Outpatient Palliative Care Clinic Research Articles

Palliative specialty care availability for adults in community oncology practices.

e24110 Background: The American Society of Clinical Oncology recommends integration of palliative care in patients with advanced cancer. Studies have shown the availability of palliative care services, especially in outpatient settings, varies widely across practice sites; factors associated with outpatient palliative care clinic availability remain unknown. Our study describes the presence and characteristics of palliative care resources in community oncology practices. Methods: Analyses used data from the 2015 Cancer Care Delivery Research (CCDR) Landscape Assessment of National Cancer Institute Community Oncology Research Program (NCORP) practices (funding support provided by 2UG1CA189824). Oncology practices were surveyed regarding availability of specialty providers and supportive services, including palliative care, as reported by designated CCDR leads. Descriptive statistics describe availability of providers and services, and logistic regression models identify practice characteristics associated with supportive/palliative care specialist availability. Results: 216 non-pediatric exclusive NCORP practice groups were included in analyses. Characteristics are shown in Table. A majority of practices had palliative care specialists (76%), oncology certified nurses (95%), and advance practice providers (80%); 45% had nurse navigators for oncology. 76% of practices had inpatient palliative care consultation services, but only 36% had a dedicated outpatient palliative care clinic. Multivariable analyses demonstrated practices with Medicaid and/or uninsured patient volumes > 25% (Odds Ratio (OR) = 2.5, p = 0.020), more oncology providers (OR = 1.02, p = 0.025), survivorship clinic availability (OR = 2.5, p = 0.005), and who participated in the Quality Oncology Practice Initiative (QOPI) (OR = 2.0, p = 0.039) were significantly more likely to have an outpatient palliative care clinic. Conclusions: Most community oncology practices reported having palliative care specialists, although only a third had a dedicated outpatient palliative care clinic. Newly discovered factors associated with increased odds of having an outpatient palliative care clinic can inform future efforts to expand the availability of outpatient palliative care clinics within community oncology practices.[Table: see text]

Managing Opioids in Cancer Patients at High Risk for Substance Use Disorders: Experience from an Outpatient Palliative Care Clinic (RP311)

Managing Opioids in Cancer Patients at High Risk for Substance Use Disorders: Experience from an Outpatient Palliative Care Clinic (RP311)

QP1: Development of PharmPAL: A Collaborative Practice Pharmacy Clinic in an Ambulatory Care Clinic

Background: As authoritative resources on the optimal use of medications in symptom management, palliative care pharmacists exemplify several clinical, administrative, and educational roles within the outpatient clinic setting. Knowledge of medication-use processes allows pharmacists the ability to improve patient safety and outcomes. In 2018 a quality improvement project to optimize the scheduling of pharmacist-provider joint visits in the Dana-Farber Cancer Institute Outpatient Palliative Care Clinic led to overwhelming Adult Palliative Care (APC) provider satisfaction. Given this success and continued desire for pharmacy collaboration, the “PharmPAL” Clinic was initiated in July of 2020. PharmPAL is a collaborative drug therapy management (CDTM) clinic where credentialed pharmacists lead intermediary and follow-up palliative care visits encompassing patient assessments, counseling, education, ordering of laboratory tests, and selecting, initiating, continuing, and modifying medication regimens. The goal of PharmPAL is to support the growth of the palliative care clinic by providing care to patients with intense symptom management needs through interval visits with a pharmacist within their credentialed scope of practice, increasing the availability of follow-up to patients. Methods: Through a survey disseminated to all outpatient palliative care providers, reasons for referral for both joint visits and PharmPAL visits were gathered. Based on an overwhelming percentage of providers in favor of increasing PharmPAL visits, the weekly availability increased from eight 30 minute appointments per week in the first seven months to twelve 30 minute appointments each week. Results: The top five reasons for PharmPAL referral include new consult requiring close follow-up, education and counseling, stable patient for refill review, schedule availability, and regimen or medication change in the previous visit or anticipated in visit. Barriers to utilizing PharmPAL include pharmacist availability, APC scheduling, and out-of-state patients. An increase in PharmPAL availability has led to an increased volume of patients and encounters for both PharmPAL and the outpatient clinic overall. Additional surveys will be employed to address feedback for ongoing areas for improvement in order to reach our goal of a 30% increase of PharmPAL referrals within the first three months and continued improvement in overall provider satisfaction with PharmPAL. Conclusion: As outpatient palliative care clinics are incorporating pharmacist-led visits into practice, identification of outcomes metrics is critical to the ongoing growth of these clinics. Over the next several months we plan to continue to assess the impact PharmPAL has on clinic operations and provider satisfaction in the Dana-Farber Cancer Institute outpatient palliative care clinic.

QP7: Use of Buprenorphine for Pain Management in an Outpatient Palliative Care Clinic Serving an Oncology Patient Population

"QP7: Use of Buprenorphine for Pain Management in an Outpatient Palliative Care Clinic Serving an Oncology Patient Population." Journal of Pain & Palliative Care Pharmacotherapy, 35(4), p. 239

Effect of Cancer Pain Guideline Implementation on Pain Outcomes Among Adult Outpatients With Cancer-Related Pain

An evidence-practice gap exists for cancer pain management, and cancer pain remains prevalent and disabling. To evaluate the capacity of 3 cancer pain guideline implementation strategies to improve pain-related outcomes for patients attending oncology and palliative care outpatient services. A pragmatic, stepped wedge, cluster-randomized, nonblinded, clinical trial was conducted between 2014 and 2019. The clusters were cancer centers in Australia providing oncology and palliative care outpatient clinics. Participants included a consecutive cohort of adult outpatients with advanced cancer and a worst pain severity score of 2 or more out of 10 on a numeric rating scale (NRS). Data were collected between August 2015 and May 2019. Data were analyzed July to October 2019 and reanalyzed November to December 2021. Guideline implementation strategies at the cluster, health professional, and patient levels introduced with the support of a clinical champion. The primary measure of effect was the percentage of participants initially screened as having moderate to severe worst pain (NRS ≥ 5) who experienced a clinically important improvement of 30% or more 1 week later. Secondary outcomes included mean average pain, patient empowerment, fidelity to the intervention, and quality of life and were measured in all participants with a pain score of 2 or more 10 at weeks 1, 2, and 4. Of 8099 patients screened at 6 clusters, 1564 were eligible, and 359 were recruited during the control phase (mean [SD] age, 64.2 [12.1] years; 196 men [55%]) and 329 during the intervention phase (mean [SD] age, 63.6 [12.7] years; 155 men [47%]), with no significant differences between phases on baseline measures. The mean (SD) baseline worst pain scores were 5.0 (2.6) and 4.9 (2.6) for control and intervention phases, respectively. The mean (SD) baseline average pain scores were 3.5 (2.1) for both groups. For the primary outcome, the proportions of participants with a 30% or greater reduction in a pain score of 5 or more of 10 at baseline were similar in the control and intervention phases (31 of 280 participants [11.9%] vs 30 of 264 participants [11.8%]; OR, 1.12; 95% CI, 0.79-1.60; P = .51). No significant differences were found in secondary outcomes between phases. Fidelity to the intervention was low. A suite of implementation strategies was insufficient to improve pain-related outcomes for outpatients with cancer-related pain. Further evaluation is needed to determine the required clinical resources needed to enable wide-scale uptake of the fundamental elements of cancer pain care. Ongoing quality improvement activities should be supported to improve sustainability.

Frequência de queixas de deglutição e alimentação durante consulta compartilhada em cuidados paliativos oncológicos

ABSTRACT Purpose to identify the frequency of swallowing and feeding complaints in cancer patients in palliative care, and to associate them with clinical and functional data. Methods cross-sectional and descriptive study, carried out with cancer patients treated during shared consultation in a palliative care outpatient clinic, through speech-language pathology screening, protocols and scales, with statistical analysis of the obtained data. Results Sample consisted of 52 subjects, seen during 8 months, with a mean age of 66.7 years, PSS (Palliative Performance Scale) a mean of 57.5. The topography of the most frequent neoplasm was the gastrointestinal tract and the treatment was surgery and associated chemotherapy and radiotherapy . Complaints identified at screening were categorized into swallowing and feeding. Thus, swallowing was the most frequent and a large part of the sample required a functional assessment of swallowing. Only the association between swallowing complaints and the topography of the gastrointestinal tract showed a significant statistical relationship. Swallowing complaints were more frequent in those undergoing radiotherapy and with lower percentages on the PPS scale. Conclusion swallowing complaints were the most frequent and the associations made it possible to relate them to the location of the tumor, and to identify their frequency according to cancer treatment and terminal functional decline.

COVID-19 - Initial Lockdown: Implications on Cancer Treatment among Palliative Care Outpatients.

Objectives:The pandemic and the lockdown has challenged palliative care patients especially those on palliative oncological treatments. This study aims to understand the effect of COVID-19 and initial lockdown on palliative oncological treatments among palliative care patients.Materials and Methods:A retrospective chart review of patients who attended the palliative care outpatient clinic, between 21 April and 12 May 2020, was done. Sociodemographic and palliative oncological treatment details were reviewed.Results:Of the 107 patients included, 53.7% were between 40 and 60 years of age, and 58.3% were women. A large proportion (63%) was unemployed and 40.2% had to rent vehicles for hospital travel. During this period, palliative oncological treatment was interrupted or deferred in 20% and 3.5%, respectively. During this period, homecare services were also affected in about 12.2% of our patients.Conclusion:The COVID-19 pandemic and the lockdown have affected the palliative oncological treatment of palliative care outpatients with cancer. The implications of interrupted and deferred treatment on patient outcomes would be seen in the months and years to follow. Palliative care teams should enhance patient and caregiver support and promote non-abandonment and continuum of care during such unprecedented times.

Prospective Study of a Novel Risk Stratification Process for Opioid-Related Harm Reduction in Cancer Patients Seen in an Outpatient Palliative Care Clinic.

Background: Oncologists and palliative specialists prescribe opioids for millions of cancer patients despite limited research on effective screening and mitigation strategies to reduce risk of opioid-related harm in that population. Objective: To evaluate the efficacy of a novel opioid risk stratification process for predicting significant aberrant behaviors (SABs) related to prescribed opioid medications. Design and Setting/Subjects: This is a prospective, longitudinal study of 319 consecutive patients referred to an outpatient palliative care clinic between 2010 and 2012, a period during which prescription opioid-related deaths began to increase in the United States. Measures: Patients completed a psychodiagnostic/substance use risk assessment with a licensed clinical psychologist or social worker at the initial palliative clinic visit. Patients were assigned to Low-, Moderate-, or High-Risk groups based on predetermined stratification criteria and were managed via an opioid harm reduction approach. The primary dependent measure was the presence of at least one SAB after the initial visit. Results: Eighteen percent of patients (n = 56) demonstrated at least one major aberrant behavior. Odds of future aberrant behavior was 15 times greater in the High-Risk versus the Low-Risk category. Five risk factors significantly enhanced our risk model: age 18 to 45 years, job instability, history of bipolar diagnosis, history of substance abuse, and theft. Conclusion: Our risk stratification process provides a useful model for predicting those at greatest risk of future aberrant behaviors and most in need of comanagement. We recommend additional studies to test our proposed streamlined risk stratification tool.

Spiritual AIM: assessment and documentation of spiritual needs in patients with cancer

The chaplain is an essential member of the palliative care (PC) team, yet, standard methods to document chaplain assessments are lacking. The study team performed a retrospective analysis of chaplaincy documentation in an outpatient PC clinic at an academic medical center over 6 months (April 2017 to October 2017). The study team identified unique adult patients with cancer, then manually extracted variables from the electronic medical record. The primary objective was to assess the number of spiritual assessments documented by the chaplain. Secondary objectives included descriptive analysis of identified spiritual needs. Out of the 376 total patient encounters, 292 (77.8%) included documentation of a chaplain’s spiritual assessment. The most frequent spiritual need was self-worth/community (n = 163, 55.8%). This study demonstrates that chaplains can effectively document Spiritual AIM-based screening and assessment. Moreover, this may be an effective documentation method across institutions to facilitate chaplain-based data.

Update in palliative care in gynecologic oncology.

This review summarizes research advances in quality of life, symptom management, and end-of-life practices within palliative care that can benefit patients with gynecologic cancers. Addressing fertility issues, sexual side effects, and possible disease recurrence can promote quality of life in gynecologic cancer survivors. Cannabis can provide some benefit for nausea and neuropathic pain, yet for nonneuropathic pain presentations, it does not appear to provide significant benefit in reducing opioid usage. Lastly, palliative care outcomes, such as reduced aggressive care at the end of life and higher rates of hospice enrollment are augmented by the presence of an outpatient palliative care clinic. Ongoing advances in palliative care research hold potential for improvement in systems delivery of palliative care as well as symptom management and psychosocial support.

Factors Associated with the Costs of Palliative Care: A Retrospective Cost Analysis at a University Cancer Hospital in Brazil.

Background: There have been few studies evaluating the costs of palliative care (PC) in low- and middle-income countries (LMICs), especially for patients with cancer. Objectives: The objective of this study was to identify the sociodemographic and clinical variables that could explain the cost per day of PC for cancer in Brazil. Methods: This was a retrospective cost analysis of PC at a quaternary cancer center in São Paulo, Brazil, between January 2010 and December 2013. Factors influencing the cost per day were assessed with generalized linear models and generalized linear-mixed models in which the random effect was the site of the cancer. Results: The study included 2985 patients. The mean total cost per patient was $12,335 (standard deviation [SD] = 14,602; 95% confidence interval [CI] = 11,803 to 12,851). The mean cost per day per patient was $325.50 (SD = 246.30, 95% CI = 316.60 to 334.30). There were statistically significant differences among cancer sites in terms of the mean cost per day. Multivariate analysis revealed that the drivers of cost per day were Karnofsky performance status, the number of hospital admissions, referral to PC, and place of death. Place of death had the greatest impact on the cost per day; death in a hospital and in hospice care increased the mean cost per day by $1.56 and $1.83, respectively. Conclusion: To allocate resources effectively, PC centers in LMICs should emphasize early enrollment of patients at PC outpatient clinics, to avoid hospital readmission, as well as advance planning of the place of death.

The Integration of Palliative Care in General Internal Medicine Practice (QI716)

1.Contrast our unique outpatient palliative care clinic model embedded within general internal medicine to more common models.2.Evaluate the feasibility and impact of implementing our embedded outpatient palliative clinic model. Over time outpatient palliative care has changed, extending to management of patients with chronic disease. Well-studied outpatient clinic models (particularly in heart failure and oncology) improve access and outcomes, especially if patients are referred early. However, there is a lack of data assessing the impact of embedding palliative care within general internal medicine. Our study aims to evaluate outcomes and patient satisfaction of our novel interdisciplinary palliative clinic model embedded in internal medicine at the Medical University of South Carolina (MUSC). In this pilot study, eligible patients identified from our clinic were enrolled in the study (n=76) (IRB# 94172). Research Assistants (RAs) orally consented and conducted single interviews with a subsection of 13 voluntarily recruited participants, completing the Palliative Care Clinic Questionnaire. Descriptive statistics, including medians and proportions, were employed using Excel. A total of 76 participants were enrolled in the study. Of those, 13 to date were consented for the sub-study and completed the questionnaire. In our preliminary analysis, the median time as a patient in this clinic was 3 months (n=11) and the median number of hospitalizations over the last year was 1.0 (n=13). Additionally, 92% (11/12) agreed to feeling an overall improvement in their quality of life (QOL) since becoming a patient of this clinic and 100% (11/11) agreed their symptoms had been better managed. Further, of those who had completed an advanced directive (AD), 33% (4/12) had completed their AD in this clinic. Benefits of this clinic include improvement in patient QOL, symptom management, and advance care planning. This model reaches patients with complex medical issues, even without a single overriding life-limiting illness. It highlights the feasibility of improving continuity of care with hospice transitions, assisting with psychosocial needs, and increasing palliative medicine exposure to resident physicians.

Palliative Care Specialist Access is Associated With Rankings of Hospital Quality

ContextIncreasing evidence has shown that access to specialty palliative care, particularly outpatient palliative care clinics, can yield improved health outcomes and be a marker of hospital quality. ObjectiveTo determine whether an association exists between access to specialty palliative care programs and hospital rankings found in the 2020-2021 U.S. News & World Report Best Hospitals. MethodsThis study used publicly available data from the Center to Advance Palliative Care (CAPC) Provider Directory to determine access to in-patient and out-patient palliative care in the 2020-2021 U.S. News & World Report Best Hospitals Rankings. Descriptive statistics and chi-squares were performed. Data were also analyzed across the four U.S. Census Bureau regions (Northeast, South, Midwest, West). ResultsAround 100% of the Top 20 hospitals include hospital-based palliative care consultation teams, and 95% offered outpatient palliative care. Of the second cohort of 83 hospitals, 99% offered inpatient palliative care, and 65% offered outpatient palliative care. Of the third cohort of 75 hospitals ranked, 96% had inpatient palliative care services, while only 41.3% offered outpatient palliative care. This represents a significant association between rank position and access to outpatient palliative care (P < 0.01). Ranked hospitals also have significantly higher access to hospital-based palliative care teams compared to the national prevalence rate (P < 0.01). ConclusionThese findings reflect the association of access to specialty palliative care with USNWR rankings for hospital quality. Further study is necessary to determine the specific influence of access to palliative care and USNWR rank position.

Rapid Conversion of a Palliative Care Outpatient Clinic to Telehealth.

The coronavirus pandemic has transformed the practice of medicine, forcing a rapid transition to telehealth. As a specialty, palliative care relies upon expert-level communication and interdisciplinary care. We describe the transition of the Dana-Farber Cancer Institute palliative care clinic into a predominantly telemedicine model. We document how we significantly increased goals of care conversations while maintaining patient volume and interdisciplinary care. We present how the components of a palliative visit translate into a virtual model. While the transition away from in person visits occurred rapidly, telehealth is likely here to stay. We define the challenges and benefits encountered through increased use of telehealth and identify disparities in healthcare access that will become more pronounced as we move into a communication technology dependent future. We discuss how the pandemic changed the delivery of palliative care in ways that will endure beyond the coronavirus pandemic.

A New Integrated Healthcare Model: Radiotherapy and Palliative Care (RaP) Outpatient Clinic

A New Integrated Healthcare Model: Radiotherapy and Palliative Care (RaP) Outpatient Clinic

Young Adult Experience in an Outpatient Interdisciplinary Palliative Care Cancer Clinic.

Young adults (YAs; defined as 18-39 years of age) with advanced cancer are a group for whom standardized age-appropriate palliative care has not been established. The purpose of this study was to explore the YA experience and perceptions of palliative care in an outpatient interdisciplinary palliative care clinic for this population. Using an interpretive descriptive design, semistructured interviews were conducted with 12 YAs with advanced cancer who were being seen jointly by a palliative care physician and psychiatrist in an ambulatory palliative care clinic. Interviews explored participants' understanding and experiences of receiving palliative care. Six family members were also interviewed to build on the YA experience. Data collection and analysis occurred concurrently, drawing on the constructivist grounded theory method to analyze the data. Participants described being referred to and seen in the interdisciplinary palliative care clinic as a conflicting and at times difficult experience because of the feeling of being categorized as palliative as YAs. Even so, there were key aspects associated with the specific palliative care approach that allowed YAs to cope with this new label, leading to a beneficial experience, specifically: provided YAs with time and space to explore the experience of having cancer at a younger age, created repeat opportunities to talk openly with people who "got it," and highlighted the importance of including family support in the care of YAs. YAs who were referred to the interdisciplinary palliative care clinic struggled with the category of palliative care but also found the care they received beneficial. Findings provide an approach to palliative care tailored to YAs with advanced cancer.

1724P Changes in the outpatient and inpatient clinic admissions during COVID-19 pandemic: Anticipating and mitigating risks for cancer patients

Prioritizing the continuum of care for cancer patients while maximizing patient safety is of paramount importance. However, COVID-19 pandemic could create a collateral damage in all domains of cancer care. Here, we evaluate the early changes in the inpatient and outpatient oncology clinics and discuss how we currently anticipate and mitigate risks for cancer patients at the Hacettepe University Cancer Institute by employing adaptive algorithms. Patients applying the outpatient clinic and outpatient palliative care (OPC) clinic for the first time and patients admitted to wards in the first 30 days after the first case of COVID-19 in Turkey were evaluated. This data was compared to data from the same time frame in the previous three years. A total of 868 inpatient and 809 outpatient admissions were evaluated in the study with a 114 OPC clinic admissions. The mean number of daily new patient applications to the outpatient clinic (9.87±3.87 vs. 6.43±4.03, p<0.001) and OPC clinic (3.87±1.49 vs. 1.13±1.46, p<0.001) was significantly reduced compared to the previous years. The reduction in new patient numbers was observed for all tumor types with the exception of lung and head and neck cancers. While the number of inpatient admissions was similar for a month frame (228 vs. 213), the median duration of hospitalization was significantly reduced (2 vs. 3 days). The frequency of hospitalizations for chemotherapy was higher than in previous years (p<0.001). By comparison, the rate of hospitalizations for palliative care (P=0.028) or elective interventional procedures (P=0.001) was significantly reduced. In our experience, continuing the patients’ treatment with simple precautions was possible with simple measures. There were significant drops in the numbers of newly diagnosed patients and patients having palliative care services and these problems should be incorporated into the risk mitigation algorithms.

Outpatient Cardiac Palliative Care Reduces Healthcare Utilization (RP524)

•Outline hospitalization and healthcare utilization savings from an outpatient palliative care clinic.•Analyze the impact of a high value cardiac palliative care clinic from for a healthcare institution. The American Heart Association and American Stroke Association have put forth policy statements recommending early and continuous access to palliative care for patients with advanced heart disease. Early integration of palliative care has been proven to improve the quality of life of patients with advanced heart failure. Other studies have suggested that palliative care in general has cost savings to hospital systems. Determine if outpatient cardiac palliative care impacts hospitalization rates and cost of care in a quaternary care center. A cardiac specific outpatient palliative care clinic was opened at a major academic medical center in the United States. In the first 6 months (N=104) patients were referred to the clinic for goals of care and symptom management. Patients were tracked 90 days prior to their initial outpatient palliative care clinic visit and 90 days post visit to assess hospital utilization and total cost of care in the university hospital system. Total hospitalizations reduced 30% (91 prior to palliative care compared to 64 post). 30-day readmission dropped by 11%. 36% (N=33) of pre-intervention hospitalizations were 30-day readmissions compared to 25% (N=16) in the post intervention time period. Total per-patient hospital system health expenditures were $121,549 pre-palliative intervention and reduced to $60,857 post-palliative intervention. This represents a total reduction in health spending of $5,886,599.51 in the post palliative care time period. Average per hospital stay cost dropped by 27% from $133,571 to $97,943. A paired T-test shows this is a statistically significant reduction in per hospital stay charges (p=0.03). Outpatient palliative care is known to improve quality of life in patients with advanced heart disease. Integration of outpatient cardiac palliative care reduces hospitalizations, 30-day readmission, total healthcare expenditures, and reduces cost of hospitalizations.

Outpatient palliative medicine consultations: urgent or routine?

BackgroundAlthough outpatient palliative care clinics (OPCCs) provide a venue for early, pre-emptive referral to palliative care on a routine basis, some patients will continue to require urgent referrals. The purpose...

Frequency of Concomitant Use of Gabapentinoids and Opioids among Patients with Cancer-Related Pain at an Outpatient Palliative Care Clinic.

Background: Patients with cancer-related pain use opioids for nociceptive pain, while gabapentinoids are common to treat neuropathic pain. The simultaneous use of opioids with gabapentinoids has been associated with an increased risk of opioid-related death. Objectives: Determine the frequency of combined use of gabapentinoids among patients receiving opioids for cancer-related pain. We also examined if concomitant use of opioids and gabapentinoids together was associated with increased scores of fatigue and drowsiness on the Edmonton Symptom Assessment Scale (ESAS) compared to patients on opioids. Design: Retrospective study of patients on opioids and opioids plus gabapentinoids at their third visit to the outpatient Supportive Care Center. Results: We found that 48% (508/1059) of patients were on opioids. Of these patients, 51% (257/508) were on opioids only, and 49% (251/508) were on opioids plus gabapentinoids. The median (interquartile range [IQR]) morphine equivalent daily dose for patients on opioids was 75 (45, 138) mg, and opioids plus gabapentinoids was 68 (38, 150) mg (p = 0.94). The median (IQR) gabapentinoid equivalent daily dose was 900 (300, 1200) mg. The median (IQR) for ESAS-fatigue in patients on opioids was 5 (3, 7), and opioids plus gabapentinoids was 5 (3, 7) (p = 0.27). The median (IQR) for ESAS-drowsiness in patients on opioids was 3 (0, 5), and opioids plus gabapentinoids was 3 (0, 6) (p = 0.11). Conclusion: Almost 50% of advanced cancer patients receiving opioids for pain were exposed to gabapentinoids. Maximal efforts should be made to minimize potential complications from the concomitant use of opioids with gabapentinoids.