Palliative care specialists infrequently discuss driving safety with their patients with cancer when prescribing opioids
Patricia S. Bramati#
, Daniel Gilbey#, Stephen Nkeonye, Alexandra Cooper, Eduardo Bruera
Contributions: (I) Conception and design: All authors; (II) Administrative support: E Bruera; (III) Provision of study materials or patients: PS Bramati, D Gilbey, S Nkeonye, A Cooper; (IV) Collection and assembly of data: PS Bramati, D Gilbey, S Nkeonye, A Cooper; (V) Data analysis and interpretation: All authors; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.
#These authors contributed equally to this work as co-first authors.
Abstract: Opioids may impair the ability to drive especially when prescribed for the first time or when the dose is increased. Because driving is closely associated with independence and quality of life, discussions regarding driving safety should be an integral part of prescribing opioids. However, little is known about the frequency with which palliative care specialists address this issue in clinical practice. In this pilot study, an anonymous survey was conducted among palliative care specialists to evaluate whether driving safety is discussed when prescribing opioids. The survey was distributed to advanced practice providers and physicians from a palliative care service of a tertiary cancer center, and 61 of 72 (85%) completed it. Fifty-seven (93%) respondents considered assessing patients' driving status to be important, and 58 (95%) agreed that driving is an important part of the quality of life of the patients. However, only 28 (46%) reported that they often discuss driving safety in general, and responses were lower when patients were on chronic opioids: 24 (39%) when the morphine equivalent daily dose (MEDD) was ≥100 mg whereas only 13 (21%) did so when the MEDD was ≤50 mg. In addition, just 20 (33%) frequently discuss driving safety when the dose is increased, and only 13 (21%) were familiar with local driving regulations regarding opioid prescribing. Despite recognizing the importance of driving safety, palliative care specialists infrequently address driving safety and opioids with their patients. Educational interventions, increased awareness of local regulations, and standardized preprinted information for patients may improve counseling and promote safer opioid prescribing practices.
Keywords: Driving; opioids; palliative care
Submitted Apr 28, 2026. Accepted for publication Jun 15, 2026. Published online Jun 26, 2026.
doi: 10.21037/apm-2026-0050
Introduction
Approximately 70% of patients with cancer experience pain, and most of the patients with advanced illness are treated with opioids (1). The majority of studies of opioid-naïve volunteers indicates that opioids impair psychomotor function (2), but whether opioids compromise driving ability and increase the likelihood of a car accident is controversial (2). Complicating the issue further, uncontrolled pain unrelated to cancer, may itself hinder driving performance by affecting physical function or cognition (patients with back pain may have difficulty operating the pedals or turning the head to assess surrounding traffic) (3).
The strongest associations of driving impairment and opioids are illicit use, initiation and concurrent use with other psychoactive medications (2). In consequence, those prescribing opioids should counsel their patients about the potential effects that opioids might have on the ability to drive or use other machinery, when they are initiated, the dose is increased or when used along with other central nervous system depressants such as alcohol or benzodiazepines (4).
In patients with cancer, palliative care specialists frequently assume responsibility for longitudinal symptom management, including opioid prescribing and titration. As a result, they are often most directly involved in counseling patients about the functional implications of opioid therapy, including driving safety. However, little is known about how palliative care providers approach this aspect of care. This study aimed to explore the attitudes and beliefs of palliative care specialists regarding driving safety and opioids. We present this article in accordance with the STROBE reporting checklist (available at https://apm.amegroups.com/article/view/10.21037/apm-2026-0050/rc).
Methods
In this pilot study, an anonymous survey was conducted among the 72 palliative care professionals [including physicians and advanced practice providers (APPs)] from the division of Palliative Care, Rehabilitation and Integrative Medicine at the University of Texas MD Anderson Cancer Center. The specialists were invited to participate via email with a link to the survey itself. Participation was voluntary and was completed electronically using the Qualtrics software (a survey tool that allows to build, distribute and analyze surveys). Weekly reminders were sent to achieve a target response rate of 80%, which was selected a priori to minimize non-response bias and improve the representativeness of the sample. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The survey and protocol were approved by the Institutional Review Board of The University of Texas MD Anderson Cancer Center (No. 2025-1606). Consent was assumed if a participant submitted the survey.
The survey (Appendix 1) consisted of 16 questions in addition to demographic information about the respondents’ age group, gender, type of provider and years of experience. Because this study was an exploratory survey of experienced palliative care specialists, psychometric validation was not performed. All questions were developed after reviewing the literature and were refined after multiple face validity checks by the investigators.
For an 80% response rate, 58 participants were needed to complete the survey. Data were summarized as averages and percentages, or mean and standard deviation (SD). The principal investigator of this study did not serve in any supervisory capacity over the participants. The identities of those who participated or opted out were kept anonymous.
Results
Sixty-one of 72 (85%) palliative care specialists completed the survey between January 12 and February 20, 2026. Forty-nine (80%) were women, 35 (57%) were physicians, 26 (43%) were APPs, 48 (79%) were younger than 51, and 44 (72%) had less than 11 years of experience. The responses are presented in Tables 1,2.
Table 1
| Survey item | Strongly agree or agree | Neither agree or disagree | Disagree or strongly disagree |
|---|---|---|---|
| I often discuss driving safety with my patient | 28 [46] | 9 [15] | 24 [39] |
| It is important to ask patients about driving status | 57 [93] | 4 [7] | – |
| I do not prescribe opioids if patient drives | 2 [3] | 11 [18] | 48 [79] |
| I’m familiar with the Texas driving guidelines regarding opioid prescription | 13 [21] | 18 [30] | 30 [49] |
| Do you think that driving is an important part of patient’s quality of life? | 58 [95] | 2 [3] | 1 [2] |
| I always discuss driving safety when a patient is on opioids with MEDD ≤50 mg | 13 [21] | 26 [43] | 22 [36] |
| I always discuss driving safety when a patient is on opioids with MEDD ≥100 mg | 24 [39] | 19 [31] | 18 [30] |
| I always review the patients’ medication list | 60 [98] | – | 1 [2] |
| I always discuss with the patients the drug interactions and driving safety | 33 [54] | 13 [21] | 15 [25] |
Data are presented as number (%).
Table 2
| Survey item | Always or very frequently | Occasionally | Rarely or never |
|---|---|---|---|
| I discuss driving safety with patients when they are taking opioids | 22 [36] | 24 [39] | 15 [25] |
| I discuss driving safety when the opioids dose is increased | 20 [33] | 21 [34] | 20 [33] |
| I discuss driving safety when patients are on long-acting opioid | 17 [28] | 22 [36] | 22 [36] |
| I provide education on driving safety at the time of prescribing any opioids | 19 [31] | 24 [39] | 18 [30] |
| How often do patients ask you about driving safety when they are on opioids? | 8 [13] | 26 [43] | 27 [44] |
Data are presented as number (%).
The majority (93%) strongly agreed or agreed that it was important to ask about the patients’ driving status, and 98% reviewed the medication list of the patients. Most (95%) strongly agreed or agreed that driving is an important part of the patients’ quality of life, with a mean (SD) importance score of 7.9 (1.8) in a 1 to 10 scale.
Only 28 participants (46%) strongly agreed or agreed that they often discuss driving safety. This proportion was lower when patients were receiving opioids, 24 (39%) when the morphine equivalent daily dose (MEDD) was ≥100 mg, and 13 (21%) when it was ≤50 mg. Just 22 (36%) responded that they always or very frequently discussed driving safety with patients taking opioids, 20 (33%) that always or very frequently discussed driving safety when the dose is increased, and 19 (31%) always or very frequently provided education on driving safety.
Finally, 13 (21%) respondents strongly agreed or agreed that they were familiar with Texas driving guidelines related to opioid prescription, although 38 (46%) reported knowing how to obtain such information. Forty-eight respondents (79%) disagreed or strongly disagreed with the statement that they would avoid prescribing opioids to patients who drive. Only 8 (13%) stated that patients always or very frequently asked about driving safety while taking opioids.
Discussion
In the present survey, most palliative care specialists recognize the importance of assessing the driving status of the patients, and almost all accept that driving is an important part of the quality of life. However, about half discuss driving safety in general, and this proportion is lower when patients are on chronic opioids (about two fifth when the MEDD was ≥100 mg and only one fifth when the MEDD was ≤50 mg). A third discuss driving safety when the opioid dose is increased, and about a fifth are familiar with local driving guidelines regarding opioid prescription.
Sparse research exists regarding whether palliative care specialists provide education and advice about driving safety when prescribing opioids. In a survey among members of the Australian and New Zealand Society of Palliative Medicine (of the 322 members, 92 responded), 76% were aware of the local driving guidelines, 91% provided advice about driving safety, 94% had asked a patient to stop driving, 27% had reported a patient to the Driver Licensing authority, and 64% advised patients to refrain temporarily from driving after taking short acting oral morphine (most commonly for 4 hours) (5). In contrast, in a retrospective study from Australia; only 1% of the patients with advanced lung cancer started on opioids received driving education (6). Additionally, two studies from England in abstract format found that documentation of driving advice to palliative patients taking opioids was limited to 11.5% (7) and 15.9% (8).
These findings are likely related to several challenges experienced by palliative care professionals (and other specialties as well). First to be considered is whether opioids impair driving ability. A recent review of the literature about the acute effects of opioids on opioid-naïve subjects found some degree of cognitive or psychomotor impairment in five of eight studies, while three found no evidence of impairment (9). In patients on stable dosages, two of eleven studies found no evidence of impairment, one found impairment in just one assessment, five found evidence of impairment, and three reported that treating opioid use disorder improved driving ability (9).
Nevertheless, epidemiological data from general population, which may provide some insight for palliative care population, show a rising prevalence of opioid-positive drivers and a higher risk of motor vehicle accidents (9). The National Highway Traffic Safety Administration reported that 7.6% of severely injured road users tested positive for opioids before the coronavirus disease 2019 (COVID-19) pandemic and 12.9% during the pandemic (9). Moreover, the odds of crash initiation due to failure to maintain the proper lane were 2.18 times higher among drivers who tested positive for prescription opioids than among those who tested negative, independent of demographic characteristics, driving history, and alcohol use (10). Even more concerning is that in the interval 1995–2015, the prevalence of prescription opioids detected in drivers who died within one hour of a crash, increased from 1.0% in 1995 to 7.2% in 2015 (11). Supporting these data, a study from Canada found a 42% increased odds of road trauma when drivers were prescribed a MEDD of 100–199 mg (12). Similarly, a study of commercial insurance claims in the United States, reported that prescribed opioids were associated with an increased risk of motor vehicle crashes even at MEDD ≤60 mg (13). However, these data are not specific to cancer or palliative care patients and should be interpreted with caution.
Another consideration is that guidelines in the United States about opioids and driving safety either do not consider it at all or do not provide a universal recommendation, suggesting that decisions should be made jointly by patients and their physicians considering local regulations (9). The CDC Clinical Practice Guideline for Prescribing Opioids for Pain recommends that before starting and during continuation of opioids, clinicians should evaluate and discuss strategies to mitigate opioid-associated risks (4). The single mention to driving is among other potentially hazardous tasks (driving, use of heavy equipment, climbing ladders, working at heights or around moving machinery, or working with high-voltage equipment), and clinicians should assess the patients’ ability to perform them safely when receiving opioids, avoiding medications that can negatively affect sleep, cognition, balance, or coordination (4). The guideline of the American Society of Clinical Oncology about opioids in adults with pain from cancer or cancer treatment does not mention driving (14), although states that some degree of sedation is common during initiation or dose escalation, so patients should be educated about this side effect and advised to limit polypharmacy if possible (14). In contrast, the American College of Occupational and Environmental Medicine, the largest medical society dedicated to worker health in the United States, updated their guidelines asserting that the acute or chronic use of opioids is not recommended for patients who perform safety-sensitive jobs such as operating motor vehicles, other modes of transportation, forklift driving, overhead crane operation, heavy equipment operation and tasks involving high levels of cognitive function and judgment (15). Importantly, these recommendations are largely derived from general pain populations, and their applicability to palliative care patients with cancer may vary depending on goals of care and functional status.
Although the state of Texas does not require physicians to report patients who may be impaired for driving, including those receiving opioid therapy (16), driving laws in the United States vary considerably from state to state [reviewed elsewhere (9)], creating challenges for specialists who prescribe opioids to out of state patients, particularly those providing care across multiple states through telemedicine (17). This variability may contribute to uncertainty regarding counseling practices and driving recommendations. Furthermore, clinicians must balance driving safety with the potential impact of restrictions on patient autonomy, quality of life, and adherence to analgesic therapy. Driving plays an important role in maintaining independence and hope among patients (18). In older adults, driving cessation has been associated with reduced life satisfaction (19), worsening health and cognitive function, increased risk of admission to long-term care facilities and higher mortality (20). Given these competing considerations, it is not surprising that discussions about driving safety do not occur until obvious concerns regarding driving ability arise (21).
Our study has several limitations. It is based on a small convenience sample, from a single tertiary institution, which only included palliative care specialists. A selection bias seems unlikely given the high response rate of a large palliative care service, but a social desirability bias could have led to an overestimation of the counseling practice. To our knowledge, our study represents the first investigation about the practice of palliative care specialists in the United States about addressing driving safety when prescribing opioids. Given that our findings are consistent with the limited previous research, our results are likely to reflect a broader clinical pattern.
Conclusions
Our study found that about half of palliative care specialists discuss driving safety in general, this proportion was lower when patients were on chronic opioids, and only a third frequently discuss driving safety when the opioid dose is increased. Physicians should be encouraged to discuss driving safety when prescribing opioids, particularly after initiation or dosage increase, addressing the need to avoid other sedating drugs or alcohol, and to self-monitor their own level of sedation and concentration before driving. Preprinted educational materials may help inform patients who continue to drive while taking opioids. Larger and multicentric studies are needed to better characterize the risks associated with prescribed opioids and driving, as well as the reasons why practitioners do not discuss this issue.
Acknowledgments
None.
Footnote
Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://apm.amegroups.com/article/view/10.21037/apm-2026-0050/rc
Peer Review File: Available at https://apm.amegroups.com/article/view/10.21037/apm-2026-0050/prf
Funding: None.
Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://apm.amegroups.com/article/view/10.21037/apm-2026-0050/coif). E.B. serves as an unpaid editorial board member of Annals of Palliative Medicine from February 2025 to January 2027. The other authors have no conflicts of interest to declare.
Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The survey and protocol were approved by the Institutional Review Board of The University of Texas MD Anderson Cancer Center (No. 2025-1606). Consent was assumed if a participant submitted the survey.
Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.
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