In this engaging discussion, Janet Ho, Sach Kale, and Julie Childers tackle the intricate overlap of substance use disorders and serious illness. Janet shares insights on why treating these patients is so challenging, while Sach details his successful outpatient clinic for cancer patients facing addiction. They explore harm reduction strategies, such as accountability without abandonment, and debate the merits of using buprenorphine versus methadone. The trio also candidly addresses the emotional complexities clinicians face, emphasizing the need for effective communication and tailored care.
51:26
forum Ask episode
web_stories AI Snips
view_agenda Chapters
menu_book Books
auto_awesome Transcript
info_circle Episode notes
volunteer_activism ADVICE
Choose Opioids By Pain Pattern And Prognosis
Use the three P’s—Pain, Pattern, Prognosis—to choose opioid strategy.
Assess pain type (acute, terminal, chronic), substance use pattern, and prognosis to decide between full agonists, buprenorphine, or specialist referral.
insights INSIGHT
Diagnosis Label Matters Less Than Pain Mechanism
Cancer versus noncancer pain distinctions often mislead; mechanism and chronicity matter more than diagnosis label.
Julie Childers notes chronic pain neuroscience can differ from tissue injury, affecting long-term opioid decisions.
volunteer_activism ADVICE
Avoid Methadone As Office-Based OUD First Choice
Avoid routine methadone prescribing in palliative clinics for OUD due to safety, regulatory, and oversight limits.
Julie Childers warns methadone requires opioid treatment program dispensing and has higher overdose risk compared with buprenorphine.
Get the Snipd Podcast app to discover more snips from this episode
Much like deprescribing, we plan to revisit certain high impact and dynamic topics frequently. Substance use disorder is one of those complex issues in which clinical practice is changing rapidly. You can listen to our prior podcasts on substance use disorder here, here, here, and here.
Today we talk with experts Janet Ho, Sach Kale, and Julie Childers about opioid use disorder and serious illness. We address:
Why is caring for patients with this overlap so hard? Inspired by Dani Chammas's paper in Annals of Internal Medicine titled, "Wishing for a no show" we talk about countertransference: start by asking yourself, "Why am I having difficulty? What is making this hard for me?"
Sach Kale set up an outpatient clinic focused on substance use disorder for patients with cancer. Why? How? What do they do? Do you need to be an addiction medicine trained physician to start such a clinic (no: Sach is not). See Sach's write up about setting up this clinic in JPSM.
What is harm reduction and how can we implement it in practice? One key tenet of harm reduction we return to multiple times on this podcast: Accountability without termination (or, in more familiar language, without abandonment).
When to consider bupenorphine vs methadone? Why the field is moving away from prescribing methadone to bupenorphine; how to manage patients prescribed methadone for opioid use disorder who then develop serious and painful illness - should we/can we split up the once daily dosing to achieve better pain control?
Who follows the patient once the cancer goes into remission? Who will prescribe the buprenorphine then? Or when it progresses - will hospice pay?
And so much more: maybe not the oxycodone for breakthrough; when the IV dilaudid is the only thing that works; pill counts and urine drug tests; the 3 Ps approach (pain, pattern, prognosis); stimulant use disorder; a forthcoming VitalTalk section…
Thanks to the many questions that came in on social media from listeners in advance of this podcast. We all have questions. We addressed as many of your listener questions as we could. We could have talked for 4 hours and will definitely revisit this issue!
GeriPal - A Geriatrics and Palliative Medicine Podcast 