Lung cancer

Why physicians should be ‘driving instructor’ when it comes to opioids: Natasha Smallwood


When it comes to opioid prescribing, respiratory physician Associate Professor Natasha Smallwood says discussion is lacking in a critical area that can put patients and the public at risk for harm: driving.

Of 1022 outpatients with advanced non small cell lung cancer (NSCLC) seen between 2015 and 2019 , 205 were commenced on opioid therapy.  Some 47 (23%) patients had driving status documented. Of those, education about driving safety while on opioids was provided to just two (1%) patients  while 10 (5%) patients received opioid-related driving education at least once at follow-up appointments which was provided by a palliative care clinician for nine patients and for one by a medical oncologist.

The review is the first Australian study to investigate practices around driving status evaluation and provision of driving advice when opioids are prescribed to people with advanced cancer.

Study investigator Associate Professor Smallwood, from the Department of Respiratory and Sleep Medicine at The Royal Melbourne Hospital and The Alfred Hospital, said the findings have highlighted a gap in clinical practice, which was not unexpected. Anecdotally, the research team had all experienced patients coming to appointments and having little awareness of their impaired driving status while on opioids, which prompted the study.

Speaking to the limbic Professor Smallwood said whether conversations about opioids and driving were not happening or were happening and not being documented was unknown but added that both cases were a problem.

“Even if we assume there is a better case scenario – that these conversations are happening and it’s just a failure of documentation – that documentation is actually very important for the next clinician who really needs to build on that conversation, particularly if there’s an opioid dose change or a change in clinical status. So this really interrupts the continuity of care that’s being provided by a very diverse multidisciplinary team.”

Professor Smallwood also points out that conversations about opioids and driving should be ongoing enabling patients to make responsible decisions especially because in the palliative care population, cancer, different treatments, comorbidities and frailty may all negatively impact driving ability, independent of opioids.

“It’s like with any medication – we should be thinking about what the risks and benefits are and what the potential interactions are and if we’re thinking about that then we have a responsibility to share that with the patient sot they can make responsible decisions, be informed and enabled to participate in the decision making for their care so that they can understand what the risks are and what the overall side effects are.”

When patients  have that information they can modify when they take the drugs she adds so that they can drive safely, retaining the independence that driving affords them – a factor relating to better quality of life outcomes, she adds.

“Particularly if patients do experience a bit of sedation or drowsiness related to an opioid a lot will decide, if they need to go out, to take the opioid at a time that will not impact on their driving.”

Patients should also be told about side effect tolerance and reminded about driving risks when opioid doses are increased, she added.

Commenting on why these important conversations and efforts to document them were so commonly sidelined, Professor Smallwood cited limited time in clinic and an assumption that perhaps other clinicians were talking to patients about driving.

But she urged clinicians prescribing opioids to start the conversation.

“People may not remember to do this – we’re talking to patients about their diagnosis, their response to specific treatments, advanced care planning and driving is probably something that’s moved down on the priory list for discussion but actually, from a patient perspective, we can see from other patient groups that this is a priority.

“You see the person sitting opposite you as a patient and you sometimes forget they have a multifaceted life and that driving is a key factor in maintaining quality of life and independence.”

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