PC for Patients with Substance Use Disorder: Janet Ho, Sach Kale, Julie Childers

Eric 00:11

Welcome to the GeriPal Podcast. This is Eric Widera.

Alex 00:12

This is Alex Smith.

Eric 00:13

And Alex, who do we have on today?

Alex 00:15

We are delighted to welcome back Janet Ho, who is a palliative care doc and addiction medicine doc and associate professor at UCSF. Janet, welcome back to the GeriPal Podcast.

Janet 00:26

Thank you so much.

Alex 00:27

And we’re delighted to welcome Sach Kale, who is a palliative care doc at the Ohio State University Wexner Medical Center. Sach, welcome to GeriPal.

Sach 00:38

Thank you very much.

Alex 00:39

And we’re delighted to welcome Julie Childers, who’s a palliative care doc and addiction medicine specialist and professor of medicine at the University of Pittsburgh. Julie, welcome to GeriPal Podcast.

Julia 00:50

Thanks for having me.

Eric 00:51

So we’re gonna be talking about caring for people with serious illness and substance abuse.

Janet 00:57

You mean substance use disorder?

Eric 00:58

Substance use disorder. Oh, my goodness. I actually have substance use here. But my medical training kicked in. [laughter]

Alex 01:06

To say the wrong word, it’s deeply ingrained. That’s what it was when we were in med school. Cause we were in med school at the same time, same place.

Janet 01:14

Yeah.

Eric 01:14

I think drug use is what we got, right.

Alex 01:17

We had the wrong terms drilled into us. We just unlearn what we have learned. [laughter]

Eric 01:21

Like narcotics. I remember as a fellow, I would come in and our nurse practitioner on our hospice team, I would say the word “narcotics”, and for half an hour, she would just lay into me. Since then, I’ve stopped using the word narcotics because of that. So I just need this, Janet. I need you to correct me every time I say the wrong one. [laughter]

Janet 01:45

Yeah. Thank you for demonstrating how deeply ingrained that can be.

Eric 01:49

Listeners, I totally did that on purpose. [laughter]

Alex 01:51

Very well planned.

Eric 01:53

Yeah. Roleplay. Who has a song request for Alex before we talk about substance use disorder and serious illness?

Sach 02:02

I do.

Eric 02:04

What is the song request, Sach?

Sach 02:07

The song is called the Drugs Don’t Work by the Verve.

Eric 02:11

Other than the title being perfect for this, any other reason you picked this song?

Sach 02:15

Yeah, the singer initially wrote the song actually to himself during the depths of an addiction to heroin. And then eventually the song evolved and the lyrics changed. And it’s supposedly also about his grief with the loss of his father after a long illness. So I just thought it resonated nicely with issues about addiction and palliative care that we’ll be talking about today.

Eric 02:34

Great choice.

Alex 02:40

(singing)

Sach 03:44

Oh, that was great. Thank you.

Alex 03:46

Thank you.

Eric 03:47

Great song choice.

Alex 03:48

Yeah.

Eric 03:49

I’m gonna open it up to actually all three of you, I guess. First one responds gets the first response. But, you know, I’ve talked to a lot of palliative care providers, a lot of people caring for people with serious illness. Myself too, I find this a very hard population to care for, which probably says more about me than them. This combination of substance use disorder and a serious illness. Why do you think that that is a common feeling amongst those who care for serious illness, or do you disagree?

Julia 04:25

I don’t think it’s only those who care for serious illness. I think it is just about any clinician. I see this in the hospital when I’m doing addiction medicine consults. Folks with uncontrolled substance use disorder typically are very impulsive. They’re often angry. They often have behavioral issues stemming from their disorder, their life circumstances, all sort of feeding into each other. And so I think for anybody, it is difficult.

Janet 04:55

Thank you for that question and for how you framed it. I think Dani Chumas actually just wrote a piece in Annals that was called Wishing for a no show where she talked about examining countertransference that we bring into a visit. And I think this is a perfect example of that. And I’ve been reflecting on that.

Right. So countertransferences, all the, like, feelings, associations, reactions that we have and that we bring, whether positive or negative, when we are interacting and taking care of a patient, as well as kind of the surrounding ecosystem around us. And, you know, I think, as Julie mentioned, most people, most clinicians feel uncomfortable in this situation, and most patients feel uncomfortable in this situation. That’s what’s come out in qualitative interviews.

And if I examine my own discomfort, it is, you know, multifactorial. Right. Like, there’s in part, some moral distress and some incompetence. It’s like, how do I help this person who likely has developed the substance use disorder in the kind of social context of not having connections or not having stable housing, not having or having experienced trauma for most of their life? And then there’s also the piece of, you know, do I know what to Say to this person, have I learned how to use words to talk about substance use disorder and pain, or do I know what to treat it with? So there’s some feelings of maybe personal inadequacy.

And then there’s this piece, I think as clinicians where we’re all maybe a little bit of people pleasers, maybe especially in palliative care, where we want to have someone feel better at the end of our visit and we want to feel better at the end of our visit. And so there’s this conflict avoidant piece too, which I know is inescapable in a visit like this, where we might have to set boundaries around prescribing that I don’t look forward to being part of.

Eric 06:42

And I love Janet, that you brought up Danny Shammas piece, which I’ll have a link to in the show notes. If you haven’t read it, you gotta read it. Because even in the way I responded to that question, because initially I was thinking that like, oh, why are these difficult patients? But the countertransference that Danny talks about is, don’t ask the question, why are they difficult? Ask about your countertransference. Why am I having difficulty with this patient? Why am I feeling frustrated with this patient? That was my take home. There’s probably something way even more deeper than my take home. But that was my take home from Danny’s article. So I love that you brought it up. Sach, I got a question for you.

Sach 07:22

Yeah.

Eric 07:23

I’m guessing that there was some of this going on where you work, because you actually created a clinic around this particular population. People with serious illness, cancer or serious illness?

Sach 07:38

Cancer.

Eric 07:38

Cancer and substance use disorder. Now I’m paying extra attention. What problem? Why did you decide to do that? What problem were you fixing?

Sach 07:50

Yeah, it’s funny to even think about it now because our palliative program has changed so much culturally in terms of how we think about managing patients with cancer and substance use disorders. But back in 2019, there was a lot of disagreement in our group about whether for a patient with cancer and cancer related pain and a substance use disorder, whether palliative care was the appropriate specialty to care for those patients.

But what everyone agreed upon was that the patients were not well served, oncologists were upset, and we were upset because we knew that these patients were vulnerable and needed help and were not getting the help from us. To move past the disagreements, those of us who are interested just created a pilot clinic and then evolved from there. And it’s really grown and really changed our entire program. Both inpatient and outpatient, about how we care for these patients.

Eric 08:44

I forget, did you have specific training in addiction medicine?

Sach 08:47

No, I did not. I got the buprenorphine waiver at that time. Get an X waiver, but that was it.

Eric 08:55

What did you do? What did your clinic look like?

Sach 08:59

We really grounded it in a harm reduction approach. We said that we had tried years before to refer patients to addiction medicine, but surprise, surprise, addiction medicine didn’t know how to manage complex symptoms in serious illness. That’s what we do. We recognize that for us, it really had to be a palliative led approach grounded in harm reduction. And then with collaboration with addiction medicine, we started the clinic, myself and a pharmacist, at just half a day a week.

One of the things we really focused on was through our leadership at our cancer institute, just highlighting that we felt like we could help care for these patients. But we needed some extra resources and started to advocate for those extra resources and really track the patients we were caring for so we could show to folks that this is a patient population that needs extra support.

Eric 09:51

Yeah.

Alex 09:51

Can you say more about what you mean by a harm reduction approach?

Sach 09:56

Yeah. So, you know, for me, it’s a recognition that patients who use substances may not be able to stop when they get cancer and they have cancer pain. And so if abstinence is not possible, where do we go to meet these patients and really reduce harm? And it starts off with there’s a paper by Mary Hawk actually from upmc. Julie, you might know her, I just know her from her former writing, but highlighted these principles of harm reduction.

Won’t go through all of them, but things like humanism, realizing that moral judgments don’t make us about our patients, don’t make us better doctors for our patients. Pragmatism, accountability without termination, which is a really important one. We started really practicing those principles and then different harm reduction strategies to help mitigate harm for our patients who continue to use substances.

Alex 10:49

And then when you say accountability without termination, that sounds like it speaks to a core principle of palliative care around non abandonment and building relationships. And I see everybody’s nodding to that.

Sach 11:01

Yeah, absolutely.

Julia 11:02

Yeah. I think the accountability piece is something that is more new for palliative care clinicians. And that’s something that I’ve had to learn. I think in the era when I trained in the 2008 timeframe, you know, it was very much just like somebody has pain, they need opioids, they have pain, they have more pain, they need lots more opioids. And I Started seeing people have problems with that and that not really having a benefit for people ultimately.

And the challenge with being the prescriber when there might be an element of addiction in the person asking me for opioids. I mean, I think we’re in a really unique position taking care of people and prescribing opioids for them. You know, and no other substance use or substance use disorder situation am I the prescriber who the person is asking me for their substance. Like if a person has an issue, struggle with alcohol, I’m not their alcohol provider, but I may be their opioid provider. And it gets very tricky to differentiate exactly what’s going on in terms of.

Janet 12:06

Requests for opioids and just to add credit where it’s due. Like harm reduction was this approach to helping folks that really arose out of people with lived experience. So is people using drugs helping other people use drugs do it more safely if their goal was not to stop or not to cut down? And so, you know, when I’m in clinic and with a patient who’s not intending to or not wanting to stop using a non prescribed substance and I feel like there’s nothing else I can do, at least I can turn to harm reduction and be like, okay, well if you’re going to continue to use, let’s think about how that can be done more safely, especially in the context of your other serious illness and treatments and potentially, you know, pain management.

Eric 12:48

I want to get into some of the practical issues. How do you actually do that? But before, I just love to hear from both Janet and Julie. Janet, do you have a similar clinic structure as SACH has? And I just want to also highlight, we’ll have a show note because there is a great JPSM article that he wrote that describes this clinic that he created with his colleagues. Janet, how are you integrating addiction medicine and palliative care?

Janet 13:19

Yeah, thanks for asking. We do have in our cancer palliative care clinic an embedded, it’s called support PC for substance use, pain and promoting opioid harm reduction together in palliative care clinic. It’s this interdisciplinary clinic where we offer a couple of different things. So there’s co management with an addiction specialist, which would be me, or co management with palliative care specialists that don’t have additional addiction training, kind of like Sach, either with our nurse practitioner or another physician. And we kind of offer some, you know, curbside advice on how to approach, you know, certain situations.

Eric 14:01

And Sacha, that’s actually what you, you do, right? So in your clinic so you have palliative care providers who have some interest and some expertise in this, but you. You also have addiction medicine, who y’all review cases with.

Sach 14:13

Yeah, that’s where we’ve evolved in terms of having that structuralized support where we’ll meet monthly with an addiction medicine specialist and also be able to call her whenever we need to for other questions.

Eric 14:25

So they’re available. Prn.

Sach 14:27

Yeah.

Eric 14:28

Julie, how do you integrate palliative care and addiction medicine?

Julia 14:33

So I went a different route. When I finished palliative care fellowship, I had developed an interest in addiction. So one of the things I started doing was prescribing buprenorphine for people with opioid use disorder within our gen med practice. So not particularly palliative care. And then that was really before the opioid epidemic became a thing. And then once it did, some years down the line, we developed a larger outpatient OUD and other substance use disorder treatment program that I got and folded into.

And then over the years, people increasingly started asking me more for help with those patients in their outpatient palliative care with who or whom there was substance use or addiction concerns. And so I started taking on more and more. I have lucky here. We have two of us. I have a colleague, Dr. Jesse Merlin, that people may be familiar with, who is also on our podcast.

Alex 15:25

She’s been on like three times.

Julia 15:27

Yeah, I would imagine. So. We have this. The general clinic is called the Internal Medicine Recovery Engagement Program, and our clinic is the Palliative Recovery engagement Program, or PrEP. And so it’s just her and me seeing these palliative folks. We are lucky also. I’m the fellowship director for addiction medicine, so I have developed a track for folks in palliative care going into palliative care, interested addiction. And so I have been lucky enough to have fellows who’ve completed palliative training and who are doing addiction with me and also see these folks.

Eric 15:57

That’s wonderful, because I got so many questions for you, but I swear the last question that I have is, Sach, you brought up some already some ideas of that. Things have changed since you started the clinic. I’m guessing some of the practices, even for those who are not in the clinic, have changed. What kind of benefits did you see with the clinic?

Sach 16:19

So there’s a lot of fear, right? Uncertainty. If you’re taking on practicing something you’re not used to before, you didn’t get trained in fellowship. And so the more we engage with these patients more, it’s rewarding. We could see the positive Health outcomes as we start to take care of them. We got admitted to the hospital, our inpatient palliative team developed their skill set because they had a place to send patients when they got discharged. Everyone started to get comfortable cross covering and it really just again just changed the culture for our entire palliative program.

Eric 16:52

Yeah, I noticed. One thing that changed for me is we had Katie Fitzgerald Jones on our podcast who for me was my entryway into buprenorphine where she didn’t force me, but she told us to get familiar, taught us how to use it and man, things have changed. And I’m wondering from a practical standpoint, when you think about pain management in those with a history of substance use disorder who have substance use disorder active like is buprenorphine like your go to drug right now? For those individuals, how do you think about that?

Sach 17:32

For me, it’s our first line opioid. So if you’re going to prescribe opioids, it’s our first line choice. And there’s an element of shared decision making, of course.

Eric 17:41

And why is that?

Sach 17:43

It has a lot of properties that make it safer than other full agonist opioids. So the risk of respiratory depression is much lower compared to oxycodone or morphine. There’s a sense that the mood modulation in terms of euphoria and things like that are less with buprenorphine. And then also it’s a first line treatment for opioid use disorder. If you’re able to, if you have a patient with an opioid use disorder, you’re able to treat the OUD and help alleviate their pain with one medication.

Janet 18:11

I think if there’s a patient who has some sort of substance use or substance use disorder as well as painful serious illness, there are usually a couple factors that I think about to decide out of the options of opioids, which one seems most appropriate. I know Julie does a little bit of this triangulation as well. I think what I’ve been teaching is this thing called the peas. But one of those facets is pain. We’ve all been taught through fellowship or through clinical practice about how to assess pain.

Then the piece that we carry with us that may not serve us so much anymore is trying to differentiate exactly like what that pain stems from. Is it cancer related pain or is it not cancer chronic related pain? And that can get confusing because we are taught to offer opioids for cancer related pain, but old opioids for non cancer related pain or addiction or anything else. And so then if you just focus on the pain part, trying to figure out like, is this an acute pain? Is this post op pain? Is this terminal end of life pain, Is this chronic pain? Because each of those things has evidence for, you know, what might serve them best.

So for instance, for like terminal pain or acute or post op pain, there’s a lot of evidence that suggests these may be appropriately treated with full agonist opioids. Whereas things like chronic pain tend not to have improvement in function or quality of life with ongoing full agonist opioids. Whereas in the chronic pain literature it’s like buprenorphine can be really helpful for this and it reduces the exposure kind of over time to harms of opioids. So that might help me differentiate between whether somebody would benefit from a filagnos opioid or benefit more from buprenorphine. And then on top of this, just to quickly layer, you know, the other thing to consider is this other P of like pattern of substance use.

Like do they have a substance use disorder or are they using substances? Like do they occasionally use methamphetamine? But it’s not really causing any consequences, right? Because addiction is ongoing use of this substance despite harmful consequences. And then if somebody does have a substance use disorder, is this a person who has been in stable remission for 20 years, like they have multiple take homes from the methadone, you know, treatment program? If so, that might be a person who may continue to be stable with a full agonist opioid.

Or this may be a person who at some point down the line, I know Julie will have more to say about this might be someone that I would consider taking over the methadone for versus someone who’s only recently stopped using substances and hasn’t been stable in recovery. Or if they use multiple substances, that might be someone that I reach out to addiction medicine for co management help with. And then the last thing is just the prognosis, right? So if somebody has a really short prognosis, this might be a person where I’m like, okay, a full agonist opioid is what I know how to titrate the best and most effectively. Whereas if they have a long prognosis, that might be again, point me towards buprenorphine.

Eric 21:12

Well, real quick, the P’s are pain pattern prognosis.

Janet 21:17

Yep. And prognosis performance status.

Eric 21:20

Performance status. I got a question because both of you talked about having this embedded into cancer clinics. And the thing that I never quite get is this idea of cancer pain versus non cancer pain. Because the pathophysiology like whether or not you break your rib from cancer versus you break your rib for something else. It’s the. The same thing. And now we have cancer patients who are surviving for decades. They may get cured. It’s not like their prognosis for everybody that we care for is weeks to months. How important is it we separate cancer versus non cancer pain versus those other important things that you talked about, like the peas that you’re talking about.

Julia 22:00

I just wanted. I wanted to say something when Janet was talking related to this chronic pain distinction. And I guess I would argue with the statement that chronic pain and cancer pain are no different because there is a cycle. And the way that chronic pain tends to work is. It is. And I’m not going to explain this very well, but just in terms of, like, what we’re thinking now about sort of the neuroscience and what perpetuates it, it is not directly related to a tissue injury necessarily.

So in the chronic pain world, they’ve done studies with people with chronic lower back pain, and, you know, sometimes a patient will say, oh, my God, I have degenerative disc dise. But if you do MRIs of like 100 people, then. And you look at the degree of degeneration in their disc, it doesn’t have. Right. It’s very much a psychosocially related disease. And, you know, I think chronic pain would be a great thing to have another podcast on.

Eric 22:57

Yeah. But it does make me really mad because you have people with cancer pain who also have chronic lower back pain. It’s not like, oh, we should now treat their chronic lower back pain differently.

Alex 23:08

Or especially the older patients who we tend to care for, who have older and have serious illness, they have arthritis, they have low back pain, they have peripheral vascular disease and vascular pain in their lower extremities. And now they have cancer pain, too.

Eric 23:21

That was one of your earlier studies, right, Alex? The most common.

Alex 23:25

Oh, yeah, yeah. Reason for pain near the end of life. One of the top ones was actually arthritis. Yeah.

Julia 23:31

Right. And I think, you know, for someone who’s evaluating a patient who comes in, who has substance use disorder, whether it’s in remission or active, really looking at where the pain is and what the etiology is, you know, if they have cancer, look at what the scans show in terms of where the tumor is, if it’s. The pain is in a whole different place, and if the exam is more consistent with osteoarthritis, think about whether you would, you know, absent cancer, offer this patient opioids for Osteoarthritis that can often get us into trouble with people with substance use disorder.

And we all know, of course, that people are living a lot longer with cancer and other serious illnesses and then can go into remission. And then we’re stuck prescribing high dose opioids for chronic non malignant pain. And then what we have found is that the substance use, you can’t sort of effectively treat substance use disorder by high dose opioid agonists through a palliative care clinic. The people still, if they have a substance use disorder, they will use fentanyl on top of the high dose oxycodone that you’re prescribing. That, I think, is the challenge that many people in palliative care call me about to discuss cases.

Janet 24:46

But I do think buprenorphine, really, it’s not the panacea. But for people who do end up with chronic pain, whether it’s non cancer related or cancer or cancer treatment related at some point, or whether they’ve developed this kind of gray area thing called complex, complex persistent opioid disorder, for all of those people, I do try to rotate them onto buprenorphine because it can help stabilize pain as an opioid analgesic. It can help stabilize the cycle of perhaps withdrawal taking an opioid. And then it can also reduce the harm of long term opioid exposure for immune suppression, which is really relevant to our cancer patients or patients with cancer or hormonal or endocrine disruption.

Eric 25:36

And that’s because opioids can cause immune dysfunction and buprenorphine may have less effects on the immune system. Is that right?

Janet 25:46

Yes. Yeah.

Julia 25:47

Yeah.

Eric 25:47

Okay. So potentially really important for people who are taking immunotherapy. But what about methadone? Have we moved on from methadone? Like why, why not methadone being our goal?

Julia 25:59

Well, you know, in my era when I trained, that was the teaching. You know, if somebody has addiction, great, just start them on methadone and all your problems will be solved. Yeah, I mean, I think, I think the challenge is that methadone and the reason why I don’t typically recommend that, that we prescribe methadone for folks is, you know, I think we all know about the properties of methadone in terms of, you know, it, it, you know, is relatively easy to overdose on, for example, as compared to something like buprenorphine, where it’s almost pretty much impossible to have an overdose on buprenorphine.

And I think just understanding a little bit more about addiction and the way opioid treatment programs work. When somebody is in an opioid treatment program, there is that sort of accountability level. And they’re there because they have an opioid use disorder. And the program knows how to handle when they use opioids outside of the prescribed methadone, they have protocols for that, they have counseling, they have an interdisciplinary team that is focused on that population. And, you know, they’ll start off by dosing it on a daily basis and observing dosing. When you have somebody with an addiction you’re seeing in your palliative care clinic and you write them a prescription for methadone three times a day and send them off with a month’s worth of that medication, you don’t know what they’re doing.

They might just decide their pain is really bad and so they’ll take double or triple the dose. Or they might, you know, they might sell their medication, which this population is also prone to. So I think you just have to be very aware. If you’re prescribing methadone to somebody with an opioid use disorder, they may use substances. And so what’s your next step? And they may also be in long term remission and stability in their disease. And then what’s your next step? Are you prescribing them methadone for the rest of their life? So usually I’d recommend it only when we have a very clear backup plan for what happens and of course, when people are really nearing the end of life as opposed to these sort of long term potential survivors.

Eric 27:53

So how do you deal with that? Sach because you’re a palliative care clinic with expertise in opioid use disorder with the as needed addiction medicine, Are they in your clinic for life? How are you managing folks? And do you have pathways for those people who are currently using or go out of remission?

Sach 28:15

Yeah, I think about our palliative clinic. We are servicing patients at a very kind of unique time frame. Right. They have a substit substance use disorder, they’re undergoing cancer treatment, and there’s not another model of care that could help them at that point. We have a lot of patients, for example, who have head and neck cancer. So we support them through their radiation, and then afterwards, if they still have a substance use disorder, well, they’re done with their cancer treatment. Our clinic is not an addiction medicine clinic, it’s a palliative clinic.

And so if they relapse into substance use disorder, the best place for them to go is to a clinic that is focused on their addiction. So that’s how we think about it. If a patient is on suboxone or sublingual buprenorphine and we put them on sublingual buprenorphine, we’ll try to transition them to a suboxone or buprenorphine clinic once they’re done with cancer treatment.

Janet 29:10

I’ll just. One more thing about why we don’t prescribe methadone for the treatment of opioid use disorder in our clinic is because it’s illegal. And really, methadone in the treatment of opioid use disorder can only be dispensed from an outpatient treatment program or methadone clinic. There is a movement to quote, liberate.

Eric 29:30

Methadone, but you can’t prescribe buprenorphine.

Janet 29:33

Exactly. It’s the frontline office based treatment that anybody with a DEA license can prescribe to either treat pain or opioid use disorder or some combination.

Eric 29:44

And what do you do in your clinic when they’re done with their cancer treatment but they still have substance use disorder, which you are the person prescribing buprenorphine?

Julia 29:55

Well, I mean, I know in my practice, luckily I’m in an addiction clinic. I’m just like, great. I keep you as a patient forever as long as you live. So it’s not an issue for me.

Eric 30:04

What does Janet do?

Julia 30:05

Yeah, with Janet and Sach, it sounds like you set. What you do is you send them onto a buprenorphine program.

Sach 30:12

I mean, we try to. They love often being with us. I mean, this is a general palliative clinic too, for us. I don’t know if you have this.

Eric 30:19

No, we were thinking about doing a survivorship podcast. Yeah.

Alex 30:22

Because this keeps coming up again and again. I was just saying, I was like in Cleveland Clinic giving grand rounds or Anne University Hospitals giving talks over there. And they were saying when they look around the room, they say, who’s going to do the survivorship care? They look at the palliative care folks now. I see everybody nodding their heads again. Right. This is becoming like, how do we hand these off? When do we hand these off? Who’s going to manage these medications? These are all questions that I think a lot of groups are grappling with.

Sach 30:50

And the resources aren’t always there to do that. Like, you know, you’re not getting the additional resources to care survivorship. So that’s an issue we think about a lot.

Eric 30:58

Janet, any other thoughts on that question?

Janet 31:00

No, I think that you’re absolutely right. This broaches Onto a bigger.

Eric 31:04

We need a bigger.

Alex 31:05

I know we have to. We gotta move on. Eric has a lot of questions, and I have a case. You know the case.

Eric 31:10

Okay, do the case.

Alex 31:10

Do the case. Okay. Because we just talked about methadone. So let’s say a patient who has lung cancer, relatively newly diagnosed, has a long history of substance use disorder, had been taking methadone as an outpatient, and now has this pain. And, boy, we feel like it would just be so easy. This is. He’s now hospitalized to break up that methadone into three times a day dosing. And we’re in communication with the outpatient clinic about doing this, and they’re like, well, I don’t know. How are we gonna do that if he leaves the hospital? Any thoughts about how we should proceed, doctor?

Sach 31:47

Yeah.

Eric 31:47

And the main thing here is the analgesic half life of methadone. I think buprenorphine, too, is shorter than a day. You’re looking at like six, eight hours, right? That’s right. But the half lives are generally much longer. How do you think about that?

Julia 32:03

Well, I think it’s challenging because opioid treatment programs that provide methadone are really not allowed to dose it for pain. They’re only allowed to prescribe it for opioid use disorder, opioid cravings and Sach. My typical approach with somebody who’s in a methadone clinic, say, a recent cancer diagnosis, and they’re relatively healthy, they can still get to the methadone clinic, although they might not like it, is to. If they think they have cancer pain, is to add an additional opioid on top of the methadone and talk to the methadone clinic, communicate back and forth so they know what they’re doing and they know what the plan is. That’s my typical approach. What, Jan, Insects.

Janet 32:42

I think in the inpatient setting, you do have the opportunity to titrate up the methadone just to account for both the opioid use disorders and cravings as well as the additional new pain from the cancer. I will oftentimes ask patients that I’m seeing whether they come in with cancer pain or whether they have, like, a large infected wound related to substance use disorder, like whether they want to break up or split dose the methadone and. Or the buprenorphine. And sometimes patients will tell me, no, like, I depend on this large bolus of methadone in the morning to feel right. And then I’m like, okay, well, let’s come up with other solutions.

But other patients Are like, sure, while I’m here, do whatever you, you know, do whatever you can to maximize my analgesic. And I let them know that when they go back out to their treatment clinic that it’s going to be consolidated once again. There are, you know, some methadone, like methadone clinics have a large variation in terms of how they practice. So there are some clinics where you can talk to the medical director and they may give people like a take home dose for the afternoon. So the person will come get dosed in the morning by the clinic and they’ll give them one take home to take in the afternoon just to help with, you know, pain management while staying in the confines of addiction treatment. But that’s kind of on a one on one basis with clinics really about.

Julia 34:05

How they interpret the regulations and how much wiggle room they want to give. I mean, at our program we will titrate methadone for addiction for folks in the hospital. But you know, we’re told if, if we say we’re increasing it for pain and we document that and then send it back to the methadone clinic, the methadone clinic won’t be able to increase, continue with that increased dose. So that’s a caution we have. We try to document that it’s for cravings or withdrawal symptoms or Sach.

Sach 34:32

This is a little bit changing the topic. But more and more I see patients on Suboxone, not on methadone. And so the other question is, you have a patient coming from a Suboxone clinic to your hospital and now they have advanced cancer, what do you do? And so we would then take over the suboxone, prescribing the dose. We would split the dose. We potentially increase the dose depending on what dose they’re coming to us on. Then we can talk about judicious use of PRN opioids as well. But that’s a case where if it’s buprenorphine, we actually will take that over, coordinate with the clinic and help manage that for patients with advanced cancer.

Julia 35:12

I was going to say especially prescribing opioids like oxycodone or morphine along with buprenorphine. It often helps to have the same prescriber because the pharmacist will call you up and they get a lot of calls from pharmacists with maybe some misconceptions about buprenorphine or worries about getting in trouble for filling oxycodone plus buprenorphine. So it’s helpful to have somebody who can sort of explain the whole situation.

Eric 35:37

Yeah.

Alex 35:37

Okay. Another quick case. Different patient who has history of substance abuse disorder dating back like, 50 years. And, you know, you were talking earlier about Janet. What are the circumstances under which this arose? You know, says that in the Korean War, he was told he had to take these substances to get by, and that’s when the addiction started. And had been on methadone as an outpatient and now in the hospital, has two cancers, has vascular pain, and it says IV Dilaudid is the only thing that works for him.

And we’ve been consulted multiple times. We are the bad guy team. We take him off of it. We put him on some oral meds, and he gets mad at us and not the primary team. And then we sign off and then eventually get consulted again because the team put him on IV Dilaudid. This will probably ring true to many of the listeners. I see people smile. I see you. Sounds like it rings true to you. Any advice you give to those clinicians, that’d be me.

Julia 36:35

Sounds like a real case.

Janet 36:37

Yeah.

Sach 36:39

I was thinking about. You had a podcast on a couple months ago about how to help manage with an angry patient. It kind of reminds me about that and sort of thinking about a little bit about, first of all, why were they receiving IV Dilaudid? But let’s say they were. What benefits are they getting from it? So really thinking about, is this an opioid response to pain, and do they need some sort of opioids? And if so, how do we think about adjusting this in the safest way? Are they getting mood modulation and getting relief, emotional relief from the opioids? If so, how do we support the patient? I mean, it must be incredibly scary.

You’re talking about a patient with two different cancers. They’re in the hospital. They’re probably alone. So how can we kind of use other palliative care skill sets to help support the patient? Obviously, eventually they’ll have to get off the IV opioids, and we’ll have to think about a plan for them, but sort of thinking about what they’re going through and humanizing them first and then trying to support them that way.

Janet 37:33

Yeah.

Julia 37:34

And it’s true that, you know, a bolus of IV Dilaudid is more likely to. I mean, there’s a reason why people who use drugs use IV drugs, you know, because they work fast and they, you know, they reach a peak really quickly. And there are other reasons why IV Dilaudid is often preferred. I mean, if you’re sitting in the hospital and you’ve Got pain and then you have to call the nurse and wait half an hour for them to answer and then another half an hour for them to get the medication and then half an hour for the oral opioid to work. You’re going to likely want an IV medication. So it’s going to work a lot faster. And I think a lot of times those things. There’s a system solution working with interdisciplinary teams. In our institution we have complex care plans for deciding what medication is appropriate based on the kind of issue that somebody’s coming in with.

Eric 38:23

For example, okay, I got some lightning round questions because we brought up the issue of PRNs adding non buprenorphine or non methadone PRNs. How do you think about that? Is there better one? What dose do you start on these patients? Any practical tips around PRNs in this group?

Janet 38:46

Yeah, I would say that you shouldn’t automatically lean towards withholding PRNs for somebody just because they use non prescribed substances. And so if it’s a patient that you would treat in any other way with PRNs, I would do that too. And know that patients who are either on moud or medication for over like Suboxone or buprenorphine or methadone have a develop some hyperalgesia and have a higher tolerance to opioids as well as a lower threshold for pain. So that’s been shown in kind of twin twin studies for one who has developed an opioid use disorder and another who hasn’t that the person with the opioid use disorder, even if it’s been stable, will have a lower threshold for pain.

And so making sure that your PRN doses make sense for that person. So I’ll say quite frequently at the general, if a patient comes in who has an opioid use disorder, we will typically start higher PRN doses than someone you might otherwise. So for instance, like hydromorphone, 2 to 4, 2 to 3 mg IV is needed. As far as the actual opioid choice, I tend to prefer other opioids to oxycodone. So either morphine or hydromorphone.

Eric 40:04

Just why is that?

Janet 40:05

There’s been some evidence that oxycodone crosses the blood brain barrier a little faster, just is a little bit more kind of euphoria producing in that way and a little bit more addictive.

Julia 40:19

And it’s also got a much higher street value. I mean oxycodone 30s on the street are called perk 30s. I have never heard of anybody refer to a slang term for Morphine and maybe just because oxycodone is the most popular to be prescribed.

Eric 40:33

But yeah, typically limit the amount of PRNs that you prescribe. Like, you know, sometimes in palp care clinics, you do a 30 day refill or 28 day refill. Like, does that get influenced by a history of substance use disorder?

Sach 40:48

So for me, if a patient has an opioid use disorder, I mean, it’s an increased risk to give them PRN opioids. Right. It might be clinically needed, but we have to kind of acknowledge that it’s an increased risk and think about ways we can mitigate that harm. So we will maximize the sublingual buprenorphine as much as we can and use non opioid adjuvants first. Before we move to full agonist opioids, we’ll think about their history. They develop a substance use disorder because they used to take Norco or let’s say oxycodone or whatever. We won’t give them oxycodone again. We’ll try to give them something else. Then we will try to limit the PRNs to two or three per day. That’s what they need. We’ll try to do shorter strips.

Eric 41:31

Do you do pill counts and urine drug tests on everybody in our clinic?

Sach 41:36

We do. We start off usually the first few visits doing pill counts and urine drug tests. We try to make it an engaging process for patients. So sometimes, believe it or not, our patients are surprised at what’s in their urine. They may have thought they were taking a real opioid pill and then they find out that they weren’t. The pill counts also are really helpful because sometimes they’re underdosing certain medications like a tca. They’re not taking their tricyclic antidepressant at night, and we’re wondering why they’re having neuropathic pain and, well, maybe we shouldn’t increase the dose because they’re not taking it in the first place. And, you know, if a patient forgets to bring their pills, we’re not withholding pain medicine from them. We’re asking them to think about it and try to bring it in next time and things like that.

Julia 42:18

And I just want to add, Zach, that I mean, I often do when I’m prescribing regular full agonist opioids. It’s often more than two to three a day. But I found that being very clear with instructions, much more than you would for the average person. So I’ll like verbally emphasize you are to take no more than eight of these a day. And in the instructions, it will say up to eight per day. And I’m still not surprised when the person comes back to me and say they’ve been taking 12 a day and that I have to reinforce that again, maybe by not giving them an early refill or maybe by saying, next time I’m not going to give you an early refill. To be super clear, do the teach back. You know, this is the plan.

Eric 43:01

What do you do, Janet, if you’ve done everything, you’ve done all of that, and the urine tox comes better and the patient said that he’s continuing to use.

Janet 43:13

I mean, I think part of it is really having that conversation with the patient about their substance use. Right. Like, what are their goals? You know, sometimes I’ll ask, like, how do you see, you know, cocaine or methamphetamine fitting into your life with everything else that’s going on with your health? So that I can be on the same page, Right. Have no intention of stopping using whatever they are, then there’s nothing that I’m going to do to move them towards that necessarily. So then it becomes this harm reduction kind of model. The thing that concerns me more is if the thing I’m prescribing is not actually in the urine. That actually causes me more panic as far as, like, taking next steps real.

Eric 43:54

Quick because we got a question from bluesky Dr. Max, who says, how do you maintain rapport with these patients who you’re managing and they’re breaking your opioid agreement? Their UTOX is coming positive.

Alex 44:09

There must be specific communication skills. Yeah.

Eric 44:11

Is there something that you’re working on, Janet, that can help people with communication skills and this?

Janet 44:19

Oh, actually there is, Eric. So Julia and I have been partnering with Vital Talk to develop a course on and communication skills just for these situations. So learning how to continue to provide the empathy and compassionate care that you try to while setting some boundaries and limits around prescribing or expectations.

Eric 44:43

When should we expect that?

Julia 44:46

In progress this month. So I don’t know. However long it takes them to edit and market and package it.

Alex 44:51

Oh, good. Soon. All right. Another one is methamphetamine. You just mentioned Janet. Any new breakthroughs, updates on patients with stimulant use disorder and serious illness? Pearls tips?

Janet 45:06

They’re probably coming to a location near you soon because the use of methamphetamine or the contamination of drugs out in the community is more widespread. So all I’ll say is that the laws that dictate what’s legal or what’s not legal are based in a lot of of, you know, racism, the political agenda at the time, etc. And so I don’t necessarily in my clinic feel that I need to be the enforcer or the patroller for certain laws. Like why are some stimulants illegal like cocaine, even though they have medical properties and other stimulants like caffeine legal?

Sorry, cocaine’s illegal. Caffeine’s legal, even though it’s killed people kind of in that giant Panera drink. And yet there’s still no regulation around that. So that aside, I’m just like, you’re in my clinic. Like, how do I get you closer to your goal? Whether that’s to stop using Back to goals. Yeah, this is goal concordant care. And then how do I maximize the safety? So back to harm reduction.

Eric 46:05

Okay, I got two other lightning questions. Harry Hahn says, any tips when you have somebody on buprenorphine and PRNs, but it’s just not enough. Do you ever consider how do you consider rotating to a full agonist? Or do you. Or you just go find the buprenorphine?

Julia 46:20

I don’t do that in my, in my stable patients. So I’ve certainly had folks with advanced cancer who have a history of addiction who are on buprenorphine plus PRN agonist. And at a certain point it’s just like we’re not sure that the buprenorphine is doing much. And so I’ll just, I don’t use a formula. I just start a long acting in a dose. It seems like relatively in the ballpark. And see and you know, some of those cases are just difficult to manage. Cancer pain. And a full agonist may not be any better than buprenorphine, but it’s sort of in the spirit of palliative care. We just keep trying things.

Janet 46:54

There’s also just to add some additional data, like there is no limit to buprenorphine effectiveness. I think a lot of people will think of like 16 or 24 milligrams sublingually just because that is what is insurance will pay for for the treatment of opioid use disorder. But so going above that, you might try increasing the buprenorphine as the PRN as well, just to give additional opioid effect. And for some of our patients with opioid use disorder, they’ve gone as high as 48 or even 60 milligrams of buprenorphine for some amount of time before then they stabilize and come down.

Sach 47:29

Part of the benefit of seeing patients and outpatient and getting to know them is their support systems. You can tell, are they showing up to oncology appointments, to palliative appointments, are there urine tests as expected? And so if they’re progressing in their cancer and their pain is getting worse, you can feel more confident rotating off of buprenorphine.

Eric 47:46

I love that because my last thing is it goes back to, you have to also learn to say no or to set limits. Right.

Alex 47:54

Accountability without discrimination, without abandonment, maybe.

Eric 47:59

What does that look like in your clinic, Sach?

Sach 48:02

So, yeah, if a patient is. What it means is if a patient, for example, has an unexpected finding, a urine drug test, what that means to me is that calls for an escalation of care. Whether that means we need to have more visits with you via telehealth or in person, whether we need to get you in with a substance use counselor, like a harm reduction counselor, whether it means that they’re really worried now about the opioids you’re prescribing. And maybe we were doing full agonist and now we have to do buprenorphine. So that’s what accountability means to me. We’re still engaging in care with the patient, but we have to do what we feel is safest based on the data we’re receiving.

Julia 48:39

Yeah. And I think you have to also expect that people might not like that conversation. It’s not always an easy conversation. People get mad. And, you know, I found if you stick with people and you show that you care over time, that rapport returns, you know, And I’ve even had patients, you know, months or years later say, wow, you know, I feel so much better now. I’m so glad we made that transition.

Sach 49:03

Yeah.

Eric 49:04

I want to thank some of the folks, like Alex Jordan and Rex Paulino, who also contributed some of these questions. I want to thank all of you for joining us. But before we end, maybe a little bit more of. What’s the song title again?

Alex 49:16

The Drugs Don’t Work.

Alex 49:22

(singing)

Eric 50:26

Julie, Janet, Sach – thank you for joining us on this podcast. So much content. Thanks for holding in with all my Lightning Round questions. I think it was the longest list of Lightning Round questions I’ve ever done. That was great. And to all of our listeners, we will have tons of stuff on our show Notes, please check it out and thank you for your continued support.

***** Claim your CME credit for this episode! *****

Claim your CME credit for EP345 “PC for Patients with Substance Use Disorder”
https://ww2.highmarksce.com/ucsf/index.cfm?do=ip.claimCreditApp&eventID=15118

Note:
If you have not already registered for the annual CME subscription (cost is $100 for a year’s worth of CME podcasts), you can register here https://cme-reg.configio.com/pd/3315?code=6PhHcL752r

For more info on the CME credit, go to https://geripal.org/cme/

Disclosures:
Moderators Drs. Widera and Smith have no relationships to disclose.  Guests Janet Ho, Sach Kale, Julie Childers have no relationships to disclose.

Accreditation
In support of improving patient care, UCSF Office of CME is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Designation
University of California, San Francisco, designates this enduring material for a maximum of 0.75 AMA PRA Category 1 credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

MOC
Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 0.75 MOC points per podcast in the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) program. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.

ABIM MOC credit will be offered to subscribers in November, 2025.  Subscribers will claim MOC credit by completing an evaluation with self-reflection questions. For any MOC questions, please email moc@ucsf.edu.