All right, so I'll jump in. And so welcome, everyone. Thank you for joining our webinar today. I'll introduce myself. I'm Brian Michalosko. I'm one of the palliative medicine faculty here at Rhode Island Hospital. I'm also boarded in addiction medicine. And I'll just go around and let my colleagues here introduce themselves as well. Seth? Hi. Seth Clark. I'm an addiction medicine physician at Rhode Island Hospital. I run the physician side of the consult service at Rhode Island Hospital. So folks who are admitted to the hospital for any reason that have a substance use disorder and want to talk with us, we're happy to do that. And I have a couple outpatient duties, but primarily here in the hospital. I work closely with Brian Beaudry, who is on our team on the addiction medicine consult services. So I'll hand it over to him to introduce himself. Thank you, Seth. So my name is Brian Beaudry, and I'm a social worker by training, and I'm addiction medicine trained as well. So my job here is I typically work with medically admitted patients who have underlying alcohol or drug use disorder. And I work alongside Dr. Clark with regards to that. So primarily my cases are hospital based. However, I do have opportunity to work with Brian M quite a bit as relates to shared cases. And Bridget? And I'm Bridget Durkin. I'm a physician at the Hospital of the University of Pennsylvania. I trained in addiction medicine as well as palliative care, and I'm joining the palliative care faculty here at Penn. Awesome. Well, I think we've got a great panel, and I know we had some questions come in advance. The way that we'll structure today is we're going to do is a very brief case vignette kind of with a typical case that we might see in a clinic setting. Each of us will take a few minutes and kind of offer a perspective on it, and then we'll open up the chat. The last may be 20, 30 minutes to questions from everyone on the chat, and we'll have a hopefully very lively discussion. So if we could just move on to the next slide, Gina or Bridget. Yeah. And before we start, I do just want to take one minute to thank our sponsor, Gentiva. They sponsored this webinar series to make it available for free for all certificates, so thank you to them. And we do have a couple upcoming events, so you can visit hmdcb.org slash community, and I'll put some information about that in the chat. So I will stop sharing my screen and allow Bridget to share hers. Great. If we can go one slide forward, Bridget. Great, so we tried to put a case here that would be relatively common. Think about a 58-year-old man with metastatic lung cancer and history of substance use disorder presents at a supportive oncology clinic. He's been receiving palliative treatments for his cancer, and his disease has been stable on imaging in the recent weeks. He's currently on oxycodone 15 milligrams every four hours as needed for his pain. He was previously managed on buprenorphine years ago and had been doing relatively well. In the past three months, a couple of things have popped up. There's been two early refill requests made after hours, as well as a urine drug screen last month that turned positive for cocaine. He reported trouble sleeping, feeling anxious, and today he comes to the clinic asking to increase his oxycodone dose. So not something terribly uncommon that might pop up, and I'm sure a lot of us are thinking about cases we've had. If we can go forward one slide, Bridget. And so I want to just say one thing to really get us started here, which is confronting non-medical opioid use is really hard. And I want to just acknowledge that because it's something that I think pops up and it's unpleasant for clinicians, it's unpleasant for patients. And I think it's a challenge in our job. I would say that fortunately for a lot of us that work in the palliative care side, having difficult conversations is an area that we are used to, where emotions are high. And I think a lot of this is just kind of changing our approach to how we have these conversations, but using skills that we've already developed over the course of our time as palliative care and hospice doctors. If we can go one slide forward. As I was thinking through this case, I tried to put what concerns would be in my mind, and I'd love to hear any of the ones that's on the chat as well. If you want to just throw your thoughts in the chat about what you might be thinking about from the case vignette. But things that were on my mind would be, how do I maintain a therapeutic alliance with this patient? How do I make sure that there's not a feeling of abandonment amongst the patient if we have to have a discussion about opioids and substances? How do I utilize a benefit-to-harm framework so that I can figure out, are the medications I'm prescribing for this patient's pain, are they actually giving benefit for what I'm trying to treat? And what is the risk of harm that they could be doing? I want to avoid stigmatization that goes along with substance use, not just in the language, but in many aspects from how the patient perceives he or she is being treated in the clinic, or more broadly. Issues of harm reduction, which we'll talk about today. I want to make sure I want to adequately manage symptom control, because at the end of the day, this patient does have metastatic lung cancer. I want to make sure that patient safety is a priority to me. Having interdisciplinary or multidisciplinary support, certainly from folks like Seth on the call and Brian. Jeffraising his lung cancer treatment, I want to make sure that whatever discussion we have about how we'll manage his pain and symptoms doesn't interfere with his oncology treatment and lead to a worse outcome. Certainly legal concerns pop up on our minds about, can I prescribe? How should I be documenting this? What should I be doing? And then certainly, I think a big part of it is, how do we manage our own discomfort with this situation? How do we have these conversations, and how do we sit with these discussions and decisions? So I'll put that there just for a thought. If we could advance one slide, Bridget. And yeah, so certainly then the question becomes, okay, what are the next steps, right? This patient's here, he's got metastatic lung cancer. He's got legitimate reason to have symptoms of pain. But we've got now some active substance use. We've got early reflow requests and behavioral issues, maybe some opioid use that's not necessarily being used for treating his pain, but rather other symptoms. He mentioned insomnia, anxiety, and such. If we can go forward one more slide. Thank you. So what I wanted just to briefly strategize is just some ideas of how we can communicate with these patients. As I was going through this, I thought about kind of five key areas to think about when we're having these conversations. And this comes from a paper that I referenced here in the end of the slide set, but things like we want to validate symptoms of suffering. So what's the language that we could use in this framework? I know that as palliative care and hospice doctors, we think a lot about this. And so some of the examples that would be, you've been through so much, I can't imagine what this is like. Thinking about asking directly about substance use. Have you ever taken your medication other than for pain? And part of this is how can we avoid stigmatizing? So rather than saying you're not using heroin, are you, or fentanyl, are you, but rather being just very direct and objective. So have you been using substances or your medication for things other than pain? Share your concern with the harm. I worry that in addition to your cancer, you have addiction problem. I think just be very upfront about it. And I think if you look at these things so far, what you'll see is that they mirror a lot of what we do in palliative care anyways, right? So think about, I would imagine that we're all familiar with nurse statements, right? The name, understand, respect, support, and explore. So things like, I can't imagine, right? That's an explore statement or understand statement, right? Delivering a headline when we're having a serious illness conversation, right? So I worry that in addition to your cancer, you have addiction problem. So these are skills that we have in our toolbox already. And I think how do we reframe them to use the right language can really help us connect with our patients. Setting clear limits. So based on what we've discussed, I can't continue to safely prescribe oxycodone, right? So being very, again, almost like delivering a headline when you're having a serious illness conversation. And then lastly, expressing commitment to ongoing treatment. So I will continue to care for you and welcome you to the clinic. So almost like using a support statement in the nurse framework. So again, a lot of these tools we have, and really we're kind of trying to retool them for this patient population. I want to be brief. So we have time for questions. So I'm going to pass the torch to Brian Beaudry and take it from here. Thanks Brian. First of all, Gina, thank you for including me in today's talk. I appreciate that. And it's an honor to be amongst professionals like Seth and Brian and Bridget on a discussion like this. It's funny. I thought I was going to prepare this in one way, and then I ended up morphing into another way as I got the slides from Brian, as well as sort of reviewed a little bit the strategies that palliative care doctors typically use for their patients already. And I also did some review of the literature just for my own benefit to try to figure out how I should best prepare for today. And I found that there was a common theme and I'll read the theme and I can go from there. It says, evidence suggests that palliative care clinicians are uncomfortable providing substance use disorder treatment without the collaboration of an addiction specialist. Reason for this lack of confidence stems from lack of knowledge, insufficient training and apprehension and treatment of the addiction process. And it struck me that comments that sort of summary of their concerns struck me because in the hospital setting, Brian M. and Seth and I work collaboratively together. And I find as a social worker in addiction medicine that the most insightful and compassionate consult service outside of ours is palliative care. And I said to myself, how is it that a profession is struggling with the idea of treating alcohol and drug use when they're already philosophically doing the work? And so I wanted to take a minute and I'll do my best to keep it in six minutes, but I want to take a minute to talk about sort of the similar philosophies because Brian M. very clearly described not only strategies, but also concerns that are raised by physicians who are managing folks that may have dual struggles, both chronic disease processes, but one may be less comfortable to manage than the other. So there was an article that I actually placed on the slides and Brian actually thankfully put that on there for me. It's a, the article's name is adapting palliative care skills to provide substance use disorder treatment to patients with serious illness, which is exactly what we're talking about right now. And I found that there was five, there was five elements that they found that they found in the review of the literature that was similar to both palliative care clinicians and substance use disorder clinicians. And these were the five. The first was individualized or patient-centered communication. Second was team-based care. Third was attention to quality of life. Fourth was the identification of the structural determinants of health. And lastly, it was ethical principles where economy is paramount. So again, thinking about this stuff in the terms of similarities of our approach, I wanted to sort of take the time to pull out three of those to accomplish two goals. The first is to challenge the perception that palliative care clinicians are ill-equipped to provide care to those individuals with substance use disorders. And two, to attempt to reframe this idea that the individual suffering from serious illness varies from those who suffer from the chronic disease of addiction in terms of approach. So the three elements that I wanted to focus on, the first is communication. And in comparing the approaches that Brian M. has, you know, graciously put on his slide, as well as what I do on a regular basis, I found that the similarities in approach of communication, typically language is paramount. So non-judgmental language, empathic statements are paramount, emphasizing both the palliative care stressor as well as the substance use disorder stressor. It's trying to avoid the stigmatization of both disease processes. And in my world, that would be utilizing language that's less punitive. Language like drug abuse, language like drug seeking, or language like addicts, which is that's a really rough one for me to talk about. But trying to avoid terminology like that. And I think in terms of talking about this ideal with palliative care doctors is they're doing that already. You know, they're talking about stages of life where there is variance in the understanding and perception of what those things are. So and you establish language that has assisted you in compassionately and empathically delving further into their understanding of the disease process. And so when I think about what I would suggest for those attending today's session, I would suggest one specific strategy would be to clearly, is not to clearly identify the palliative care as the issue, or the substance use issue, but to look at it in terms of the dualness of both of them. So the idea that there is both instances happening simultaneously, and how does one explore that with their patient? The second thing that I wanted to talk about was, where am I here? Is the attention to quality of life. And you know, palliative care doctors are incredibly good at consistently assessing for quality of life for their patients. And what I find is that for those clinicians that work with substance use disorder patients, we're also looking at quality of life. And I think what that translates for us is having conversations not only about the abstinence of a substance, whether it be alcohol or drug, but also the alternative measures that might be available to those folks that are struggling. So for example, looking at harm reduction strategies to assist. And there may be instances where the quality of life actually is directly not going against the palliative care clinicians or physicians' hopes for the patient. So where not using a substance is not on the patient's priority list, as relates to their quality of life, sadly, there's consequences to those decisions. And I think Brian in his slides referenced that a little bit in saying, you know, we're worried about the ideal that you're using opioids, that using cocaine, for example, in the context of your treatment with us. And so what does that mean for you? What does that mean for you in terms of our understanding of how we're working collaboratively on this process? But also, is there something additional that we could look at that might be able to assist with bringing the trajectory of care back to a more healthy modality? So for example, the comments that I thought were interesting in Brian's review or his case example was the fact that the patient was also identifying symptoms, symptomology of anxiety, and also sleep disturbance. So there was elements there that were not, we don't know where they flushed out. We just know the patient has identified them as a struggle at the time. Also, we really don't know much about the rationale for the short, the need for a refill of his opioid medications two times prior to his meeting with that doctor on that particular day. So my hope for folks within this forum, as well as in my own offices, is that I'm hoping that conversations are happening fluidly with their patients, meaning that when they arrive to their first session with the palliative care doctor, that a conversation about their buprenorphine prescription is covered, meaning what did that mean for them then? Because I would imagine that those things are, at one point, stabilized. They were, at one point, stabilized. And so where does that stand now? So that would be a suggestion that I could provide that would sort of look at quality of care, but also to reference how that may have shifted from when they first started working with you with the doctor all the way to the incident where we see on the slide where he may be showing evidence of struggling within the context of his care process. And the last thing I want to say briefly is that we do, we both, both disciplines have shared, have a shared philosophy on considering social and structural determinants of health for our patients. And that includes everything from social, environmental, family, faith, financial supports, as well as stressors within those environments. And so when I thought about this case, the case that Brian had presented, I said to myself, I wonder what might have happened recently that's resulting in this current behavior. And was there something that's happening that may have intentionally or unintentionally assisted with this change? And I would be exploring that further, whether it be a shift in their support network, maybe an exacerbation of a stressor or obstacle that they're undergoing. Sadly, a lot of our patients, patients that I work with, there's opportunity for using substances again in the context of attempting to remain away from them. And that happens by nature of their exposure to other things, whether it be family members who are struggling, diversion of medications for those folks that they believe need it, as well as the environment that may be not conducive to a sobriety standpoint longitudinally. And how do you look at that? Do you include other disciplines to assist with that? And I think that fourth, one of the five is the team effort. And it's not even worth talking about, frankly, because that's an easy one. It's one where if you see there's evidence that it's outside of your purview, and frankly, our philosophies are very similar in terms of approach, then it would be fair for you to look outside of yourself to ask for assistance. So whether it be through psychiatry intervention, whether it be through spiritual care intervention, social work intervention, and a lot of teams in palliative care have those components within. So it would not be unreasonable to ask for help when these types of instances arise. That's what I have for now. Thanks, Brian. Really appreciate it. So I'll take it from here just a couple of minutes just to discuss the medications for opioid use disorder. So I get to do the brief part that's actually objective in black and white before we get into all the nuances afterwards. So just quick overview. So three FDA-approved medications for opioid use disorder. First, naltrexone, that's an opioid antagonist. So it sits on the opioid receptor, prevents other things from binding. You have to, and so it doesn't provide, so it doesn't activate the receptor. So there's varying studies, varying case reports that folks think it does help with their cravings. I think it's a different mechanism. But in general, it's opioid antagonist. You have to go through withdrawal. So you have to be off of all opioids for at least a week is the recommended length for most long-acting things, closer to two weeks. And so you have to go through withdrawal to get on this medication. And that process makes it too difficult alone for a lot of people to tolerate, especially in this community or in this specific case where opioids are fundamental. So that one's off the table, not super efficacious for the reasons we discussed anyway. So that's the first one. The next one is methadone, which is a full opioid antagonist, can utilize its long-acting half-life, its slow onset of action to abate opioid withdrawal without causing euphoria, without causing increasing tolerance. And so that's a medication that is full opioid antagonist, activates the mu opioid receptors in the same way to get rid of withdrawal, but at an adequate dose, gets rid of withdrawal, gets rid of cravings, long-acting nature, the doses overlap. So you don't have kind of a peak and trough for your symptoms. And so that's the general pharmacokinetics of methadone. The main issues of methadone come in the regulation. So it's highly regulated. It has to be, for opioid use disorder, it can only be dispensed from an opioid treatment program. Those are very restrictive. You know, you start off needing to come daily, and then you can work your way up to take-homes based off a number of criteria. And that happens slowly. So you earn your take-homes, then all of a sudden, okay, you just come Monday through Friday, and you can have two doses for the weekend. And after weeks to months of that and other kind of arbitrary measures, including toxicology results, you can work your way up to three weeks of take-homes. And so you don't have to come to the clinic every day, but that takes over a year to get to that level of take-homes. So that's why folks will reference that as the liquid handcuffs. So you can't really travel. Certainly, there are ways to communicate with clinics and get your doses there, or if you can take, you know, if you have all those take-homes, take them with you, but it's very restrictive and it's tough. And so it has to be dispensed from one of those clinics. It cannot be prescribed. It can be prescribed for pain. And so someone with chronic pain, with co-occurring pain, that's where the line gets a little bit blurred. But if it's prescribed multiple times a day dosing for pain, it can be prescribed and filled at a pharmacy like any other opioid for pain medications. And then the last piece is buprenorphine. So that was evolving. So they had the buprenorphine waiver. So when they first approved this medication to be prescribed from a doctor's office, filled at a pharmacy, because of the much improved safety profile. So it's a partial opioid agonist. It sits on the mu-opioid receptors, activates them enough to get rid of withdrawal and get rid of cravings at adequate dose, but not so much that it would cause respiratory suppression, overdose, death. And so on its own, it has a ceiling effect on the respiratory suppression, which is much more, sorry, which is a much higher safety profile that can be given from the doctor's office. But in combination with other central nervous system depressants, a lot of alcohol, benzodiazepines, other medications, it can contribute to an overdose. And so it's not without risk, but it's much, much safer than other full opioid agonists when it comes to overdose risk. That actually, a study relatively recently showed that folks who use non-prescribed buprenorphine, patients who use buprenorphine are at much lower risk for overdose death than patients who don't, prescribed or not. And so that's a little bit of the pharmacokinetics of buprenorphine. The partial opioid agonism, the high binding affinity puts folks at increased risk for precipitated withdrawal if there are opioids in those synapses. So if someone is prescribed opioids or using non-prescribed opioids, if you're going to initiate this medication, there's some ways to do that. Periods of abstinence versus low dose inductions, a little in the weeds for this. But once the buprenorphine is in those synapses and active, then you can add additional opioids without precipitating withdrawal. It's really the timing thing that works there. And then the regulations around buprenorphine, they have gotten rid of the waiver requirement. And so you do not have to do additional, okay, you do have to do additional training. I'll get to that in one second. But you don't have to apply for a separate waiver, a separate DEA number. It is lumped in with your DEA now, as is the one-time training. And so with the DEA, anyone with the DEA can prescribe buprenorphine as you would any other controlled substance. And so that's liberalized a lot of the restrictions there just for everyone's edification. So starting June 27th, so a few weeks ago, there's a one-time training that's required. It's pretty nebulous regarding substance use disorders and buprenorphine management. So like this would count as an hour if you need to aggregate some of these trainings to attest to that. But next time you're due to renew your DEA, you just have to attest that you've had eight hours of, I can read the actual words, all new and renewing Drug Enforcement Administration registrants must now attest to completion of eight hours of training in substance use disorders and the use of FDA approved medications for substance use disorder. So that one-time training. If you already got your suboxone waiver, you can attest you don't need additional training. Caveat being, if you got your waiver when the additional training wasn't available at the beginning of the COVID epidemic. So when the DEA initially lessened the regulations, they said, hey, you don't need this extra training. Just tell us you want to provide bup. We'll give you a certificate. That one doesn't count. If you did the eight hour training and got that certificate, that counts. If you're board certified, that counts. Otherwise, there's a number of other training opportunities available. Like I said, including this one that would meet those requirements. If you need those additional resources, let me know. So that's the main thing I want to do with the medications for opioid use disorder. And now we can talk about more of the nuances there. So I'll hand it over to Bridget. Thank you. So I'm not going to provide clear answers, unfortunately, to tough questions, but I will hopefully provide a framework for us to approach how to tailor pain treatment for different patients. So as you've heard already, the lens that I view treating pain through, particularly for patients with substance use disorders, is through the harm reduction lens. So the philosophy of harm reduction, as you heard, is just that while people are all in different places with different goals in their lives, that may not always include stopping the use of substances. And even if that's not their goal, there's still an opportunity to minimize the negative consequences of use and improve the overall health of people who use substances. And for those of us in palliative care, I'd say core to that is minimizing pain, distress, withdrawal, and other symptoms. So what we do is very easily fitting into our harm reduction framework. And I use this harm reduction framework to help guide how I approach any decisions with any patients, which is that all I'm doing is I'm balancing potential benefits and potential harms. And that really helps me step back from some of the challenging situations because I'm doing so, I'm really putting aside my own personal discomfort and my own personal feelings and feeling, am I reacting to my own disagreement with how the life choices a patient is making? Am I reacting to my own feeling hurt that this patient may not have been, not have trusted me enough to be truthful with their use initially? And so setting aside the personal discomfort, I use this framework of benefits and harms in order to decide how best to proceed. And as we've talked about, and in the articles, benefits are often emphasizing and prioritizing patient autonomy. And I would say also building trust in an individual provider and in the healthcare system in general, really helping to respect all of our patients as individuals and also helping them with symptoms and pain and substance use. And balanced against that, I think is often the fear that we do harm to a patient by continuing to prescribe a medication that is high risk such as opioids. And so I'm going to talk through some strategies that we can use to think through this and also maximize benefits while minimizing harms. So a common question is how can I treat pain in patients who are already on buprenorphine? So for example, our patient earlier in his illness when he was on buprenorphine, what can I do here? And as in most things in palliative care, it is dependent on the prognosis for the patient, both how much time do they have in length of life, but also what does their function look like? Are they bedbound? Are they still walking around and up in the community? Are they in a hospital or an inpatient hospice? Or are they home? And also what are patient desires? Where are they in their recovery? Have they been stable? Are they still using in addition illicit substances in addition to the buprenorphine and what are their hopes and goals? And so keeping all that in mind, a few different ways to think about this in addition to always optimizing our non-opioid analgesia is thinking about, is there an opportunity to split dose sublingual buprenorphine for pain? So it's analgesic properties last less long than it's anti-craving properties. And so usually for analgesia, I'll dose it three or four times a day. There's no shown ceiling effect for its analgesic properties. I will say that often after 24 milligrams a day, insurances require prior authorizations and it's much harder to get a prior auth above 36 milligrams a day. Though, if you can get approval, it can be worth increasing that dose in addition to splitting the dose for additional pain control. There's also something to keep in mind for people who are already familiar with this approach. There's a monthly depo injection called sublocade and that can take several months to reach steady state but can be a good solution for patients who are maybe dealing with more chronic pain post an oncologic illness, for example, or who have a longer prognosis of many months to years. And you can use the sublocade and then additional films on top of that to help with pain control. Other things you can do for patients on buprenorphine is you can actually add a full agonist in addition to the buprenorphine. So if they've already been on eight milligrams of buprenorphine, you can safely add oxycodone or morphine without worrying about precipitated withdrawal. And so this can be really helpful for patients who are coming in peri procedure or while awaiting radiation for a pathologic fracture and you need some more acute pain control. You continue them on their buprenorphine and you add full agonist on top. And then often at some point in a patient's journey with a life-limiting illness, there may come a point where it makes sense to stop buprenorphine where you really want to free up all of their receptors for full agonist when perhaps they're not interacting with the community and at risk for cravings as much or for return to use when they're not able to take the medication regularly. Though some patients feel very attached to their medication because they've been taking it for so long and they view it as it is a life-saving medication. And so for some patients, they may want to continue buprenorphine right until the very end. And sublingual buprenorphine is actually a formulation that's safe to use in patients as long as they're managing their own secretions. And then when you're using this medicine, you always want to make sure that you're coordinating with the patient's outpatient prescriber of buprenorphine, as well as considering if you're titrating it for pain or providing other additional pain medications, you may also want to take over prescribing of the buprenorphine yourself. Because as you heard from Seth, that is now something that all providers with a DEA can do. So for patients on methadone, similarly, the approach is very dependent on the patient and all of the other factors that we discussed. An easy way to increase the methadone's analgesic effect without going up on your total OMEs for a day is to split dose into Q8 hours, as we're much more familiar with for pain. As Seth mentioned, it becomes challenging when a patient is no longer in an inpatient setting because OTP programs only dispense methadone for addiction really once a day. And so you need to decide if after, say, an acute hospitalization, if it makes sense to reconsolidate back into one's daily dosing, or if it makes sense to say that this patient's primary use of the methadone has changed from really something that was originally used primarily for addiction to something that's now being used and needed primarily for pain, in which case it can be prescribed by a palliative care provider. This, again, needs to be balanced against the value that the patient is getting from the OTP, methadone programs, wraparound supports, if they have a counselor there, if the regular appointments and accountability and urine toxicologies are all helpful for them, then they not want to step away from that stability. And so an alternative in that case would be to continue the daily methadone dosing at the OTP and add a full agonist on top of that. Again, it would be really important to coordinate with their team there to make sure that the team there, this is in alignment with the philosophy there as well as the expectations, because you wouldn't want them to see unexpected oxycodone in this patient's urine and then be having a different conversation where really it's a prescribed medication that they're taking for their pain. And then methadone, again, can be a medication that is very important to patients and they can have a strong emotional attachment to, even at the very end of life. I've had a few patients where that's the very last medication that they were able to take orally was their methadone dosing for their addiction. And if for some reason, you lose oral access and you're using all IV medications or you don't have an IV formulation of methadone, it's really important to make sure that you're meeting your patient's basal OME requirements, which can be quite high if they've been chronically on methadone in order to prevent withdrawal. So I'm going to talk a little bit just gesture briefly at some additional strategies for support, which you've already heard about, which is that, as usual, we want to focus on function, regular appointments, setting gentle but firm boundaries, and then also making sure that opioid use is being used for pain and not to treat other symptoms. We can talk in more detail about when I might consider using urine toxicology, but it can be a challenging discussion. Always support a patient by prescribing Narcan, instructing them how to use it, and then making sure, as Brian talked about, that there's additional wraparound support, whether it's for addiction or pain, we know that this is really important for patients. And then very briefly to talk about pain in patients with active opioid use disorder, and say that the important piece of this, I think, to consider is that you need to treat this kind of basal opioid need that's going to treat their withdrawal before you can even start to think about using opioids for pain control. So often, this long acting is a methadone, a basal rate PCA, or even morphine ER, and then using shorter acting PRNs on top. And I just put this little box up here to give you an idea about the OMEs that we're talking about when patients are using opioids in today's functional crisis. This is the estimate that we use in Philadelphia, and based on the national numbers, it's a fair estimate that you can use. I'll caution that the ranges are very large. So I just usually put this in the back of my mind to say I'm being very safe, even giving oxycodone at 100 milligrams ER three times a day is still a very low dose compared to what they're getting in their fentanyl use. And then I'll say for patients with stimulant use disorders, don't stop their needed opioid pain medications because of concern for stimulant use. Make sure that we're treating enough pain. Stimulants are often used because of depression or because of poorly controlled pain. And then really consider harm reduction. We are seeing in Philadelphia, but also nationally, a lot more opioids, a lot more fentanyl contaminating our stimulant supply, particularly cocaine, and that can be deadly for patients. So, and then in all of these kind of just discussions, thinking through how we balance these harms and risks. So the risk of what happens if a patient, you know, if I prescribe oxycodone and they continue to use, or they misuse that oxycodone, or they divert it, what are the risks there really and truly versus against what are the risks to this patient? If I don't prescribe this medication, are they more likely to use? Are they going to have uncontrolled pain? Or am I risking them not following up for their medical therapies that could potentially have, you know, big implications in their cancer treatment, for example. So I will stop my screen share here. I know we got a little into the weeds there, but hopefully some of that was helpful and addressed some questions that people shared before the session. And I think we'll open it up to some of the questions that people have in the chat now. Awesome. Thanks, Bridget. So we've got about almost 17 minutes left. I think Bruce, I want to open up to you. I think you had some comments that you wanted to share, and then we'll open up to the floor and the panel for questions. Not any major comments aside from the fact that I appreciate you being here. Thanks to the panel for being here and thanks to everybody for attending. I did want to just share in the chat early on, Brian M had shared the article from Katie Fitzgerald-Jones and several other authors. Those folks are really well-respected addiction medicine practitioners, substance use disorder practitioners. They know their stuff. I know Katie and others have spoken at AHPM before, and they do a nice job of kind of bridging the hospice and palliative care and addiction medicine fields. So I'd highly recommend folks take a look at that article and utilize that as kind of a tool because it's really well done by really well-respected practitioners in this area. So thought I'd just share that briefly as we go. Awesome. We have a couple of questions. We've been kind of in the chat here responding to the best we can. I see one, Alan, can the panel please comment on any organizational process changes or enhancements in hospice practices? Alan, can you clarify a little bit about what you mean by that? Sure. So I was just curious in this context, more than just say an opioid use disorder or other types of more standard approach precautions, which often are medical legal, what are you seeing in this evolution of care as an organizational practice? So it was alluded a little earlier with Bridget about the extent of testing, whether doing urine drug testing, whether opioid agreements, other particular principles could be adapted to this higher level clinical management integration, specifically around hospice, that this may be a new evolutionary opportunity for those of us in organizations to revisit what are our practices and process. Thanks. Bridget, do you want to comment on that? Sure. I think that you're asking absolutely the right question. And I think that unfortunately the answer is probably it depends. I think that it's hard logistically at the very end of life on hospice to regularly get urine drug screens. And I think they have a limited role often just because as we're thinking about patient function, there's usually not as much opportunity to really for patients to obtain their substance of choice just based on where they are in function. And I'll say that I find personally that urine toxicologies can be really helpful, which is not without controversy in the addiction medicine field. But I think that if you can really use it as a tool to build consensus and to use it as a way to talk about medications, needing to be in a person's body in order for them to be helpful, it can be a really good way to kind of to align with the patient. But rather than it being used punitively, but I think it's challenging towards end of life to be a strong tool there. I think that the other piece of things in terms of expectations or contracts, opioid contracts, I think that there's very mixed data on whether a contract itself is important, is useful. I think expectations are really useful. So building alliance over when we're able to refill medicines, what's the proper procedure. I think that creating boundaries for all of our patients, but in particular for patients who have use disorders is really helpful. And that also goes to, I think that there's a lot of freedom in the way that we look at needed PRN medications. And I think that one way that we can help our patients with use disorders is really helping them strategize how and when to take those medications because the mechanisms of like, I feel physical pain and I take my opioid medicine is not always wired as simply for them as it is for other patients. And so really strategizing, this is take one before bed, take one before you go out to your granddaughter's play recital. But really helping that way is another way that we can kind of tailor things for our hospice patients. I think that other opportunities are making buprenorphine more available on formularies for hospice is a challenge that I think that some patients have run into. And so while it may not have a role or it may have a role for some patients, but it may not have a role for as many patients who have days to hours left, it probably has a very big role for patients who have months to weeks left. And so that's one opportunity to really help patients. And then finally, I think the other piece of things to think about is around kind of just safe opioid custody practices and what the risk of home life looks like. So, does family or any caregivers have risk or history of substance use? I think is an important other piece of things because we're also placing a very dangerous, high-risk medication into a home. And along with that, I think that prescribing naloxone and making sure that people know how to use it and that it might not be for patients who are in their final days to hours of life because it's hard to distinguish the signs of dying versus the signs of overdose, but it is for accidental use and overdose if anyone else in the family or household got it is I think another best practice that hospice can be doing for our patients. Those are great points. And one thing I was thinking about as you were speaking, Bridget, is just kind of going back to that idea of this kind of benefit-harm framework when we're discussing the role of opioids in serious illness. And certainly I think that prognosis is a big part of it. And so, certainly like in the case, we talked about a patient who has mesothelic cancer and he's had stable scans, but wanting to increase the oxycodone. And I don't think, certainly to respond to the question, which I don't think we were saying that naloxone should be stopped, but I think it helps you understand some of the data that what is the benefit of increasing the oxycodone at this point versus what is the harm of increasing? And I think there's, at least in this case, maybe you can make an argument that there's more harm to increasing the oxycodone if we're not actually treating a symptom that is clear from imaging or from a change in progression of disease or whatever it is that normally we think about bumping up the dose. One of the things I think of a lot in the questions that were sent in before the talk today was really, I think about a little over half of them were about buprenorphine. And I think certainly I'll just say that our experience here at the hospital is that we use it quite a bit. I think more than other places, more than other places I've practiced at. And I think that as we've done that, there's been a lot of interest from community providers as these patients have left the hospital and they've gone on and say, hey, when I was in the hospital, I wasn't being treated with the usual oxycodone or dilaudid or whatever it was for my pain, but I had a B-trans patch where I was maintained on Subutex for a short time. And actually I felt pretty good. And so probably about half my patients say they do well with it. Other half are asking, why are you choosing this medication? And I think with education, they come say, okay, this actually worked pretty well. It takes a little bit of convincing. And some of the things I always get are outpatient providers emailing or messaging me saying, well, how do I continue this? And so a couple of tips I had, and this is probably to the hospice population, but one of them certainly is, how do I get this covered? And one of the things that I came across this year, I thought was a really good tip I wanna share was at the ASIM conference, they had talked about how Suboxone and Subutex, which are approved for maintenance therapy and not necessarily pain, insurance may not cover that. But one of the ways they will cover it is if the patient is opioid dependent, which is very different for an opioid use disorder. Patients that are on opioids for some chronic amount of time can be dependent, and that can be the billing code that actually then will trigger the insurance company to cover these medications for them as kind of a very nice way to get around the issue of if you code it as pain, they may say, no, we're on a prior auth, we're gonna deny it, but opioid dependence, they will. So just a little, something I thought I'd pass along. In contrast to, let's say, Belbuco or Butransit, which are approved for pain specifically, but not maintenance therapy. So just to put out there. I think some of the other questions I saw in the questions that came in before the webinar began today were, how do you deal with some questions of diversion? I don't know if, Brian or Seth, you want to address some of the things that you guys see? Yeah, I'm happy to. And so I think, you know, various concerns with diversion. A lot of our thoughts and feelings around diversion come from paternalism. Just anecdotally, from what I've seen, hey, you're not doing what I said to do with this medication. You know, I don't, I work a lot with folks who are not in palliative care, who are not certainly on hospice care, and they're helping out a buddy. I have folks who, you know, call me on the Suboxone hotline, you know, saying, hey, I haven't gone back to use, but only because my friend's, you know, giving me their medication. So we at Addiction Medicine really gatekeep Suboxone buprenorphine more than we should be. We're working towards that, getting rid of the waivers, a huge piece of that. And so I have low concerns for buprenorphine diversion, primarily because of the safety profile, but also because it's primarily used to alleviate withdrawal in the studies that they've shown. And, you know, it decreases risk for overdose death. And so I have very low concern for buprenorphine diversion. That being said, if we're doing urine toxicologies and it's negative and someone's reporting that they're taking it and this and that, certainly don't want someone just, you know, giving out, you know, a controlled substance because it's not perfectly safe. That being said, I think it's a different patient population. So if we're talking about full opioid agonists that are getting diverted, that's what got us in this overdose death crisis to begin with, right? And so that's something to pay close attention to, much higher misuse potential than buprenorphine, you know, for the short-acting opioids and methadone. And so it's certainly something to pay attention to. But for buprenorphine specifically, it's less of a concern that I have. There's ways to look at that if that is a big concern of you, doing pill counts, you know, doing toxicologies. You know, they have the suboxones individually wrapped. And so you can bring in the empty wrappers. You know, I think I just really like to do that on a risk-benefit conversation. You know, what am I seeing objectively? What are my concerns? Hey, you know, I said to use this, and you didn't do this, or you gave it from a friend, or you ran out of your prescription and missed an appointment, and you used a friend's buprenorphine until you got to me. I think that's a treatment failure on our end. Again, I'm overly simplifying, and that's specific to buprenorphine. I think there's additional concerns around full opioid agonists, but most of our patients that we're talking about full opioid agonists aren't prescribed to them. So that's the different beast. One of the things that really struck me in some of the patients, as we've been using more and more buprenorphine here in the hospital, and that I've been reading about is that, and patients have told me this directly, they'll say, buprenorphine is quote-unquote a boring drug. And I'm like, awesome. That's like why we like it. And when I first heard that from a patient, this was a patient I'm thinking about who had a very long history of substance use disorder, and had actually never been on buprenorphine, never even heard of it. His substance disorder was kind of remote in the 70s. And he came in for a chronic pain issue, then had to have surgery, and we started him on B-transpatch. And he's like, wow, my pain actually feels pretty good. I don't feel like I'm high or like I'm, you know, that euphoria. And in his words, this is a very boring drug. I was like, yeah, that's what we like about it. And so I think to kind of echo what Seth was saying about, you know, it's not something that I'm always thinking about as, you know, if it is diverted, it's right. It's helping a friend or someone who, you know, doesn't want to go into withdrawal. And there's some evidence too that it acts more on the receptors in the spinal cord as opposed to the brain. And so you don't get that reinforcing effect of like you do with some of the other opioids that are more, you know, at least in the initial stages, euphoric producing. I think we have time for maybe one last question. Any comers? Well, I have one and maybe I'll toss it to Bridget. I was thinking about is, you know, when we're in the clinic and there is a patient, I think this kind of came up earlier from one of our participants was, you know, and the patient is either dishonest or you're concerned about there's, you know, a breach of trust between what, you know, was a good therapeutic Alliance. I wonder if you have any tips or thoughts on how you can maintain or recover that, that, that relationship after you've had either a diversion issue or, or they haven't been totally straight coming with you or any thoughts on that. Yeah. I think that, that one of the most important pieces is to, for me is to just recognize that, that this is often a part of their illness. And so, so there is a part of their brain that, that there's a, there's a large part of their brain that is seeking help and is trying to be here and show up. And that's why they're sitting in front of me. And then there's another part of their brain that is scared and is also trying to make sure that there is some way that they, they still have a chance to go back and use. And so might not be able to be totally honest with me in this moment. And so I think for me, it's important to recognize that, that I'm not taking it personally. And I often just take patients through my reasoning and, and I don't try to, to, you know, to, very careful not to accuse them or be judgmental. I often use kind of distancing language and to say like there, this shows me that there's meth, there's methamphetamines in your urine rather than, you know, you are using methamphetamines. And then I kind of ask them, I was like, do you have any ideas about how that might be there or why that might be there? And then see what they say. And sometimes they're open and tell me. And sometimes that they don't, they don't feel and appropriate. And they, they give me a reason. And I often just take them through my logic. I'm like, that's weird. That just doesn't really make sense to me. But I don't, you know, hammer at home. And I say, you know, because, because this came back positive, you know, I am, you know, it's, you know, it's, it's our policy to bring you back next week and to do the same thing. And that's what we need to do to keep you safe. And that's what I need to do in order to feel comfortable, continuing to prescribe this dangerous medicine to you and this important medicine. And so just really a lying around safety and, you know, just recognizing that every time that they're showing up, that's the most important piece in, in building and rebuilding trust with them. Yeah. I think that's said so well. And I think one thing I hear really here is there's two kinds of conflicting things where on one hand, as a pallet of our hospice medicine doctor, you know, we don't have the training necessarily in addiction medicine. On the other hand, a lot of the skills that you need to practice, which are very skillful communication with patients. I think we do have those baseline skills already. And so in my mind, I think, you know, if we can just kind of shift some of that to use the right language, know the right things to say in our toolbox, I think we can be more effective at this than we realize, but certainly having a collaboration input from our colleagues is incredibly helpful. So I know it's just over three o'clock. So I'll hand it back to Bruce and Gina for any closing words and just thank everyone for their time today, joining us. And especially a big thank you to Seth and Brian and Bridget for joining this panel. I think we have an amazing group here that was really able to give us some amazing insight. So thank you. Brian, you've done the job. You've done the job for me already in closing out, essentially. Thank you all so much to the panel for being with us. Thanks to all you attendees for being with us. And we really, really appreciate this. This is a topic that was highly sought after by our certificants. And so we really, really appreciate you spending your time with us panel and all of you who attended. So we'll see you next time. Thanks again for being here. Really appreciate it and have a great rest of the afternoon, everyone.

pain management

substance use disorders

palliative care

harm reduction

individualized approaches

trust building

open communication

urine drug testing

naloxone

patient-centered approach