Keeping Fentanyl in the Palliative Care Clinician’s Pain Management Toolbox

Larry Beresford

Fentanyl is a powerful, Food and Drug Administration–approved synthetic opioid analgesic. When appropriately prescribed, it is a highly effective painkiller—both in the hospital and as a 72-hour, timed-release transdermal patch. The fentanyl patch has an important place in the pain management armamentarium of hospice and palliative care clinicians for patients with severe pain of long duration due to cancer or other serious illnesses.

But this strong analgesic, when illicitly manufactured and distributed, is also at the heart of an epidemic of drug overdose deaths in America. Fifty to 100 times stronger than other opioids such as morphine and heroin, and cheap to manufacture, it played a big part in the rapid growth of drug overdose deaths, from 52,623 in 2015 to 106,881 in 2023. Overall death rates have since declined, but the Centers for Disease Control and Prevention attribute nearly 50,000 overdose deaths in 2024 to fentanyl.¹

Recently the federal Drug Enforcement Administration (DEA) launched a “Fentanyl Free America” law enforcement and public awareness campaign aimed at disrupting the illicit supply chain for this dangerous drug, reducing its availability on the street, and thereby saving lives. A campaign summit including law enforcement personnel from across the country and families who had lost a loved one to the drug was held July 13 to 16 in Orlando, FL.

Although the DEA has not proposed limiting fentanyl’s legitimate use in hospice and palliative care, the medication’s public perception has become increasingly negative, creating barriers for clinicians who must navigate patient and family apprehension regarding its therapeutic role in symptom management. That is true even when the clinician believes it is the best choice medically for relieving the patient’s suffering. Providers have not been immune from the impact of the increased attention to fentanyl in the public sphere. For example, physicians have cited their own increased cautiousness about prescribing opioids while reporting pharmacies refusing to stock them, manufacturing quotas and shortages, and younger physicians shying away from pain training.²

“Last June [2025], after the annual meeting of the American Medical Association, a group of us there were talking about what we could do about these barriers to pain management,” said Chad Kollas, MD FACP FCLM FAAHPM, a supportive and palliative care physician with Orlando Health Medical Group in Orlando, FL. That resulted in the formation of the pain care discussion page on AAHPM Connect, to serve as a place for discourse and collaboration among Academy members.

The online discussion group now has 93 members. And fentanyl has been one of the topics discussed on that page, along with the DEA campaign. “So, then the question arises, well, what can we do about that?” Dr. Kollas noted. “The important thing that we try to do here in our own clinic [at Orlando Health]—and in some of the work I’ve done with AMA—is to clearly distinguish between illicit fentanyl and prescription fentanyl, which are really two different things. The media is really bad about making that distinction,” he said.

Confident Clinical Judgment

Sandeep Kapoor, MD, who teaches pain medicine, addiction medicine, and emergency medicine at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell in Hempstead, NY, is course director for a 4-year longitudinal curriculum focused on pain and substance use care, including an intensive core-learning week-long training for Zucker’s third-year medical students.

According to Dr. Kapoor, there is a lot of suffering out there from unrelieved pain, and a lot of negative messaging about opioids, especially fentanyl. “It’s hard not to be terrified by that word, especially because of the narratives that are out there, and obviously the prevalent loss of life that we’ve seen over the past decade due to fentanyl contamination,” he said.

“Regardless of what campaigns are out there, there is something to be said for sound-minded, evidence-based clinical judgment,” Dr. Kapoor explained. “And I would argue that these medications, including fentanyl, have a place in health care—and in palliative care. Clinicians will encounter patients with a cancer diagnosis as well as a history of substance use, and the latter should not cause you to freeze up and stop doing your job.”

“These medications, including fentanyl, have a place in health care—and in palliative care.”

The essential challenge for clinicians is to be confident in their clinical judgment, he said. “Do you know what you’re doing, and are you able to act on that confidence in an evidence-based way?” He emphasized that it is important that clinicians are able to talk about the evidence with confidence in order to share the positive impact of these medications for promoting quality of life through the relief of pain.

But Dr. Kapoor sees a lot of discomfort these days among clinicians around opioid prescribing, even hospice and palliative care clinicians, although one might say that discomfort is at the heart of palliative care. The key to comfort and confidence is knowledge. And the path to greater knowledge, he said, is education—whether through medical training, hospice and palliative medicine (HPM) fellowships, or subsequent training opportunities such as workshops and webinars offered by the Academy, the Hospice and Palliative Nurses Association, the End-of-Life Nursing Education Consortium, the Center to Advance Palliative Care, and others.

“One of the things we’ve tried to do at Hofstra/Northwell is to ensure that our students, before they leave our four walls at graduation, have a level of comfort, confidence, and competence in terms of supporting someone with acute or chronic pain and substance use disorders,” said Dr. Kapoor, who was recently elected president of the board of a national nonprofit called Coalition on Physician Education in Substance Use Disorders (COPE). COPE encourages medical schools to reflect on their current curriculums and to drive evolution in how they educate their students on pain and substance use.

Using These Medications Appropriately

Ben Thompson, MD, national medical director for workforce development and strategy at the hospice company Gentiva, was elected to AAHPM’s Board of Directors earlier this year. He is board-certified in both HPM and addiction medicine, and he noted that HPM clinicians routinely confront a lot of stigmas in their daily work. Dealing with the stigma of fentanyl is just one more big challenge for the field.

HPM clinicians routinely confront a lot of stigmas in their daily work. Dealing with the stigma of fentanyl is just one more big challenge for the field.

“If you’re using these medications appropriately, you know you don’t start an opioid-naïve patient on a long-acting fentanyl patch,” he explained. “You’re starting it on people who require a long-acting medication, based on their experience with short-acting drugs, and you’re using the evidence-based opioid equianalgesic formulas.”

Dr. Thompson cited a 2023 study in the Journal of Clinical Oncology showing that, from 2007 to 2017, there were steady declines in access to opioid analgesics, with patients receiving smaller doses of opioids.³ The study also found that Black and Hispanic patients were particularly impacted by these disparities.

HPM clinicians who also bring a background in addiction medicine have been trying to encourage the field’s routine screening of HPM patients for opioid use disorder (OUD)—normalizing this screening as a standard frontline practice, he said. They have brought many of the risk mitigation and harm reduction strategies from that field to palliative care. These include opioid risk assessments, behavioral contracts and prescribing agreements with patients, urine drug testing, use of state prescription drug monitoring programs, smaller and more frequent analgesic prescriptions, and lock boxes to hold medications in homes where security is a concern.⁴

Opioid stewardship has been defined as a greater focus on appropriate prescribing, monitoring opioid use, improving communication between patients and clinicians, and increasing patient involvement in decision making regarding both prescribing and deprescribing.⁵ It has been reported that many palliative physicians now document their opioid decisions in greater detail, more explicitly incorporating functional goals, symptom burdens not being met, prior nonopioid therapies that were attempted, and discussions of risks and benefits with the patient.

The Opioid Risk Tool (ORT)^6,7 is a brief self-report screening tool designed for use with adult patients in primary care settings to assess which individuals prescribed opioids for treatment of chronic pain may develop aberrant behaviors. But on the Academy’s social media platform, the standard ORT has been getting attention recently, with some Academy members expressing interest in developing alternative tools. “ORT is a screening tool, not very nuanced,” Dr. Thompson noted.

Meghan Murphy, DSW LCSW, whose current work focuses on the psychosocial and systemic factors that shape clinical practice, affirmed the need for nuanced approaches to risk assessment in palliative care. She said this is an important area of her own research, drawing on 13 years of experience as a palliative care social worker to explore how language, policy, education, and stigma impact care for patients with complex pain and substance use concerns.

Opioid use disorder is not just one thing, and it doesn’t happen in a vacuum. “There can be lots of reasons why someone might misuse drugs or opioids or any other illicit substance,” Dr. Murphy said. “There’s still this underlying issue where we blame the patient or blame the doctor. When we say ‘drug seeking,’ we lose sight of someone who is expressing their pain,” she said. “When you label a patient an addict, it’s in their chart like a scarlet letter. It’s like this person is a problem before we’ve even seen them.”

Harm Reduction

“Risk mitigation and harm reduction should be part of everything we do,” Dr. Thompson noted. “My former outpatient practice included those elements regularly to make sure that the patients under our care were appropriately screened and managed and monitored to mitigate the risks associated with these medications,” he said.

“We know that screening doesn’t happen universally with every patient, every time, as it should,” he added. “But in my own outpatient palliative care practice, every single patient who came into the clinic gave a urine sample. We used that and the ORT because we believed the way to combat stigma is with normalization. If you screen everyone every time, then you’re not going to miss anyone, and you take out prescriber bias.”

Diana Martins-Welch, MD, a hospice and palliative medicine physician at Northwell Health, said she doesn’t normally get a behavioral contract on file or subject her patients to random urine testing. “Most of my patients have stage IV cancer, and I’m the one trying to urge them to use the opioids,” she said.

“Most of my patients have stage IV cancer, and I’m the one trying to urge them to use the opioids.”

“I try to train doctors to have empathy and to put themselves in the patient’s shoes. We’re not dogmatic, and we’re not going to be taken advantage of. But that is a delicate balance,” she said. How do you prepare yourself for that role, and how do you prepare your students?

Dr. Martins-Welch encourages hospice and palliative care clinicians to keep doing what most are already doing: “you know, prescribing judiciously. We are comfortable prescribing opioids, but today we do so under a microscope. And what has become frustrating in my day-to-day practice is having to bargain with patients or act like a drug pusher, because I’m begging them to take the opioid. And they are scared. They don’t want to ‘die an addict.’ This is what I hear a lot,” she said.

“This is what I do for a living, and I’ve been doing it for a decade now. It hasn’t gotten better; it’s only gotten worse. People are more aware of these ‘terrible opioids.’ And so, you know, we get a lot of pushback. That’s not my goal. My goal is to use alternatives—nonopioids whenever possible, maybe some more holistic measures to get symptoms under control. But at the end of the day, opioids are the gold standard for pain control. So that’s what we have to work with,” she explained.

Realities of Clinical Practice

Fentanyl, unfortunately, has become one of the most emotionally charged words in health care today, said pharmacist Ebtesam Ahmed, PharmD, professor at St. John’s University College of Pharmacy and Health Sciences in New York City. “One of the biggest challenges we face as healthcare professionals, whether pharmacist, nurse, or physician, is to help patients distinguish the headlines about illicit fentanyl from the realities of appropriate medical use,” she said. “Our responsibilities are to educate, monitor, and counsel patients with the same evidence-based approach that we bring to all aspects of symptom management.”

“One of the biggest challenges we face as healthcare professionals, whether pharmacist, nurse, or physician, is to help patients distinguish the headlines about illicit fentanyl from the realities of appropriate medical use.”

Dr. Ahmed serves in two professional roles that have shaped her perspective. As a faculty member at St. John’s University, she teaches graduate pharmacy students about pain management in the context of cancer care, emphasizing when fentanyl is clinically appropriate, its indications, monitoring, adverse effects, and safe prescribing practices. She also helps students understand the critical distinctions between illicit fentanyl driving the overdose epidemic and pharmaceutical fentanyl used appropriately for carefully selected patients.

Her second role is as clinical consultant for supportive oncology at Mount Sinai’s Ruttenberg Treatment Center, also in New York City, where she works closely with physicians, nurse practitioners, and nurses caring for patients with cancer. “I spend a great deal of time teaching not only about fentanyl but about opioids as a whole, when they are indicated, how to monitor patients, dose titration, managing side effects, opioid conversions, and selecting the safest option for patients based on factors such as renal or hepatic impairments,” she explained.

“One of the most important roles pharmacists play is helping patients make informed decisions and use these medications safely and effectively,” Dr. Ahmed said. “One of the important conversations we have is about setting realistic expectations for pain management.” She added that pharmacists are valuable partners for physicians, reinforcing education about opioid pharmacology, expected benefits, potential adverse effects, medication storage and safe disposal, and ongoing monitoring throughout treatment.

She believes another opioid crisis has emerged that receives far less public attention. “We are now facing what my colleagues and I have called a silent opioid crisis, the growing lack of access to opioids for patients with cancer and other serious illnesses.” Their recent commentary in NEJM Catalyst describes how increasing barriers to legitimate opioid prescribing and dispensing are negatively affecting patient care. These barriers contribute to delays in treatment, unnecessary hospital admissions, poorer quality of life, and increased frustration among the clinicians who care for patients with serious illness.⁸

For Dr. Ahmed, this issue is also deeply personal. “As a cancer survivor, I’ve been through it firsthand. You can have a legitimate prescription for severe pain yet spend hours trying to find a pharmacy willing or able to dispense the medication. Sometimes it’s simply unavailable and no one knows when it will be back in stock. Patients end up returning to the emergency department because their pain is uncontrolled, leading to hospital admissions that often could have been prevented.”

Confronting Opioid Phobias 

Dr. Murphy noted that recent decades have seen repeated rounds of opioid phobia and societal overreactions that impinge on medical use for managing pain. Hospice and palliative care providers need to critically examine the history of the opioid epidemic, including how public policy, media narratives, systemic racism, and professional education continue to influence how clinicians approach pain, addiction, risk, and prescribing.

Her advice for hospice and palliative care clinicians struggling with these issues: “The first thing I’d want to know is what’s driving the fear. Is it fear that the patient will become an addict? Is my license on the line? Not that anyone should feel shame that they have a worry or fear. But to name it and then start working with that reality is important,” she said. “And my next recommendation, always, is to use your team. Social workers can bring helpful perspectives and suggest some of the safe, reasonable, feasible techniques that can be adapted to this case.”

Among the low-hanging fruit for palliative clinicians, Dr. Kapoor said one of the lowest is choice of language. Using pejorative terms like “pain seeker,” “drug abuser,” “addict,” or “junkie” does a disservice to the patient, to the community, and to the profession.

“Last but not least, I would say that self-reflection is important,” Dr. Kapoor said. “There may be a feeling, an undertone, that we can’t make a difference, because the opioid epidemic is so big that we can’t know where to start, or the pain problem is so big. The reality is that every single health care professional has power in this equation. It just takes some self-reflection and some commitment to learn and to diversify our current practices. That may mean going out of our comfort zone to learn new techniques.”

References

1. National Center for Health Statistics Public Affairs. US Overdose Deaths Decrease Almost 27% in 2024 [press release]. US Centers for Disease Control and Prevention. May 14, 2025. Accessed July 16, 2026. https://www.cdc.gov/nchs/pressroom/releases/20250514.html
2. Arthur J, Edwards T, Lu Z, et al. Healthcare provider perceptions and reported practices regarding opioid prescription for patients with chronic pain [preprint]. Res Sq. 2023:rs.3.rs-3367358. doi:10.21203/rs.3.rs-3367358/v1
3. Enzinger, AC, Ghosh K, Keating NL, et al. Racial and ethnic disparities in opioid access and urine drug screening among older patients with poor-prognosis cancer near the end of life. J Clin Oncol. 2023;41(14):2511-2522. doi:10.1200/JCO.22.01413
4. Beresford L. Looking for balance in prescribing opioids. AAHPM Quarterly. Summer 2018. Accessed July 16, 2026. https://aahpm.org/publications/aahpm-quarterly/issue-archive/summer-2018/summer-18-feature/
5. Shrestha S, Khatiwada AP, Sapkota B, et al. What is “opioid stewardship”? An overview of current definitions and proposal for a universally acceptable definition. J Pain Res. 2023;16: 383-394. doi:10.2147/JPR.S389358
6. Webster LR, Webster R. Predicting aberrant behaviors in opioid‐treated patients: preliminary validation of the Opioid Risk Tool. Pain Med. 2005;6(6):432-443. doi:10.1111/j.1526-4637.2005.00072.x
7. Cheatle MD, Compton PA, Dhingra L, Wasser TE, O’Brien CP. Development of the revised Opioid Risk Tool to predict opioid use disorder in patients with chronic nonmalignant pain. J Pain. 2019; 20(7):842-851. doi:10.1016/j.jpain.2019.01.011
8. Rodin R, Afezolli D, Pelleg A, Ahmed E, Easton E, Chen J. The silent opioid crisis: finding a balance between combating abuse and increasing access for seriously ill patients. NEJM Catalyst. 2025;6(5). doi:10.1056/CAT.24.0380

Larry Beresford is a medical journalist in Oakland, CA, with a strong interest in hospice and palliative care.