Caring with Complexity: Developing and Implementing a Pilot Substance Use Disorder Workflow in Palliative Care

Key Message: Caring for persons with cancer-related pain and SUD is challenging for PC teams lacking dedicated addiction medicine infrastructure. In this QI initiative at an academic medical center, we developed and implemented targeted trainings and institutional workflows around SUD, leading to increased PC team comfort caring for this complex patient population.

Abstract:

Introduction: Caring for persons with cancer-related pain and substance use disorder (SUD) is complex, but palliative care (PC) providers often lack addiction medicine training and skills and report discomfort managing this population (1,2). While PC expert consensus statements and harm reduction clinics (3,4,5) offer guidance, implementing these approaches remains difficult in PC settings with limited addiction medicine infrastructure.

Objectives: This quality improvement (QI) project aimed to 1) assess PC team comfort, 2) provide targeted training, and 3) standardize PC workflows around caring for persons with SUD.

Methods: This QI project was conducted within the interdisciplinary PC team at a tertiary academic medical center. A pre-survey assessed baseline comfort among PC team providers, chaplains, and social workers in caring for persons with SUD. The intervention included the development and dissemination of 1) evidence-based educational sessions on SUD and 2) a risk-stratified pilot workflow guiding opioid prescribing and harm reduction protocols. During the four-month intervention period, the workflow was iteratively updated based on challenges and gaps identified in patient cases (i.e., SUD diagnostic uncertainty, unexpected urine screens). After the intervention, a post-survey evaluated changes in PC team comfort.

Results: The pre-survey (n = 27, response rate 71%) showed that 66% of respondents felt uncomfortable caring for persons with SUD, and only 19% of prescribers felt comfortable managing opioids for this population. During the intervention, four SUD educational sessions were delivered to the PC team and the pilot workflow was applied to ten patients (ages 38–76; 70% male; all with cancer). In the post survey (n=22, response rate 58%), fewer respondents (32%) still felt uncomfortable caring for persons with SUD; 55% of prescribers now felt comfortable managing opioids for this population.

Conclusion: At institutions without addiction medicine infrastructure, developing evidence-based trainings and workflows can improve PC team comfort caring for persons with SUD.

References: 1. Merlin JS, Patel K, Thompson N, et al. Managing Chronic Pain in Cancer Survivors Prescribed Long-Term Opioid Therapy: A National Survey of Ambulatory Palliative Care Providers. J Pain Symptom Manage 2019;57:20–27.
2. Check D, Osazuwa-Peters OL, Marais AD, et al. Prevalence and Characteristics of Substance Use Disorders Among US Cancer Survivors (FR205B). J Pain Symptom Manage 2023;65:e274–e275.
3. Merlin JS, Khodyakov D, Arnold R, et al. Expert Panel Consensus on Management of Advanced Cancer-Related Pain in Individuals With Opioid Use Disorder. JAMA Netw Open 2021;4:e2139968.
4. Fitzgerald Jones K, Khodyakov D, Arnold R, et al. Consensus-Based Guidance on Opioid Management in Individuals With Advanced Cancer-Related Pain and Opioid Misuse or Use Disorder. JAMA Oncol 2022;8:1107–1114.
5. Kale SS, Tosto GD, Rush LJ, et al. Creating a Palliative Care Clinic for Patients with Cancer Pain and Substance Use Disorder. J Pain Symptom Manage 2024;68:e138–e145.