Consensus-Based Management of Opioid Misuse, Opioid Use Disorder in Cancer

This illustration image shows tablets of opioid painkiller Oxycodon delivered on medical prescription taken on September 18, 2019 in Washington,DC. – Millions of Americans sank into addiction after using potent opioid painkillers that the companies churned out and doctors freely prescribed over the past two decades. Well over 400,000 people died of opioid overdoses in that period, while the companies involved raked in billions of dollars in profits. And while the flood of prescription opioids into the black market has now been curtailed, addicts are turning to heroin and highly potent fentanyl to compensate, where the risk of overdose and death is even higher. (Photo by Eric BARADAT / AFP) (Photo by ERIC BARADAT/AFP via Getty Images)
A team of investigators conducted a Delphi study to provide evidence-based guidance to clinicians about management and care of patients with serious illnesses who misuse opioids or have opioid use disorder.

A study on the proper management of patients with serious illnesses who misuse opioids or have opioid use disorder is currently underway, the results of which will be disseminated through national stakeholder networks, peer-reviewed manuscripts, and conferences, according to protocol data published in BMC Open. Ultimately, the results from the study will be used to develop a toolkit for clinicians who care for patients with serious illness who are at risk for opioid misuse or opioid use disorder.

As little literature exists about management of opioid misuse and opioid use disorders among people with serious illnesses, a team of investigators conducted a Delphi study to provide evidence-based guidance to clinicians about management and care of this patient demographic. The study is being performed asynchronously online and relies on identifying participants with appropriate expertise.

The study researchers used a modified Delphi (RAND/UCLA Appropriateness Method [RAM]) approach aiming to recruit at least 40 to 60 clinicians with expertise in palliative care, addiction, or both to investigate the management of opioid misuse and opioid use disorder in patients with advanced cancer. The RAM panels used clinical scenarios and questions about the appropriateness of several treatment and management techniques.

To mimic possible challenges associated with management in patients with serious illness who are prescribed opioid therapy, study researchers created 7 patient cases. These included, “(1) inadequate pain control on highest recommended dose of buprenorphine/naloxone, (2) inadequate pain control on stable methadone dose, (3) requests early refills, (4) positive urine drug screen for benzodiazepines that were not prescribed, (5) positive urine screen for cocaine or methamphetamine, (6) aggressive patient behaviour in clinic and (7) history of untreated OUD not currently on pharmacologic treatment, with unmanaged pain.” Following each case was a series of questions on the appropriateness of varying management strategies, which was rated using a 9-point Likert scale from the RAM.

After conducting modified Delphi panels, participants underwent 3 rounds of data collection. In the first round, participants rated and commented on the appropriateness of management choices for each of the cases. In the second round, they reviewed and discussed numerical responses and comments from round 1. The third round, which is currently ongoing, includes discussion of the results of rounds 1 and 2; however, participants are permitted to change their final numerical responses.

Study researchers utilized ExpertLens, the online program used to conduct the modified Delphi panels, to automatically determine whether or not the panels were in agreement. They will only use the responses from the third round to assess the final panel consensus.

“Results from this modified Delphi study will help inform policy. These could include policies that would reduce barriers to consensus strategies (eg, use of medications for opioid use disorder like increasing availability of buprenorphine/naloxone in settings where patients with serious illness are managed) at the clinic, health system, state or federal level,” the study authors concluded.


King C, Arnold R, Dao E, et al. Consensus-based approach to managing opioids, including opioid misuse and opioid use disorder, in patients with serious illness: protocol for a modified Delphi process. BMJ Open. 2021;11(5):e045402. doi:10.1136/bmjopen-2020-045402