Abstract
Background Practices related to the handling of controlled substances (CS) in Ontario hospices have not been previously published and therefore, are unknown. Objective The objective of this study was to determine current practices, and policies, standard operating procedures (SOPs) and guidelines related to handling and disposal of CS at hospices across Ontario. Setting This study was a cross-sectional survey of hospices in Ontario. Method A list of all hospices in Ontario, 39 in total, was obtained from Hospice and Palliative Care Ontario. The Director at each hospice was contacted to request contact information on the person most likely to be knowledgeable about handling procedures related to CS. All participants who provided consent were asked to complete a telephone survey composed of 32 questions: 20 multiple-choice and 12 open-ended. Of the 20 multiple-choice, eight requested demographics of the hospice, nine were related to disposal and documentation practices. Main outcome measure Demographic information, disposal practices and patterns of care were summarized and presented as frequencies or means. Responses to open-ended questions were analyzed qualitatively to identify themes related to the handling and disposal of controlled substances in hospices. Results Twelve hospices (12/39; 31%) participated in the survey, 25 did not, and two were ineligible. Two (2/12, 17%) hospices served both pediatric and adult patients while 10 (83%) served adults only; 100% indicated that 76–100% of their patients were on CS at time of death. Eight (67%) had a policy for controlled substances handling, two had policy and SOPs and two had no policies, guidelines or SOPs. Qualitative analysis indicated variability in procedures for obtaining CS (patient’s own supply, other patient’s supply, hospice associated pharmacy), storage and dispensation of CS (location, secure lock, dispensing by staff or family), documentation (dispensing records, double signature, tracking returns and disposal), and disposal of CS (return to pharmacy, disposal at hospice, return to families). Conclusion Although most of the hospices have a policy, guideline or SOP on the handling of CS, there is considerable variation in practice of dispensing CS to patients, documentation and disposal of CS, which may provide an avenue for inappropriate use, abuse or diversion of CS.
Similar content being viewed by others
References
Fischer B, Pang M, Tyndall M. The opioid death crisis in Canada: crucial lessons for public health. Lancet Public Health. 2019;4(2):e81–2.
Gomes T, Tadrous M, Mamdani MM, Paterson JM, Juurlink DN. The burden of opioid-related mortality in the United States. JAMA Netw Open. 2018;1(2):e180217. https://doi.org/10.1001/jamanetworkopen.2018.0217.
Government of Canada. Updated numbers on opioid-related overdose deaths in Canada - Canada.ca [Internet]. Public Health Agency of Canada. 2019. https://www.canada.ca/en/public-health/news/2019/04/updated-numbers-on-opioid-related-overdose-deaths-in-canada.html. Accessed 11 Nov 2019.
Gomes T, Khuu W, Martins D, Tadrous M, Mamdani MM, Paterson JM, et al. Contributions of prescribed and non-prescribed opioids to opioid related deaths: Population based cohort study in Ontario. Canada. BMJ. 2018;2018:362. https://doi.org/10.1136/bmj.k3207.
Government of Canada. National Report: Apparent opioid-related deaths in Canada - Data Blog - Public Health Infobase | Public Health Agency of Canada. 2019. https://health-infobase.canada.ca/datalab/national-surveillance-opioid-mortality.html#AORD. Accessed 11 Nov 2019.
Health Canada. Framework on Palliative Care in Canada. 2018 https://www.canada.ca/en/health-canada/services/health-care-system/reports-publications/palliative-care/framework-palliative-care-canada.html#p1.1. Accessed 13 Nov 2019.
World Health Organization. WHO | WHO Definition of Palliative Care . https://www.who.int/cancer/palliative/definition/en/. Accessed 12 Feb 2020.
Health Quality Ontario. Palliative Care at the End of Life: Report Update 2019. https://www.hqontario.ca/Portals/0/documents/system-performance/palliative-care-report-2019-en.pdf. Accessed 2 Dec 2019.
British Columbia Ministry of Health, Doctors of BC, BC Cancer Agency. Palliative care for the patient with incurable cancer or advanced disease Part 2: Pain and Symptom Management. 2017. www.bc-cpc.ca/cpc/symptom-management-guidelines/. Accessed 13 Nov 2019.
Mejin M, Keowmani T, Abdul Rahman S, Liew J, Lai J, Chua M, et al. Prevalence of pain and treatment outcomes among cancer patients in a malaysian palliative care unit. Pharm Pract (Granada). 2019;17(1):1–9.
Speer ND, Dioso J, Casner PR. Costs and implications of discarded medication in hospice. J Palliat Med. 2013;16(8):975–8.
National Hospice and Palliative Care Organization. NHPCO Facts and Figures: Hospice Care in America. 2012. https://www.medpagetoday.com/upload/2012/1/16/2011_Facts_Figures.pdf. Accessed 13 Nov 2019.
Wood H, Dickman A, Star A, Boland JW. Updates in palliative care—overview and recent advancements in the pharmacological management of cancer pain. Clin Med J (Lond). 2018;18(1):17–22.
Durán-Crane A, Laserna A, López-Olivo MA, Cuenca JA, Díaz DP, Cardenas YR, et al. Clinical practice guidelines and consensus statements about pain management in critically ill end-of-life patients: a systematic review. Crit Care Med. 2019;47:1619–26.
Caraceni A, Hanks G, Kaasa S, Bennett MI, Brunelli C, Cherny N, et al. Use of opioid analgesics in the treatment of cancer pain: evidence-based recommendations from the EAPC. Lancet Oncol. 2012;13(2):58–68.
World Health Organization. WHO | WHO’s cancer pain ladder for adults. WHO. 2013. https://www.who.int/cancer/palliative/painladder/en/. Accessed 13 Nov 2019.
Madadi P, Hildebrandt D, Lauwers AE, Koren G. Characteristics of opioid-users whose death was related to opioid-toxicity: a population-based study in ontario. Canada. PLoS One. 2013;8(4):e60600. https://doi.org/10.1371/journal.pone.0060600.
Blackhall LJ, Alfson ED, Barclay JS. Screening for substance abuse and diversion in virginia hospices. J Palliat Med. 2013;16(3):237–42.
Kneuss TG, Protus BM, Lovell AG, Kullgren JG. State legislation to prevent diversion of opioids in hospice programs. J Hosp Palliat Nurs. 2019;21(5):365–72.
Government of Canada, Minister of Justice. Part III: Disposal of Controlled Substances. Controlled Drugs and Substances Act 2015.
Canadian Hospice Palliative Care Association, Canadian Home Care Association. The Pan-Canadian Gold Standard for Palliative Home Care Toward Equitable Access to High Quality Hospice Palliative and End-of-Life Care at Home. Ottawa, ON: Canadian Hospice Palliative Care Association, 2006. https://www.acsp.net/product/the-pan-canadian-gold-standard-for-palliative-home-care-download-anglais/ Accessed 14 Feb 2020.
Canadian Hospice Palliative Care Association. A model to guide hospice palliative care. Ottawa, ON: Canadian Hospice Palliative Care Association 2013. https://www.chpca.ca/wp-content/uploads/2019/12/norms-of-practice-eng-web.pdf Accessed 14 Feb 2020.
Government of Canada. Controlled Drugs and Substances Act. 1996. https://laws-lois.justice.gc.ca/eng/acts/c-38.8/ Accessed 14 Feb 2020.
Ali MM, Henke RM, Mutter R, O’Brien PL, Cutler E, Mazer-Amirshahi M, et al. Family member opioid prescriptions and opioid use disorder. Addict Behav. 2019;95:58–63.
McCabe SE, Cranford JA, Boyd CJ, Teter CJ. Motives, diversion and routes of administration associated with nonmedical use of prescription opioids. Addict Behav. 2007;32(3):562–75.
Ontario College of Pharmacists. Destruction of Narcotics, Controlled Drugs, and Targeted Substances. https://www.ocpinfo.com/practice-education/practice-tools/fact-sheets/destruction/. Accessed 12 Feb 2020.
Hospice and Palliative Nurses Association. Position statement: medication safety in hospice and palliative care settings. J Hosp Palliat Nurs. 2019;21:E24–7.
Acknowledgements
The authors would like to thank Hospice and Palliative Care Ontario for their assistance with this study.
Funding
None.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflicts of interest
The authors declare they have no conflicts of interest.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Patel, T., Hasan, S., Chang, F. et al. Controlled substances in hospices after patient death: a cross-sectional survey of Ontario hospices. Int J Clin Pharm 42, 1344–1353 (2020). https://doi.org/10.1007/s11096-020-01097-y
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11096-020-01097-y