Substance Use Disorder in Aging and Serious Illness: A Podcast with Katie Fitzgerald Jones, Jessica Merlin, Devon Check

Eric: Welcome to the GeriPal podcast. This is Eric Widera.

Alex: This is Alex Smith.

Eric: And Alex, we’re going to be talking about substance use disorder and serious illness and aging, with three amazing experts. Who do we have with us today?

Alex: We are delighted to welcome back to the GeriPal podcast, Katie Fitzgerald Jones, who’s a nurse scientist at the New England Geriatric Research Education and Clinical Center, and a palliative and addiction nurse practitioner at the VA in Boston. Katie, welcome back to GeriPal.

Katie: Oh my gosh, can’t believe I’ve been here more than once now. Bragging rights.

Alex: Yeah. Last time you were on, you said, all clinicians should sign up for an X waiver. Maybe we’ll get to talking about that, and whether that’s still the advice. That was in April of 2022.

Jessie, we’re delighted to welcome you back as well. Jessie Merlin is an addiction and palliative care physician, and professor of medicine at the University of Pittsburgh. Jessie, last time we had you on in 2017, we asked you the question, should palliative care fellowship training include management of chronic pain? Maybe we’ll get to talking about that today. Jessie, welcome back to GeriPal.

Jessie: Thank you. It’s such a pleasure to be here with two of my favorite colleagues and two of my favorite podcasters.

Alex: Wonderful to have you back again. Also delighted to welcome, Devon Check, who is a health services and implementation researcher, and assistant professor at the Duke University School of Medicine.

Devon, I see that you have an R21 to study concurrent prescribing of opioids and benzodiazepines, which are like the second most common thing I prescribe in combination after opioids and laxatives for people in hospice. I look forward to your findings of your study. Devon, welcome to GeriPal.

Devon: Thanks so much. Great to be with you all.

Eric: So, before we jump into the topic of substance use disorder in aging and serious illness, I think someone has a song request. Is that you, Katie?

Katie: It’s me. It’s me. I told them I get the song request every time. Super excited to hear it.

Eric: What is it?

Katie: It’s Cocaine by Eric Clapton, and I picked it for a couple of reasons. See, Eric, I’m such a fan of your podcast. I know the questions you’re going to ask, so I’m just going to cut into it.

Eric: I’m just going to go mute right now. You can take it over from here. [laughter]

Katie: I got this. I got this. So, I picked this song for a couple of reasons. One is, Eric Clapton has been referred to as somebody that’s highly lyrical. His guitar actually sings the lyrics when he’s playing. And I know Alex broke his hand, so he’s going to not be playing the guitar. But I love the idea that he sings with his guitar and his music has been said to cut through not just heads, but hearts. And I hope that’s what our research does, too, is break down stigma and use the empathy that people have for serious illness to improve substance use disorder care for everybody. And also, it’s just an absolute jam.

Alex: It certainly is. And for those of you listening to the audio podcast, you get my son, Kai, singing on the guitar. And for those of you watching on YouTube, a little bit of piano version. Here we go.

(singing)

For those of you watching on YouTube, I’m laughing because my dog started to whine in the middle of my playing. [laughter]

Eric: Okay, Katie, we’ve got a lot to cover with substance use disorder. We’re going to be covering it in both cancer and in aging. We got a couple of articles to discuss and a lot of different components of this.

I was wondering, because Alex did mention that we talked with Jessie before about whether or not we should be teaching some of this stuff in palliative care fellowships. That was from our what? 2017 podcast. But I think one aspect there was, what’s up with cancer pain, in general? Is cancer pain really different? Should we be excluding it?

And Katie, I was going through your Twitter feed, and a tweet I noticed was this one, “All opioid guidelines caution long-term use in people with active substance use disorder.” Okay, seems right. All prominent opioid guidelines exclude people with cancer. What the heck is up with that?

Katie: I feel like, to this point, it’s been just figure it out then. You have no guidelines and you shouldn’t do it, but yet you’re compelled to do something. And really, this has been just kind of no man’s land and we’ve been working really hard to try to fill some of these research gaps.

Eric: Yeah. Should these guidelines be excluding people with cancer from thinking about substance use disorder, and is it a different population?

Katie: I worry there’s a lot of cancer exceptionalism, that cancer is so different than every other chronic pain condition in every other serious illness. And I think it doesn’t necessarily benefit people with cancer that may incur opioid harms, and it doesn’t benefit other people that might have serious illness other than cancer and can’t get opioids in situations that offer benefit. So, I don’t think we should have these silos.

And you wrote, actually, a beautiful GeriPal blog about it a while ago. What is it called? Cancer Pain, Non-Cancer Pain: A Distinction Without the Difference?

Eric: I barely remember that.

Katie: I’ve read it several times.

Eric: But I do remember Jessie talking about that in the last podcast. Jessie, you were also arguing there’s not a distinction or a big difference. Is that right? Am I remembering that right?

Jessie: Yes. Right. I mean, I think we draw these really artificial lines between what does it mean to have cancer pain? If somebody has cancer and they’re recently diagnosed, somebody has cancer and they’re undergoing active treatment, somebody has cancer and they’re in early remission, now they’re a year or two years, three years, four years out and they still have pain. I mean, we expect some people with cancer to continue to have pain. When does that become chronic cancer pain? What does chronic cancer pain mean? How does that differ from other types of chronic pain?

Our field really lacks specificity in the terms that we use, and I think we really don’t know how chronic cancer pain, let’s say, a few years out from that initial diagnosis differs from, let’s say, chronic low back pain. I don’t think we really know how different those things are and what the meaning of those differences are, but…

Eric: And is the neuropathic pain you see with cancer really that different than the neuropathic pain that you see with another condition?

Jessie: Right. I think that’s an unanswered question. My feeling working in this field, and I think from what we know, they’re probably more similar than different. I mean, we know that neuropathic pain, for example, across conditions, responds to cognitive behavioral therapy. Why would CBT work for neuropathic pain and diabetes differently than it would work for neuropathic pain and cancer? Why would that be? What would the biologic mechanism be that would make that different?

So, there probably are more similarities than differences, but like Katie said, excluding people from study, simply because they have cancer and treating them with kid gloves, maybe that felt benevolent, at some point, in our history, but patients with cancer are living a long time, thank goodness. And so, let’s help them.

Eric: And it’s also this assumption that people with cancer don’t also have concurrent substance use disorder, don’t also have opioid use disorder, and that we shouldn’t mitigate the risk for that in those individuals, just because that they have cancer.

Jessie: Exactly.

Eric: Which brings us to an article. I think two of you published, at least. Jessie, you weren’t on this… JAMA Oncology …

Jessie: I was.

Eric: Oh, you were? All three of you, Substance Use Disorders Among US Adult Cancer Survivors. Just published… yesterday, on JAMA Oncology. We’re recording this before publication of the podcast. So, that was… What? The 11th of January?

Jessie: Yes.

Eric: Devon, do you want to describe a little bit about why you all decided to do this project?

Devon: Sure. This just a quick sort of overview of what we did. We leveraged data collected as part of the national survey on drug use and health, which examines people substance use behaviors and whether they meet diagnostic criteria for substance use disorder, based on how they describe their substance use in the past 12 months. And as of 2015, the survey started to ask folks about cancer history, just some broad questions about lifetime history of cancer and whether they’ve had a cancer diagnosis in the past year. So, we thought this was a good opportunity to answer some unanswered questions about prevalence of, in particular, active substance use disorder, i.e. meeting criteria based on behaviors in the past 12 months among cancer survivors. And here, just to clarify, we’re using that term to mean, people diagnosed with cancer, not necessarily people who were treated with curative intent.

One thing we were really interested in and thought was important to answer had to do with cancer type specific prevalence of substance use disorder with the eventual goal of channeling attention and resources, with respect to intervention development to those populations of people with cancer where prevalence is higher and thus interventions might be most beneficial.

The other thing we wanted to understand has to do with the distribution of specific substance use disorders, alcohol use disorder, opioid use disorder and so on, in those sort of higher SUD prevalence cancer populations, since those different disorders necessitate different interventions, might interact with cancer in different ways.

Eric: So, what’d you find? How common is substance use disorder in cancer?

Devon: And Jessie and Katie should chime in, too. Prevalence varies quite a bit based on cancer types. Overall, the average prevalence, meaning across cancer types, we saw about a 4% prevalence of substance use disorder. Substance use disorders, I should say. But the range was huge when we looked at cancer type specific prevalence estimates, and when we looked among people who were ever diagnosed with cancer and then those more recently diagnosed.

So, I’ll just take head and neck cancers as a group with particularly high prevalence, based on our study. So, among folks ever diagnosed with head and neck cancers, prevalence of substance use disorders was 9%. About 9%. And then, looking at-

Eric: Wow. So, one out of 10?

Devon: Yes. Yeah. And I’ll get into whether that might actually be an underestimate in a minute. But focusing on people diagnosed with head and neck cancers in the past year, prevalence was up around 18 or 19%. So, closer to one in five.

Katie: I wanted to jump on when… Underscore one thing Devon said, which was the 4% prevalence. That number doesn’t feel huge to me, and yet when we looked at the other literature, it’s about as common, if not a little bit more, than other things that have entirely dedicated clinics and cancer centers, like diabetes-

Devon: Cardiovascular-

Katie: … cardiovascular disease, kidney dysfunction, liver dysfunction. So, all this funding dedicated centers, and at the minimum, it’s 4%.

Eric: I mean, it just makes you think-

Alex: Wow.

Eric: … out of the 20 patients that you see in one day, potentially, one of them has substance use disorder, potentially based on these… Depending on, again, the types of cancers that you see, obviously, more in head and neck lessen some others. What were some low frequency cancers? Were there low frequency cancers?

Devon: Breast was relatively low. You mean low-

Eric: Is that because there are… Is substance use disorder higher in men than women?

Devon: Yep. So, that’s really good question. And just to contextualize that sort of 4% average prevalence, that was probably a little bit lower than we were expecting to see, but there are a few contextual things going on. One, our sample is mostly women, driven by a high prevalence of breast cancer. And indeed, substance use disorders are less common in women than in men. Our population was also older which, again, makes sense because these were people with a history of cancer. And although rates of substance misuse and substance use disorder are on the rise in older adults, STDs are still more common in younger adults.

Alex: Can I just comment that when I think of substance abuse disorder in cancer, the patient that comes to mind, and maybe we’ll get to Katie and Jessie’s New England Journal article about the patient who had substance use disorder is trying to get methadone and also get treated for cancer pain. The patient that comes to my mind is a woman who had breast cancer, who died relatively recently, and the way she would come in and out of the hospital and the challenges that we face clinically in trying to prescribe appropriately for her really intractable issues, which raises the point that, though the prevalence may be lower in some of these populations, there are still people who are living with the opioid use disorder and cancer.

Devon: Right. And Alex, good point about breast cancer was a relatively low substance use disorder, prevalence cancer, but it’s a super common cancer. So, if you have a low percentage of people with substance use disorders in that population, it’s still going to be a lot of people.

Katie: Yeah.

Devon: Yeah. So, that’s just something-

Katie: And then, the prevalence, as you mentioned, was higher in head and neck cancer and it’s just worth noting… And Devon and I both have papers about this in JPSM, that this is a population that 90% or above get opioids during their cancer care. So, prescribing opioids for patients undergoing aggressive head and neck cancer treatment is really a standard of care and it improves their ability to tolerate chemotherapy and radiation. And yet, how you follow them through that journey when they have a preexisting or active substance use disorders is a challenge.

Jessie: The other thing that foggles my mind about this is how we measure this stuff. The NSTA, which is the survey that we used in this study, it’s not designed, first of all, to measure cancer. This was just a recent addition. But we know from other studies of the NSTA, the prevalence rates, you usually have to use a four to five multiplier. So, we’re talking about 4%, we probably should be multiplying that by four to five, because this database, when it measures prevalence, probably underestimates things by a lot.

But on the flip side, cancer registries do not measure substance use. So, we are not screening for substance use in cancer care, so we don’t get good estimates among people with cancer, which is really how we would prefer to ask the question. We were trying to answer this question using substance use data, but what we would love to do is answer this question using cancer data. And we have really looked and tried, and Devon could probably talk about this better than I could because she’s much more familiar with large data sets than I am. But we have looked and tried, and cancer registry data just do not collect this. So, this is another-

Eric: Despite how common it is or-

Jessie: Yes.

Eric: … or we’re learning how common it is.

Jessie: Yeah. There is neglect. Yeah.

Devon: I think just to close out the implication of what Jessie’s saying, having to use a substance use specific database versus a cancer specific one, means that our numbers started to get pretty small when we focused on a specific cancer type. People diagnosed in the past 12 months, for example, so our… I think this was published in JAMA Oncology because it’s novel and we don’t have a lot of information about prevalence, but our estimates weren’t particularly precise because of our small sample sizes. But the cancer specific databases just don’t have this information. We could look at cancer registry linked with… Like, I see here Medicare type big data sets, but then you have to rely on insurance claims and that’s going to underestimate SUD when most people aren’t getting treatment and it’s a tough nut to crack.

Eric: I guess, one practical question when we think about things that we should be doing, do you think we should be screening all individuals for cancer for substance use disorder? And is there a way to do so, that doesn’t take 15 minutes of a 20-minute visit?

Katie: Yeah. I have so many thoughts. I mean, the simple answer is, yes, we should be screening people for substance use disorder. I will say that people are so afraid to do that. I don’t know if it’s stigma or they feel like it’s an awkward conversation and they struggle to bring it up. But I feel like, as a field, we have been relying on these screening tools, like the Opioid Risk Tool and the SOAP tool to kind of do this for us, and those ask questions about substance use, and they’re meant to be filled out in the waiting room by a patient. And they ask questions like, have you used substances? Have you had a family history of substance use disorder? The old version of the ORT, the Opioid Risk Tool asked about pre-adolescent sexual abuse. Most of our population has trauma. I can’t think of a less trauma-informed approach to screening for substance use than putting somebody in the corner to fill out a form and ask them about the most traumatizing thing that’s ever happened to them.

So, I digress. However, I will say that, just being real with people and asking, do you use substances? Have you used substances? How often do you use substances? What substances do you use? What draws you to them? That’s why another reason why I picked the song Cocaine is, I feel like the song highlights that people use substances for both good and positive and negative reasons, right? They can acknowledge some of the bad parts, but they can also acknowledge, like Eric Clapton, cocaine wasn’t letting him down.

Eric: Is substances the right word? Do people understand what we mean when we ask that?

Katie: I start with that because as a palliative care person, I’ll titrate my language to what resonates with the person, but I’ll start with substances. I might say alcohol, and then I might say other drugs.

Eric: In the study, Devon, what were the top three or four substances that you saw in cancer?

Devon: Alcohol, unsurprisingly. It’s also the most common substance use disorder in the general population. Opioid. And then, it started to vary by… So, in cervical cancer, for example, stimulant use was really common. And head and neck prescription in substance abuse disorder was more… Not very common, still around 1%, but that was one of the most common in that population. But alcohol and opioids are up there.

Jessie: And I mean, this is not what we’re seeing in terms of take a substance use disorder history is… Whatever our backgrounds, internists, family medicine, whatever our background brought us to hospice and palliative medicine, this is med school level substance use disorder history. We’re just asking the bare minimum here for people to take that type of history. And if we’re talking about screening at the level of a research cancer registry stuff, this is the night of quick screen, just something really basic, we would take care of it.

I think part of the issue is, like what Katie was saying, some of it’s stigma, and some of it is also, I think people don’t know what to do with the answer, right? I think-

Eric: I was going to say that. It’s opening this stock box of, all of a sudden, now what do I do with this information?

Katie: Yeah.

Jessie: Right. When we take a mental health history, for example, I think we ask people, we do the PHQ, or whatever it is that we’re doing, asking people that mood. I mean, I think, generally, we’re comfortable, I would think. Most of us are comfortable prescribing SSRIs, for example, or attending to people’s depressive symptoms. But I think where people become a whole lot less comfortable is addressing people’s substance use disorders. And so, I think that’s where it’s really important.

You were asking before about training, Katie and I do a whole lot of training in this space around the country, really important to make sure people are trained from the very beginning, but to the degree that people really know how to respond when there’s an active or past substance use disorder. Yeah.

Alex: Let’s say, we have an oncologist listening to this podcast and they’re thinking, “Oh, no…” You only screen for something when you can do something about it. I can’t do anything about it. I don’t have an X waiver.

Eric: Oh, Alex.

Jessie: Oh, Alex. [laughter]

Eric: You should listen to the GeriPal podcast here, Katie told us.

Alex: Help this listener. Help this listener, if you could.

Katie: No, we’ll just shame you. [laughter]

Jessie: Dear listener without an X waiver, there’s good news for you. The X waiver has been axed. As of December of 2022, there is no X waiver anymore. Anybody with a DEA and… I should be very careful because this is different for physicians and advanced practice providers. And Katie, as an advanced practice provider, is much better than I am at explaining how this works. But for physicians, anybody with a DEA cannot prescribe buprenorphine for opioid use disorder, and you do not need an X waiver.

Now, does that remove the barrier? From an implementation science perspective, does that mean that, now, everybody’s prescribing buprenorphine for opioid use disorder left and right, and we don’t have any problems anymore with getting people the treatment they need? No, obviously. However, you don’t need an X waiver, as a physician.

And Katie, I don’t know if you want to say more about APPs.

Katie: No, it’s the same, anybody with a DEA license. Some states have caps or stipulations about collaborating physicians, but if you have a DEA license, you can prescribe buprenorphine, like you can prescribe other opioids. And that’s because we were on the podcast. That probably happened after the podcast.

Eric: This comes down to also like, if I find… As an oncologist, somebody has very high hypertension, is it my role to control that hypertension? Most oncologists would say no. Most palliative care clinicians would refer back to their primary care provider and not change their hydrochlorothiazide dose or add another agent.

When you do-do it, who is responsible for the buprenorphine? The oncologists are probably not going to be the ones prescribing the buprenorphine because they’re not going to be managing this patient. Even if the cancer gets cured, they’re not going to become their buprenorphine prescriber, the palliative care consultant. Should they? If the buprenorphine is being prescribed for opioid use disorder, they’re not going to be following… Should they be following that longitudinally? Should it just be referral to their PMD, who’s all, “Why are these people telling me to do all this stuff all the time?” Thoughts on that?

Katie: I mean, I’m of the mindset of stabilize the patient and figure it out, because I think we spend a lot of time upfront, doing the right thing. And in this instance, it’s providing buprenorphine for opioid use disorder, which is a lifesaving treatment. We don’t decide before treating an MI like, “Who’s going to be treating this MI?” Right? We just treat the MI, and then we figure it out.

And so, I think in these instances, recognizing that buprenorphine is a lifesaving treatment, it needs to be started, and then putting the pieces together to figure out a long-term plan. And everybody should play a role, right? If it needs to be involving palliative care at the beginning or involving addiction at the beginning, and then figuring out some collaborative care model down the line.

But I think in terms of Alex’s question, whose responsibility is this to screen for substance use disorder? If we’re talking about cancer and we’re talking about opioids, I think of it as the hands that writes the opioid prescription writes the bowel regimen, like the hands that’s writing the opioids or writing for the chemotherapy needs to nail with the context of the person’s life in order for them to appropriately engage in cancer treatment.

So, if they have an alcohol use disorder and that’s really impairing their ability to make it to chemotherapy appointments or it’s causing them to have even more mucositis related pain, you need to know about that. And I know that everybody can’t be everything to everyone, so there might have to be some figuring out, who’s best position? But I think who’s writing the opioid is a good start.

Devon: Something I’ve kind of just started thinking about is the potential to kind of piggyback on what’s… I’m not sure if this holds for opioid misuse or use disorder, but perhaps with alcoholic, piggybacking on what’s been done with universal tobacco use screening and referral to treatment in many cancer centers, some of that infrastructure is there. It’s a quality metric in some cancer centers to screen everybody who comes in the door for tobacco use history, and increasingly common for cancer centers to have in-house tobacco cessation programs.

So, I don’t know. I wonder if, at least, some of the groundwork… That’s a little bit different, right? Because nobody questions whether there’s a safe amount of cigarettes to smoke and not develop cancer or have suboptimal cancer outcomes. But some of it’s happening.

Jessie: I think, in this case, just to amplify what both Katie and Devon said, I mean, pain is clearly in the purview of a palliative care physician. I don’t think anybody or palliative care clinician, I don’t think anybody would argue with that. And addressing somebody’s substance use disorder directly impacts their pain treatment. And furthermore, when people are started on any treatment for their pain, we don’t ask, “Well, what if they develop chronic pain, who’s going to manage that in the long-term?” I mean, how many of our patients end up on long-term opioids from their cancer care, even if they’re just going to live for another one to two to three years? I mean, so many, right? We don’t think about that.

So, what’s the difference here? I think the difference is stigma, and also the way that we’re trained, right? We’re not trained to consider this to be part of our purview. We’re not trained to consider this to be part of pain management. We’re trained to consider this to be completely separate. I mean, if I had a nickel for the number of times I hear people say like, “I just do pain, I don’t do addiction”, and it’s like… I get where that’s coming from because that is precisely how I was trained. I won’t mention where I was trained, but-

Eric: Well, let me ask you this. Is it a failure of us? Or let’s say, I have somebody I want to start on methadone for opioid use disorder, can I do that?

Jessie: That’s a very good question. And I imagine, it’s a segue to… Right, this is how the system is set up, right? I mean, this is part of how the system is set up. Is it ingrained in us? No, you can’t-

Eric: Why not?

Jessie: … unless you are in a methadone clinic, which you’re not, I’m assuming-

Eric: So, you have to be in a methadone clinic to prescribe once a day a federally… Not qualified or fairly certified methadone clinic, right? To be prescribing once a day, methadone. But if I prescribe it for pain three times a day, I can knock myself out all I want.

Jessie: That’s cool. Yeah, exactly. Exactly. And that is the result of a very long history of the carceral-based methadone treatment system could go on and…

Eric: Yeah. Which creates issues, so I want to turn to Katie. The New England Journal paper on methadone. I have the title here, Juggling Two Full-Time Jobs — Methadone Clinic Engagement and Cancer Care in The New England Journal. You wrote about a patient, Mr. C. Do you want to describe Mr. C real quick?

Katie: Yeah, sure. I mean, I think we’ve all had a Mr. C. It sounds like, Alex, you’ve had a Mr. C. I frequently encounter patients that come into their cancer, and they have opioid use disorder, and they’re on methadone or they have untreated opioid use disorder, or develop an opioid use disorder in the context of their serious illness. And there are people for which methadone is the preferred treatment over buprenorphine. The treatment of medication for opioid use disorder should really be guided by patient preference, but often, and other factors, like Mr. C, he had head and neck cancer, he couldn’t absorb the buprenorphine, his mouth felt like it was a blowtorch, had been blown to it and couldn’t tolerate strips in his mouth.

And so, the option was really a methadone, to treat his opioid use disorder. And we really struggled. Like many of these cases, I have others right now in my practice. Whereas, what do you do? Because I think, to your point, Eric, I can prescribe it three times a day and nobody blinks an eye, it’s sometimes like a reflection of how much I want to lie or how much I want to-

Eric: So, what’s the truth?

Katie: The clinical record, reflective of what’s actually going on, right? It’s not one or the other, it’s that the patient has opioid use disorder and pain.

Eric: What are the challenges with opioid use disorder, methadone, in particular, while people are getting cancer care?

Katie: The methadone clinic system, it’s worth noting that it is changing significantly after COVID. So, since the ’70s, it had remained stagnant that everybody had to go every day, making these… In most cases, everybody had to go every day. They had to have certain amount of urine drug tests in a year, and they had to wait in line. And often, people had to drive an hour to go to their clinic, and then since-

Eric: Every day, driving an hour, driving back two hours a day, just in transportation to get your methadone once a day, every day.

Katie: Yep. So, really great solution for people who are trying to get their life in order, get a job, and improve their wellbeing is make them have to-

Eric: Eat up half of their day just getting-

Katie: … high threshold treatment. And so, again, that is getting better with increased use of take home doses for people. But nonetheless, the methadone clinic system is entirely separate from the rest of the healthcare system. You don’t see it on the PDMP. You don’t sort of know what’s in the black box of a methadone clinic. I’ve had a lot of palliative care colleagues say to me like, “I don’t want to take them out of their methadone clinic because they’re getting so much support from their clinic.” And then, what type of support they’re having is so highly variable from clinic to clinic. Sometimes, they have no support at all. I’ve heard people say that their counselor was the front desk person. They didn’t actually have that in place.

And so, for-profit hospices, for-profit methadone clinics pop up everywhere, and their care is pretty variable.

Eric: So, what happened to Mr. C when you wanted… Oh, yeah, I got some echo going on here. Okay, I think it’s gone. What happened to Mr. C when you tried to get… What? Continuous methadone? Start methadone in him?

Katie: Yeah. So, he was on it for a long time and he was doing really well, which was, again, a pretty common success story of methadone. It works. And we all met and tried to figure out a plan like, how could we get the clinic to keep him on? None of us felt eager about circumventing a federal system. And ultimately, the clinic really pushed back, and this has happened to me a couple of times where they’re like, “Can’t you just prescribe it? Can’t palliative care just prescribe it?” Again, that’s the exceptionalism. Rules don’t apply to us. Of course, we can just do whatever we need.

Eric: So, in order to prescribe it, you just switched to multi day dosing and call it for pain?

Katie: Yep. We perseverated about it for quite a bit, and then ultimately landed on dividing his dose by three, and dosed it TID, but-

Eric: Because he was also having pain, so it’s like-

Katie: He was also having pain.

Eric: Choose the indication.

Katie: Choose the indication.

Jessie: Let’s not pretend that this isn’t common. I’m not going to let my sister Katie out here like she’s the only person that’s ever done this on the planet, okay? [laughter]

Eric: What happens, though, if their cancer gets cured and they don’t have pain anymore, what happens to their methadone?

Katie: And also, what happens if they don’t have pain? I’ve had people dying on hospice that don’t have pain.

Eric: Yeah.

Jessie: Right. That’s a good point, too. Yeah.

Katie: Well, Mr. C never made it back to his clinic because his pain never… I mean, he had head and neck cancer, and even though the treatment related pain, the mucositis got better, it accelerated his aging. He had chronic pain from other sources, a multi-site pain. He had neuropathy from his cisplatin. And so, we ultimately kept him on in palliative care clinic for a while.

Eric: Yeah. And it kind of lends you to think about also opioid use disorder and substance use disorder in the aging population, because again, you wrote an article in the… Was it Lancet? Or one of the Lancet journals on age-friendly care for older adults with substance use disorder. And I loved it because you correlated it with the five Ms, the five things that we should be focusing on from an age-friendly healthcare system, and how those interact with substance use disorder. Do you want to just briefly describe that, too?

Katie: Sure. So, Mr. C experienced this and I have another veteran right now. Again, this sort of comes up a fair amount, in my practice, but the five Ms mobility being one of them, the times and I’ve… When I was getting my addiction certification, I was shadowing in the methadone clinic. And at times, people are coming in with a walker or wheelchair to get their methadone is not uncommon.

And so, you think about just, again, these high threshold treatments, like methadone clinics, where you have to be mobile enough to get it. And yet, for many of them, their mobility was declining. And so, trying to figure out a way to an age-friendly substance use approach would be trying to optimize mobility, while also not making that a stipulation to treatment.

Eric: What matters most is spending the few remaining days, weeks, or months with their family, maybe not having them trek for the entire afternoon to get their methadone.

Devon: And Katie, that’s true of residential treatment centers, too. I know many won’t take folks who have mobility problems.

Katie: Absolutely.

Eric: Just for the aging population, what about long-term care?

Katie: Yep.

Eric: Who manages, once a day, methadone once they’re admitted to a nursing home?

Katie: Well, I think you’re assuming that they’re accepting them to nursing homes, which is usually the first stop sign. There’s an amazing paper by Shawn Cohen and colleagues at Yale, and then also some others at BU that lots of patients on methadone or buprenorphine for opioid use disorder get denied by SNFs, purely because of the medication.

And so, there’s lots to be done in terms of implementation of having to make this available to SNFs. But in SNF’s defense, in skilled nursing facilities’ defense, to actually dose somebody on methadone in the current system, is quite challenging. So, assuming they are not mobile, the patient would have to pay for an ambulance to go get their methadone, to go to the clinic, to show up, even though they’re in a health system. And then, they get dosed, and then they have take home doses of methadone, which they can choose to keep in a locked box in their nursing home room with, perhaps, cognitively impaired patients all around them. And the nurse can’t dose it, they have to individually dose it.

And so, it’s just this whole cluster of like, how does this actually happen on the skilled nursing facility side? And it’s something that we really have to think about, because older adults are entering opioid treatment programs at really high rates, and the ones that have been in long-term methadone clinics are aging and they have lots of complexity.

Jessie: Yep. There are nursing homes that… Or I should say, methadone clinics that contract with nursing facilities and other types of residential treatment facilities. But these are often sort of one-off kind of situations. So, figuring out a more systematic approach to these things is really important.

Katie: And just a quick plug, Ben Han, who’s on that paper as well, we’re doing something at AGS on aging with opioid use disorder at a congruent session.

Eric: We had a great podcast with Ben, too, a couple of days ago. I wonder, real quickly, as we get closer to the end, we’ve talked about screening, we’ve talked about who should be managing and treating the opioid use disorder. Are there things that we should be thinking about with substance disorder? For example, when we’re treating cancer pain with opioids that we should be doing, including risk mitigation strategies? For example, should all of our patients that we’ve been describing, should we do risk mitigation strategies for everyone, universally independent of opioid use risk or use disorder risk? Should we be getting UToxes on everybody? Should we be checking cures on everybody? Should we be prescribing naloxone to everybody? Should we be doing pill counts with everybody? Thoughts?

Katie: Devon, do you want to say something?

Devon: No. As the only non-clinician, I’m going to let you [inaudible 00:44:29].

Katie: Well, I think, a couple of things. One is, in the stimulant paper that inspired the cocaine, the stimulant Delphi paper in cancer that inspired the Cocaine song choice was that, one of the things that kind of came out was what to do in terms of risk mitigation. And one of the biggest things people wanted to do was follow people more closely, and that involved shorter prescriptions, and also just giving us time to develop a therapeutic relationship, explore why people might be using substances or not, what cultivates a motivational interviewing, and also see if there’s a pattern. Are they using substances intermittently or is there a pattern of substance use disorder?

One other thing that came out that was, in hindsight, interesting, was that, there was some kind of nihilism there, too. Like, they’re using cocaine, they have cancer, they’re dying. I’m not sure I care. And I did an interview, a press interview, and the headline after was something like, “You can use cocaine in cancer care. No big deal.” I was like, “Wait, that wasn’t the point.” But I think what that taught me was that, it’s not that you do nothing, like you said, Eric. There are risk mitigation things you can do. You can prescribe naloxone, and you should for everybody. And if you don’t prescribe it, they can now get it over the counter.

Eric: And it’s interesting, too, because that almost… It assumes like, “Oh, they’re dying from their cancer. Let them have this one piece of joy left, which is their opioid use disorder”, which, by definition, is not bringing them joy, right?

Jessie: Rught. And I think you still want to remember asking people what their goals are as it relates to the useful thing like… I was reminded of this recently with a patient using stimulants with a fairly limited prognosis, and she’s like, “Yeah, I don’t necessarily want to stop my stimulants. I’ve been using them for a long time and that’s just what I do.” And it’s like, yeah, that’s a useful thing to talk about. What’s the goal? Yeah. Anyway. I’m so sorry, Katie, I didn’t mean to interrupt.

Eric: In your consensus, if I’m remembering it correctly, about opioid use disorder, is that, it’s not that you would just, let’s say, stop the opioid in somebody who may be having some issues. You may be increasing their monitoring, you may be doing other things.

Jessie: That’s right.

Eric: And we’ll have a link to that paper, too.

I guess, one question. I’m going to go back to this, is like, our palliative care clinic is created in standard operating procedure where, pretty much, everybody gets a UTox, I guess, a urine drug screen. I’ll call it correctly. You get the CURES check, you get the pill count, and you get naloxone, independent on risk with some minor exceptions, like if you’re stuck at home and you can’t come because your cancer is so bad, they’re not going to force you to do a urine drug screen. Do you think that’s right or do you think that there should be…

Katie: Perhaps, this is a hot take, but I don’t really… Opioid agreements and urine drug tests, they’re not evidence-based. They’re something we do to make ourselves feel better, and they’re a teachable and intervenable moment. And so, I kind of partner with my patients and say… First of all, I use agreements. I have to do them where I work, but I use them as an opportunity for informed consent.

Eric: So, use agreements, they’re not evidence-based, but you’ll still use them.

Katie: Because I have to, and I’ll use it for an opportunity for informed consent, and then urine drug test screen. I personally do not do universal use of urine drug screening, both because we know from papers, like Andrea Enzinger’s, in JCO, that they’re ordered… I understand the reason to do universal, because otherwise, they’re ordered on a racial basis, and we don’t want that either. But they do incur costs for patients, too, and they do send a message of mistrust at times. And so, I often do a substance use history, as I described, and then sometimes talk to people about urine drug testing, do them on occasion, or letting them know that I’m doing them. And then, if it comes back as something that I wasn’t expecting, engaging in that conversation, but I don’t use them in a punitive fashion. I think that would really be the mistake.

But it often is a practice decision to… People should decide as a group like, “What are you going to do?” And everybody do it.

Eric: Yeah. Jessie, what do you think?

Jessie: Yeah, I agree with everything Katie said. I have a practice within an addiction clinic where I do palliative care in an addiction clinic for patients with opioid use disorder and advanced cancer. And so, we use opioid treatment agreements and we do sort of annual urine drug testing. And I use urine drug testing as a way to open a conversation with a patient, and I do a good substance use history and just have conversations with patients. And echoing what Katie said, I mean, I use opioid treatment agreements as a way to talk to patients about, what is my role as a clinician? I want to make sure people understand that I am here to… I try to de-stigmatize the whole process of… Oftentimes, I may be one of the first people who said to them like, “I’m really going to be here to help you with your opioids, and I’m going to be prescribing them for you, and you can count on me to do that.”

Sometimes, people get very nervous about the power differential, so I try to use it as a way to level set and make sure that they understand that I’m not trying to lord the opioids over them. So, I use it to emphasize what my role is.

Katie: What you’re saying is, you treat it like any other diagnostic test, right? And if it would change your management, maybe you do it, but if it doesn’t, which is often the case with buprenorphine, like, “I’m not going to stop buprenorphine”, if somebody is using a stimulant, so I’m not going to order it.

Jessie: Exactly, yeah.

Eric: But you may change other things, frequency, if you use the consensus statement, potentially. Frequency of monitoring. I wonder, though… I know we’re running out of time. I just want the lightning question, if everybody has a little time. If you had a magic wand, what’s one thing that you would hope that we, as a system, as providers, would do different when it comes to substance use disorder for cancer, for aging?

Katie, I’m going to start off with you.

Katie: Yeah. I think I would create a research and clinical agenda that marries the two, that marries cancer and substance use rather than treat them kind of separately. So, rather than-

Eric: Or just exclude cancer completely from substance use disorder guidelines.

Katie: Yeah. I would like them to get married and unite, and have this real integrated care model. Most cancer centers don’t have anyone that has addiction training, and I think that’s a real problem.

Eric: Great. Devon?

Devon: Certainly agree with Katie’s wishlist. But I think starting with systematic screening, and as we talked about earlier, folks are going to be reluctant to screen for something that they can’t treat or if there aren’t services available to offer someone. But it’s kind of shocking the extent to which clinicians often don’t seem to know about someone’s substance use history. So, coupled with that has to come, like Katie was saying, better, more integrated systems of care where folks who take care of patients with cancer and substance use disorder, like palliative care clinicians, like oncology care clinicians, have the support that they need from experts, like Katie and Jessie. There aren’t very many Katie’s and Jessie’s, but we need more of them and we need better linkage across health systems to that expertise.

Eric: And I also have to add, it’s really hard, sometimes, to find it in the EHR, that somebody has a substance use disorder.

Devon: Right. It’s not well-documented. And what if they’re coming from a different system? In some of my work right now, we’re sort of exploring what cancer care clinicians current practices are, with respect to assessing for substance use disorder. And there’s a lot of… Well, if I sort of get a feeling or I had a concern about it, and that’s where bias comes in. Yeah. So, I think systematic screening is really important, coupled with, of course, systems of support.

Eric: Jessie, the wand has a little bit energy left.

Jessie: Stigma. I mean, there is so much substance use stigma in healthcare. And one of the things I love about my job is that, patients thank me constantly. The bar is so low. Mostly, patients are thanking me for just treating them like human beings. That’s generally… I mean, I had a couple of trainees this morning in clinic with me, and they were like, “Your patients just all love you. I mean, that lady cried and that one gave you a hug.” And I was like, “It’s just because I treated them like they were human, it really wasn’t…” The bar is low.

Primarily, I’m a researcher. The thing I want most is more research in this space to be able to integrate addiction treatment into palliative care. So, all this stuff, like Katie said, and Devon said, but on a human level and on a clinical practice level, just reducing healthcare stigma for our patients, I think, is what would make the most everyday difference in what we do.

And one last thing, I really want to highlight the suite of papers we have on recommendations, real world recommendations based on Delphi studies for how to treat these patients. We have three of them. One in JAMA Oncology, one in JAMA Network Open, and one in cancer.

Eric: And we will have links to all three in our show notes.

Jessie: Yes. Yes. So, really appreciate your patience.

Eric: Alex, give us a little bit more Cocaine.

Jessie: More cocaine.

Alex: That sounded weird. [laughter]

(singing)

Eric: Devon, Jessie, Katie, thank you for joining us on the GeriPal podcast.

Jessie: Thanks so much.

Devon: It was a delight. Thank you.

Katie: Thank you.

Eric: And to all of our listeners, thank you all for your support.