37439217 PMCID: PMC10787045 DOI: 10.1017/s1478951523000871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/14/2023]
Abstract
OBJECTIVES The Cut down, Annoyed, Guilty, and Eye opener- Adapted to Include Drugs (CAGE-AID) questionnaire (CA) is a validated screening tool used to assess risk for nonmedical opioid use (NMOU) in patients receiving opioids for cancer pain. Data on consistencies and variations in responses to the CA between different clinical settings are lacking. We evaluated the frequency and consistency in scoring of the CA among patients seen between the first inpatient consult (T1) and the first outpatient follow-up (T2) visits. METHODS A retrospective chart review of 333 consecutive patients seen at both T1 and T2 within 3 months between August 2016 and March 2017 was reviewed. RESULTS Median age was 58 years (range, 18-87 years); 53% were female. CA was completed for 88% of patients at T1 and 94% at T2. Of these, 10% and 13% were CAGE-AID positive, respectively. CA score changed from negative to positive in 4% and from positive to negative in 1% of patients between T1 and T2. Kappa coefficient for agreement of CA between T1 and T2 was 0.74 (95% CI: 0.62-0.86, p = 0.02). SIGNIFICANT OF RESULTS Completion rate and consistency of patient responses to the CA were high irrespective of clinical setting. Of these patients, 10% and 13% were CA positive which is suggestive of high risk for NMOU. Further studies are needed to evaluate ways to ensure more consistency in the completion of the CA and enhance its utilization in routine clinical practice.
Collapse
Affiliation(s)
- Tonya Edwards
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer, Houston, TX, USA
| | - Joseph Arthur
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer, Houston, TX, USA
| | - Manju Joy
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer, Houston, TX, USA
| | - Zhanni Lu
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer, Houston, TX, USA
| | - Seyedeh Dibaj
- Department of Biostatistics, The University of Texas MD Anderson Cancer, Houston, TX, USA
| | - Eduardo Bruera
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer, Houston, TX, USA
| | - Donna Zhukovsky
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer, Houston, TX, USA
| |
Collapse
|
6
|
Lau J, Zimmermann C, Selby P, Furlan AD. Opioid Disposal Practices of Patients with Life-Limiting Cancers in an Outpatient Palliative Care Clinic: A Cross-Sectional Study. J Palliat Med 2023. [PMID: 36656166 DOI: 10.1089/jpm.2022.0355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Background: Patients with life-limiting cancers are commonly prescribed opioids to manage pain, dyspnea, and cough. Proper prescription opioid disposal is essential to prevent poisonings and deaths. Objective: We examined opioid disposal practices of patients referred to a Canadian outpatient palliative care clinic (OPCC). The primary objective was to determine the prevalence of OPCC patients who did not routinely dispose their opioids. The secondary objectives were to examine their methods of opioid disposal and to identify patient characteristics associated with routine disposal of opioids. Design and Setting: This cross-sectional study involved a retrospective chart review of new, adult patients who were seen in a Canadian OPCC (September 2018-August 2019) and completed a survey about opioid-related constructs: source of prescriptions, use, storage, disposal, and knowledge about associated harms. Results: Among the 122 study participants, half (58/111, 52.3%) reported that they did not routinely dispose their opioids. The most common method of disposal was by giving them to pharmacists (69/88, 78.4%). Cannabis use (odds ratio [OR]: 3.7, 95% confidence interval [CI]: 1.1-11.8) and neuropathic medication use (OR: 3.0, 95% CI: 1.2-7.2) were positively associated with routine disposal of opioids. Conversely, reports of an increased amount of opioid use in the past six months were negatively associated with routine disposal of opioids (OR: 0.38, 95% CI: 0.16-0.88). Conclusion: The high prevalence of people with life-limiting illnesses who do not routinely dispose their opioids requires increased attention. Interventions, such as education, are needed to reduce medication waste and opioid-related harms.
Collapse
Affiliation(s)
- Jenny Lau
- Department of Supportive Care, University Health Network, Toronto, Ontario, Canada.,Division of Palliative Care, University of Toronto, Toronto, Ontario, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Camilla Zimmermann
- Department of Supportive Care, University Health Network, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Peter Selby
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada.,Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Andrea D Furlan
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada.,Institute for Work and Health, Toronto, Ontario, Canada
| |
Collapse
|
7
|
Cleary N, Mulkerrin OM, Davies A. Oral symptom assessment tools in patients with advanced cancer: a scoping review. Support Care Cancer 2022; 30:7481-7490. [PMID: 35657401 PMCID: PMC9385820 DOI: 10.1007/s00520-022-07169-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 05/19/2022] [Indexed: 11/24/2022]
Abstract
PURPOSE Oral symptoms are common in patients with advanced cancer. The aim of this scoping review was to identify oral symptom assessment tools that have been specifically utilised in patients with "advanced cancer". METHODS The review was conducted/reported according to international guidelines for undertaking scoping reviews. PubMed, Embase, and CINAHL were searched for articles involving adult patients with advanced cancer, which involved assessment of ≥ 2 oral symptoms, and which involved patients with > 1 type of cancer. RESULTS The review identified four validated symptom assessment scales, including one cancer-specific quality of life scale (EORTC QLQ OH-15), one generic tool for assessing the "social impact" of specific oral problems (OHIP), one cancer-specific generic symptom assessment scale (MSAS), and one cancer-specific oral symptom assessment scale (OSAS). CONCLUSION Symptom assessment tools can facilitate good symptom control in clinical practice, and are an integral component of clinical research. The review identified four validated symptom assessment scales that could be utilised to assess oral symptoms in patients with advanced cancer.
Collapse
Affiliation(s)
- Niamh Cleary
- Trinity College Dublin, Dublin, Ireland.
- Our Lady of Lourdes Hospital, Drogheda, Drogheda, Ireland.
- Our Lady's Hospice Dublin, Dublin, Ireland.
| | | | - Andrew Davies
- Trinity College Dublin, Dublin, Ireland
- Our Lady's Hospice Dublin, Dublin, Ireland
- University College Dublin, Dublin, Ireland
| |
Collapse
|
8
|
Jones KF, Abdulhay LB, Orris SR, Merlin JS, Schenker Y, Bulls HW. The Relevance of State Laws Regulating Opioid Prescribing for People Living With Serious Illness. J Pain Symptom Manage 2022; 64:89-99. [PMID: 35561937 DOI: 10.1016/j.jpainsymman.2022.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 04/29/2022] [Accepted: 05/02/2022] [Indexed: 10/18/2022]
Abstract
CONTEXT Opioids are commonly used to relieve symptoms such as pain and dyspnea in people living with serious illness. In recent years, 36 states enacted limitations for opioid prescriptions to mitigate the impact of the opioid overdose crisis. Palliative care clinicians have been vocal about the unintended consequences of opioid policies, yet little is known about how state policies apply to opioid prescribing in non-cancer-related serious illness. OBJECTIVE To summarize current state-level limitations to opioid prescribing and exemptions relevant to people living with non-cancer-related serious illness. METHODS Investigators searched publicly available laws ("[state] + opioid legislation") to extract information on opioid prescribing and exemptions. Laws were examined for application to palliative care, hospice, non-cancer-related serious illness, and language about specific symptoms was documented when applicable (e.g., pain, dyspnea). RESULTS Most state laws focused on acute pain and/or initial opioid prescriptions. Thirty-three of the thirty-six states with opioid-limiting legislation exempt situations applicable to people living with non-cancer-related serious illness. Three states did not have any exemptions relevant to people living with non-cancer-related serious illness. DISCUSSION The results indicate that while most states recognize the importance of timely opioid access for palliation of pain, clinically relevant exemptions for people living with non-cancer-related serious illness may be lacking. When present, language describing palliative care, hospice, and terminal illness exemptions is often broad and may generate confusion between primary and specialty palliative care.
Collapse
Affiliation(s)
- Katie Fitzgerald Jones
- William F. Connell School of Nursing (K.F.J.), Boston College, Chestnut Hill, Massachusetts, USA.
| | - Lindsay Bell Abdulhay
- Section of Palliative Care and Medical Ethics and Palliative Research Center, Division of General Internal Medicine (L.B.A., S.R.O., J.S.M., Y.S., H.W.B.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Steve R Orris
- Section of Palliative Care and Medical Ethics and Palliative Research Center, Division of General Internal Medicine (L.B.A., S.R.O., J.S.M., Y.S., H.W.B.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jessica S Merlin
- Section of Palliative Care and Medical Ethics and Palliative Research Center, Division of General Internal Medicine (L.B.A., S.R.O., J.S.M., Y.S., H.W.B.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Yael Schenker
- Section of Palliative Care and Medical Ethics and Palliative Research Center, Division of General Internal Medicine (L.B.A., S.R.O., J.S.M., Y.S., H.W.B.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Hailey W Bulls
- Section of Palliative Care and Medical Ethics and Palliative Research Center, Division of General Internal Medicine (L.B.A., S.R.O., J.S.M., Y.S., H.W.B.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
9
|
Lau J, Mazzotta P, Whelan C, Abdelaal M, Clarke H, Furlan AD, Smith A, Husain A, Fainsinger R, Hui D, Sunderji N, Zimmermann C. Opioid safety recommendations in adult palliative medicine: a North American Delphi expert consensus. BMJ Support Palliat Care 2021; 12:81-90. [PMID: 34389553 PMCID: PMC8862037 DOI: 10.1136/bmjspcare-2021-003178] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 07/11/2021] [Indexed: 11/04/2022]
Abstract
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.
Collapse
Affiliation(s)
- Jenny Lau
- Division of Palliative care, Department of Supportive Care, Princess Margaret Cancer Centre, Toronto, Ontario, Canada .,Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Paolo Mazzotta
- Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada .,Temmy Latner Centre for Palliative Care, Sinai Health System, Toronto, Ontario, Canada
| | - Ciara Whelan
- Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada.,Temmy Latner Centre for Palliative Care, Sinai Health System, Toronto, Ontario, Canada
| | - Mohamed Abdelaal
- Division of Palliative care, Department of Supportive Care, Princess Margaret Cancer Centre, Toronto, Ontario, Canada.,Division of Palliative Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Hance Clarke
- Department of Anesthesia, Toronto General Hospital, Toronto, Ontario, Canada.,Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Andrea D Furlan
- Department of Physiatry, Toronto Rehabilitation Institute, Toronto, Ontario, Canada.,Division of Physical Medicine and Rehabilitation, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Institute for Work and Health, Toronto, Ontario, Canada.,Toronto Academic Pain Medicine Institute, Toronto, Ontario, Canada
| | - Andrew Smith
- Toronto Academic Pain Medicine Institute, Toronto, Ontario, Canada.,Centre for Addiction and Mental Health, Toronto, Ontario, Canada.,Wasser Pain Management Centre, Sinai Health System, Toronto, Ontario, Canada
| | - Amna Husain
- Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada.,Temmy Latner Centre for Palliative Care, Sinai Health System, Toronto, Ontario, Canada
| | - Robin Fainsinger
- Division of Palliative Care, Department of Oncology, University of Alberta, Edmonton, Alberta, Canada
| | - David Hui
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Nadiya Sunderji
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada.,Waypoint Centre for Mental Health Care, Penetanguishene, Ontario, Canada
| | - Camilla Zimmermann
- Division of Palliative care, Department of Supportive Care, Princess Margaret Cancer Centre, Toronto, Ontario, Canada.,Division of Palliative Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|