Driving for patients in palliative care-a reality?

Opioids and driving: education gaps in advanced cancer

OBJECTIVES

Opioids may impair the ability to drive safely, particularly when first prescribed or with dose titration. We investigated whether clinicians evaluate driving status and provide opioid-related driving advice when initiating opioids among people with advanced lung cancer.

METHODS

A retrospective medical record review of outpatients with advanced non-small cell lung cancer seen at an Australian tertiary referral centre between 1 January 2015 and 31 December 2019 was undertaken to determine frequency of opioid prescription and documentation of driving status and education regarding driving safety while taking opioids.

RESULTS

Of 1022 patients screened, 205 were commenced on opioid therapy. Forty-seven (23%) patients had driving status documented. According to medical records, education about driving safety while on opioids was provided to two (1%) patients on opioid initiation. Ten (5%) patients received opioid-related driving education at least once at follow-up appointments. The content of the education was infrequently documented, and when documented, focused on opioid side effects impacting driving. Opioid doses were often escalated at follow-up appointments.

CONCLUSIONS

According to documentation in medical records, clinicians infrequently assessed driving status on opioid initiation and rarely provided education regarding opioid-related driving risks. Further research and clearer guidance regarding opioids and driving safety in the cancer population are required.

Driving communication forward: improving communication for palliative care patients around driving and opioids - a quality improvement report

INTRODUCTION

The number of people requiring palliative care is increasing with an ageing comorbid population. Pain is a prevalent symptom for palliative care patients and is often managed with opioids. Opioids reduce reaction time and can cause drowsiness and visual disturbance. Evidence recommends that driving should be avoided until a stable dose of opioids has been reached. It is vital for patient and public safety that these facts are communicated to patients who are prescribed opioids, as well as the legal consequences if guidance is not followed. These discussions facilitate joint decisions, optimising patient freedom and quality of life. Surprisingly though these important discussions around driving and opioids do not always occur, and so this project sought to develop a systematic approach to integrating them into practice.

DESIGN

Retrospective case note analysis and prospective interventional quality improvement study.

SETTING

A 16 bedded specialist palliative care inpatient unit.

POPULATION

Hospice inpatients with an Eastern Council Oncology Group performance score of 0-3 who had been prescribed opioids.

INTERVENTION

Three plan-do-study-act cycles were performed. First, the issue was discussed in the daily multidisciplinary team meeting to raise awareness, second a prompt was added to a pre-existing clerking proforma. Finally, a reminder poster was placed in the ward office to promote discussion prior to discharge.

OUTCOME MEASURES

Primary measures were the proportion of patients with the presence of documented driving status, and the presence of a documented discussion surrounding driving and opioids.

RESULTS

Baseline data found that 11.5% of patients had a documented driving status and 11.5% had a documented discussion surrounding driving and opioids. Over the course of the study, the proportion improved to 65.2% and 60.9%, respectively.

CONCLUSION

Use of quality improvement change methods have resulted in the successful integration of new interventions to increase discussions around driving when prescribed opioids. A previously overlooked issue in this facility, thus improving clinical and patient information sharing, and patient empowerment to take charge of their own health.

Patients' and caregivers' experiences of driving with chronic breathlessness before and after regular low-dose sustained-release morphine: A qualitative study

BACKGROUND

Chronic breathlessness is a disabling syndrome that profoundly impacts patients' and caregivers' lives. Driving is important for most people, including those with advanced disease. Regular, low-dose, sustained-release morphine safely reduces breathlessness, but little is known about its impact on driving.

AIM

To understand patients' and caregivers' (1) perspectives and experiences of driving with chronic breathlessness; and (2) perceived impact of regular, low-dose, sustained-release morphine on driving.

DESIGN

A qualitative study embedded in a pragmatic, phase III, randomised, placebo-controlled trial of low-dose, sustained-release morphine (⩽32 mg/24 h) for chronic breathlessness. Semi-structured interviews were conducted immediately after participants withdrew or completed the randomised, placebo-controlled trial. Informed by grounded theory, a constant comparative approach to analysis was adopted.

SETTING/PARTICIPANTS

Participants were recruited from an outpatients palliative care service in Adelaide, Australia. Participants included patients (n = 13) with severe breathlessness associated with chronic obstructive pulmonary disease and their caregivers (n = 9).

RESULTS

Participants were interviewed at home. Eleven received morphine 8-32 mg. Three themes emerged: (1) independence; (2) breathlessness' impact on driving; and (3) driving while taking regular, low-dose, sustained-release morphine.

CONCLUSION

Driving contributed to a sense of identity and independence. Being able to drive increased the physical and social space available to patients and caregivers, their social engagement and well-being. Patients reported breathlessness at rest may impair driving skills, while the introduction of sustained-release morphine seemed to have no self-reported impact on driving. Investigating this last perception objectively, especially in terms of safety, is the subject of ongoing work.

The impact of therapeutic opioid agonists on driving-related psychomotor skills assessed by a driving simulator or an on-road driving task: A systematic review

BACKGROUND

Driving cessation is associated with poor health-related outcomes. People with chronic diseases are often prescribed long-term opioid agonists that have the potential to impair driving. Studies evaluating the impact of opioids on driving-related psychomotor skills report contradictory results likely due to heterogeneous designs, assessment tools and study populations. A better understanding of the effects of regular therapeutic opioid agonists on driving can help to inform the balance between individual's independence and community safety.

AIM

To identify the literature assessing the impact of regular therapeutic opioid agonists on driving-related psychomotor skills for people with chronic pain or chronic breathlessness.

DESIGN

Systematic review reported in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis statement; PROSPERO Registration CRD42017055909.

DATA SOURCES

Six electronic databases and grey literature were systematically searched up to January, 2017. Inclusion criteria were as follows: (1) empirical studies reporting data on driving simulation, on-the-road driving tasks or driving outcomes; (2) people with chronic pain or chronic breathlessness; and (3) taking regular therapeutic opioid agonists. Critical appraisal used the National Institutes of Health's quality assessment tools.

RESULTS

From 3809 records screened, three studies matched the inclusion criteria. All reported data on people with chronic non-malignant pain. No significant impact of regular therapeutic opioid agonists on people's driving-related psychomotor skills was reported. One study reported more intense pain significantly worsened driving performance.

CONCLUSION

This systematic review does not identify impaired simulated driving performance when people take regular therapeutic opioid agonists for symptom control, although more prospective studies are needed.

Assessing the practice of palliative care doctors: what driving advice do they give patients with advanced disease?

BACKGROUND

There is little research and no clear guidelines for clinicians to follow when instructing patients with advanced disease about driving.

AIMS

To investigate current practice in providing advice to patients with advanced disease and identify areas of consensus or variation with the Australian driving guidelines.

METHODS

An online survey was distributed to Australian members of the Australian and New Zealand Society of Palliative Medicine. Responses were analysed using descriptive statistics.

RESULTS

The survey was distributed to 322 Australian and New Zealand Society of Palliative Medicine members and received 92 responses (29% response rate). Most respondents were aware of the driving guidelines (76%) and about half of the respondents had read the driving guidelines (55%). The majority of respondents had been asked to provide advice about driving to their patient or patient's caregiver (91%). Most respondents had asked a patient to stop driving (94%), but only 27% had reported a patient to the Driver Licensing Authority. Only 14% of respondents were in consensus with the guidelines in providing driving advice to a patient with asymptomatic brain metastases. Most doctors (64%) advise patients to refrain temporarily from driving post-short-acting oral morphine, with 4 h (36%) being the most common time period for not driving.

CONCLUSIONS

This is the first survey investigating the practice of Australian doctors in assessing fitness to drive of patients with advanced disease. The survey found wide variability in practice and substantial discordance with current driving guidelines.