Okay, good afternoon, everybody. We're going to be starting the webinar. Welcome to today's AOAAM and ORN webinar on Managing Opioid Complexity in Individuals with Serious Illness by Dr. Jessica Merlin. My name is Julie Kimmick, and I'll be your moderator for this session. This is the third of a six-hour webinar series on hot topics in the treatment of opioid use disorder and stimulant use disorders. Dr. Merlin is an associate professor in the Division of General Internal Medicine and the Section of Palliative Care and Medical Ethics at the University of Pittsburgh and Director of Pitt's Challenges in Managing and Preventing Pain, CHAMP Clinical Research Center. She is board-certified in internal medicine, infectious disease, palliative care, and addiction medicine. She's also a PhD-trained behavioral scientist and an NIH-funded clinician investigator. Her program of research focuses on the intersection of chronic pain and opioid misuse and use disorder across populations and settings, especially in individuals with serious illnesses like advanced cancer. To that end, she is the MPI of the NIH-funded Tailored Retention and Engagement for Equitable Treatment of Opioid Use Disorder and Pain, TREATOP Clinical Research Center, one of four NIH-funded centers focusing on the intersection of pain and opioid use disorder in the U.S., and the MPI of an R01 to investigate opioid benefits, risks, and decision-making in individuals with advanced cancer. Her work in this area is widely published, and she serves as a scientific mentor to many PhD students, postdoc fellows, and faculty with similar interests. Clinically, she co-directs the Palliative Recovery Engagement Program, a palliative care clinic embedded in an office-based addiction treatment program, where she sees patients with serious illness, particularly advanced cancer, who also have pain and opioid misuse. She's been nationally recognized with a Sojourn Scholars Leadership Award from the Cambia Health Foundation, and with research awards from the American Academy of Hospice and Palliative Medicine, American Pain Society, and Association for Multidisciplinary Education and Research in Substance Use and Addiction. She was recently awarded the 2022 Society of General Internal Medicine Mid-Career Research Mentorship Award. So, I'd like to turn it over to Dr. Merlin. Thank you, Dr. Kamek, for that kind introduction, and hello to all of you. I see we have 54 people here, which is a great turnout, so thank you all for your interest in this topic. I have the chat up in front of me, and so I'm gonna be, or the Q&A, I should say, up in front of me, and so I know we have two hours, one hour today and another hour next week, so I'm very flexible, and so if people have questions that they want to throw into the Q&A, I'll try to incorporate my answers into the talk, and if that means that we don't get to all the slides today, and we cover some of those slides next time, I'm fine with that if you are. So, let me go ahead and share my screen. Okay, so, sorry, hang on one second here. There we go. Excuse me. So, this is our funding acknowledgement here regarding SAMHSA, and then here are my disclosures and Dr. Kimmick's disclosures. So, as Dr. Kimmick mentioned, the topic today is Managing Opioid Complexity in Individuals with Serious Illness. I often give this talk with a colleague of mine, Katie Fitzgerald-Jones, and so just want to acknowledge her contributions as well. So, our objectives for this talk are to understand complexities of managing pain and opioid misuse, disorder in patients with serious illness, apply the available evidence on chronic pain, long-term opioid therapy, and opioid misuse disorder to your patients, and plan at least three things you'll do to change your practice in this area. So, before I go any further, it might be helpful for me, if folks don't mind, just in the Q&A, just throwing in there, like, where you're from and what your role is. So, are you a physician, nurse practitioner, pharmacist, social worker, peer, etc., etc.? It might be helpful to me just to to see that, since I know we probably have a pretty diverse audience today. Great. So, I see so far we have a physician, an OTP clinic, LPN, suboxone coordinator. Fantastic. Okay. I'll keep my eye on the chat as we go on to see who else answers my question here. I think we've got people doing both the chat and the Q&A box for them. Really? Oh, you know, and I have to scroll here too. Physician, PA, great. Pharmacist, FQHC is represented. I love it. APRN, fantastic. Suboxone coordinators, this is great. Okay. Excellent. Thank you all so much. This is really helpful for me to kind of get a sense of things. So, it sounds like we have folks today who are prescribers, as well as folks who collaborate with prescribers. And so, what I would say to you is, if you're a prescriber, if you have a DEA license, get your ex-waiver. And if you don't, if you already have your ex-waiver, then, or if you're not somebody who can be ex-waivered, if you are a social worker or a pharmacist, recruit a colleague. You're not FQHC either, right? So, a lot of what we're going to be talking about today requires folks to be ex-waivered and to be able to prescribe buprenorphine. So, just wanted to give that PSA. Oh, I love it. We have emergency medicine folks here, telehealth. Wow. What a great group. Fantastic. Okay. So, before we dive into the nuts and bolts, just wanted to kind of set the stage in terms of context. So, we know that stigma is a really important problem in people who use drugs. And there's also a lot of what we call intersectional stigma at play as well, meaning that there are people who experience multiple stigmas because of multiple identities they hold. And so, we know that those types of intersectional stigmas can include stigma related to race, gender, whether people are prescribed long-term opioids, whether people prescribe buprenorphine for their opioid use disorder. And we also know that not only are people who use drugs stigmatized, but chronic pain is also a highly stigmatized condition. And so, I just kind of want to make sure that we all acknowledge that, that we're dealing with a really vulnerable population. The other thing that, you know, I'm probably preaching to the choir to a large degree here, but it's really important to also acknowledge is the importance of language and how we talk about our patients and their challenges. So, we know that the words that we choose impact how patients are seen and treated in the healthcare system. So, trying to avoid words like substance abuse and instead of using substance use disorder is a really important part of how we communicate with other clinicians about our patients and make sure that it's clear that substance use disorder is a medical illness and not a choice or a lifestyle as the word abuse might imply. The other thing that we know is that stigma influences how people view the effectiveness of medication treatment for addiction. And so, trying to avoid terms like medication assisted treatment and just say treatment. We don't call insulin diabetes assisted treatment, we just say it's treatment for diabetes, right? And so, trying to kind of put addiction on par with other medical illnesses. We also know that stigma influences our policies, right? So, I mean, a classic example of this is, you know, methadone as a treatment for opioid use disorder is really not available to a lot of people because it's really provided in almost a separate healthcare system. And we know that people who use drugs really internalize this stigma and this might be a reason they avoid treatment. So, again, just as a preface for the rest of the talk, just to make sure we're all on the same page. Okay, so let's dive right in to this serious illness question. So, here are some common situations that we are going to review. So, we're going to talk about people with serious illness who are prescribed long-term opioid therapy. We're going to talk about opioid misuse in people with serious illness and opioid use disorder. And then we're going to talk about some useful skills to have. Some of these skills folks on the call may already have. And again, you're not off the hook. It means you need to share these skills with others. And so, please feel free to use these slides if it's helpful in sharing this knowledge with others. And then tapering, which comes up a lot in people on long-term opioid therapy. So, I also want to note that for the rest of these slides, I'm going to be presenting data from people when I can with serious illness. Most of the serious illness literature is about cancer, although cancer is certainly not the only serious illness. It's just far and away overrepresented in the literature about serious illness. And when there's not literature specific to serious illness or cancer, I'll present literature from the general population and think about how to apply that to the serious illness context. And I will try to highlight which of these things I'm doing when I'm doing them. All right. So, serious illness prescribed long-term opioid therapy. And, you know, I realized that actually I think I lost a slide from this that I should just, I'll just describe to you, which is what is serious illness. So, serious illness is any life-limiting condition that significantly impacts the patient and family. So, this could be anything from, you know, I've mentioned cancer several times, but also things like dementia, COPD, advanced neurologic conditions like Parkinson's, congestive heart failure, end-stage kidney disease, and people who have multimorbidity and frailty. So, it could be any of those things. Okay. So, some key concepts here. Long-term opioid therapy. So, I think many of you probably are familiar with this, but just to give a specific definition to it, long-term opioid therapy is opioids prescribed for at least three consecutive months. So, how does this intersect with serious illness? Why is this an issue in people with serious illness? So, people with serious illness certainly can have chronic pain and be on long-term opioid therapy prior to their serious illness diagnosis. So, maybe somebody has chronic low back pain and now they have a new diagnosis of metastatic breast cancer, right? And we know from research on patients with advanced cancer that they don't necessarily think about their pain as cancer-related or not. They just think about the fact that they have pain in their oncopioids. People don't really necessarily distinguish their own causes of pain. And sometimes those causes of pain can actually be really difficult for clinicians to distinguish too, right? Is it their pre-morbid chronic low back pain or is it because of that spinal mat? Maybe the answer is both. Chronic pain not on long-term opioid therapy, but serious illness fuels opioid prescribing. So, in that situation of somebody who has chronic low back pain, let's say they're not prescribed opioids and then they're diagnosed with metastatic breast cancer, sometimes we see that now that they have cancer, it's sort of their clinicians feel like they're given a license to, you know, be more liberal with opioid prescribing and end up prescribing opioids for what really is chronic pain, but is now being interpreted as pain in the context of cancer. And then you have people with serious illnesses who develop pain related to their serious illness and are treated with opioids for that pain. So, you know, somebody has no prior history of chronic pain, but has metastatic breast cancer with spine meds, maybe they're getting opioids for that spine med. And sometimes it's a combination of these things, right? So, one thing that we know about opioids is that opioids beget more opioids. So, up to 80% of people with cancer are exposed to opioids at some point during treatment. And so, you know, obviously in order to be prescribed long-term opioids, you have to have some kind of initial opioid exposure, but this happens a ton in patients with cancer and likely other serious illnesses. So, we know that for people who are prescribed, have one initial opioid prescription, 20% will remain on opioids for one year. And if there is an initial 90 day prescription, 60% will remain on opioids for two years. So, this is important to remember in the context of initiating people on opioids. There is a risk that this will become a long-term commitment. Okay. What do we know about the benefits of long-term opioid therapy? So, in the general population, it might surprise you to know, given how common it is for people to be prescribed opioids for garden variety chronic pain, whether it's chronic low back pain or headaches or chronic abdominal pain or other regional musculoskeletal pain, arthritis related pain, et cetera. But there are really few high quality and no long-term clinical trials of opioids for chronic pain. The studies that exist, and I've listed here some in these citations, some meta-analyses, systematic reviews and meta-analyses that suggest that there are small improvements in pain intensity and function that are very small and of uncertain clinical significance. This third citation is a study by Dr. Aaron Krebs that was one of the best done prospective studies of opioids. The comparison group there was NSAIDs and really found no difference. In terms of pain and serious illness, again, the vast majority of literature is patients with cancer. And if you want to read more about this, this Huang et al systematic review is a great reference for this. This was a systematic review of patients with quote, unquote, chronic cancer pain, which as I just described a few minutes ago, it can be kind of difficult to know what that even means, right? Is it just pain in the context of cancer? Is it pain because of the cancer? How are they determining that? So even the language that we use to talk about chronic pain in the context of serious illness is very imprecise. But in this study, they found that non-opioid analgesics were better than NSAIDs, which were better than opioids. And that only lidocaine and codeine plus aspirin, which is not something that we really use to manage cancer pain, were better than placebo in terms of global impression of change. And for pain, they found that opioids as a class, and then all of the single drugs that they looked at within the opioid class were not better than placebo. So that might also surprise you if you spend any time taking care of patients with cancer, because certainly in patients with cancer, opioids are, you know, used really as first line therapy for pain. And if you look at the National Cancer Care Network or ASCO clinical guidelines, opioids are really viewed as first line. And, you know, despite the fact that there's very little literature. And Julie mentioned at the beginning, a study that we're doing to try to answer this question, like what are the benefits and potential harms of opioids in patients with advanced cancer? That's a prospective study. So in the setting of those fairly limited benefits, what do we know about harms of long-term opioid therapy? So this is from the general population. There's very little literature on this in patients with cancer. I will say that we've presented some work that's under review for publication, but we presented at a national conference that suggests that the rate of overdose in patients with cancer is the same as patients without cancer. There's nothing special about patients with cancer, for sure, that protects them from these types of adverse outcomes. So in terms of harms, decreased function, return to work, induced depression, which seems to be more of a duration than a dose effect of a long-term opioid, motor vehicle accidents, which, you know, the inflection point for that is 20 milligram equivalents of morphine a day. That's 15 Percocets a day. That's very little, right? Falls, especially soon after initiation. Opioid use disorder. So depending on the setting that you look at, you know, the rate of opioid use disorder differs, but we generally think that it's probably somewhere around 10% of people who are prescribed long-term opioid therapy develop opioid use disorder. And then overdose and mortality, which we know is worse with higher doses. The inflection point there seems to be 100 milligram equivalents of morphine a day. But as I'll show you in a second, those odds ratios go up even around 50 milligram equivalents of morphine a day. And we know that overdose and mortality are worse when there's co-prescription of benzodiazepines, co-prescription of gabapentinoids. And we know also that opioids include tramadol, despite the fact that, you know, there's some sort of folklore around tramadol being a safer opioid, it's actually, you know, it's not. It carries the same risk in addition to other risks, like it's a weak SSRI, so serotonin syndrome and concussive hypoglycemia, et cetera. There's a palliative care podcast that a lot of us in the palliative care field listen to called Jerry Pal, and their most popular episode is called Tramadont. So sorry to go off on a little tangent on tramadol, but I feel pretty strongly about it, as you can see. So again, this slide just kind of hammers on the point that that inflection point for dose-related harms, you know, the inflection point goes, you know, the slope of the line goes way up when you go over a hundred milligram of the length of morphine a day, but even just over 50, you can see that the odds ratios are substantially greater than one. These are some of the original studies that showed that back around 2010, 2011. So this is a slide summarizing a study that one of my mentees, Katie Fitzgerald-Jones, who I said before I often present this content with, did where she looked at factors associated with long-term opioid therapy in cancer survivors. And what she found was these kind of various factors. So specifically cancer types, so head and neck cancer, but also lung and cervical cancer appear to be high risk for staying on long-term opioid therapy. Uncoordinated prescribing, which is a really big problem in this population. They're seeing oncologists, they're seeing radiation oncologists, they're seeing palliative care clinicians, primary care doctors, you know, et cetera, et cetera. Racial disparities. We know that opioids traditionally have been prescribed more to white than black patients. Cancer treatment. So for example, surgical treatment is more highly associated with staying on long-term opioid therapy. Opioid characteristics. So being on opioids prior to their diagnosis of cancer and being on higher doses of opioids prior to a cancer surgery increases the likelihood of prolonged opioid use. People with lower socioeconomic status are more likely to end up on long-term opioid therapy. And then other patient-specific factors. So prior history of substance use disorder, anxiety, depression as well. And in this study, she found that the average prevalence of long-term opioid therapy in cancer survivors was around 24%, which is five times higher than the national average. So this is a very adverse population. So why does long-term opioid therapy in individuals with serious illness matters? So this might sound like a strange statement if you don't spend a lot of time in this space, but there's no reason why serious illness or cancer would be protective against long-term opioid therapy related adverse outcomes. So the reason I say this is because in the field of palliative care and in oncology, it has sort of been a dogma for a very long time that if you're prescribing opioids for quote-unquote legitimate reasons, if it's because somebody has cancer and they have pain and you're doing it under medical supervision, that the risk of developing adverse effects, especially addiction or overdose from those opioids is exceedingly small. And that's just not the case. As I said, we have a study coming out that suggests that those rates are fairly equivalent for patients with and without cancer. And if you think about it biologically, like what is it that would make somebody with cancer less likely to develop those adverse outcomes? And even more so than that, you can think about patients who, as I said before, like people who are more likely to end up on long-term opioid therapy, like patients with head and neck cancer who often have a personal history of substance use, whether it's tobacco use, alcohol use, and those are things that increase people's risk for adverse outcomes on opioids. So if anything, one would think it might even be higher in patients with cancer. We also know that some of our most complex patients end up being prescribed long-term opioid therapy. So Mark Sullivan, who's an opioid researcher and psychiatrist at the University of Washington has called this adverse selection, that basically patients with higher rates of mental illness and prior substance use disorders are more likely to be prescribed opioids. This has been demonstrated again and again in the literature. I mentioned a minute ago that the evidence of long-term opioid therapy benefit in general and in patients with serious illness is not strong. And we know the risks, right? We understand the risks of long-term opioid therapy. So for this reason, and also for the reason that it is so common for people with serious illness to be prescribed opioids and to end up on long-term opioid therapy, this is a very important issue. So what are the latest recommendations for long-term opioid therapy? This comes from the general population. I think it sort of holds up in patients with advanced cancer. So, you know, on the left you have patients with chronic pain who are not currently receiving opioids. And so for those patients, the general recommendation is to try to avoid starting them on opioids, use risk stratification tools to identify, sorry, avoid, I'll talk about this more in a second, but avoid the use of risk stratification tools because they don't work as I'll show you in a second. And, you know, that may not work all the time, right? So in somebody with cancer-related pain, you might decide that the benefits of opioids outweigh the risks, but you wanna start with at least considering non-opioid therapies. And for acute pain, we generally try to avoid opioids or provide them in very short durations, like less than a week. But for folks with, so, but most of our patients are probably in this middle box, right? So people with chronic pain who are currently receiving opioids. And for those folks, what you don't wanna do is taper their opioids rapidly, you know, kind of apply a one-size-fits-all approach. What you do wanna do is develop individualized treatment plans for folks like this and really decisions to remain on opioids at their current dose are a risk-benefit decision. And so it's about talking to the patient about what are the benefits you're getting from this medication? What are the potential harms that you might experience? Have you experienced any harms? And then in a patient-centered way, using shared decision-making, really talk about whether to continue the opioids at the same dose, reduce the dose, or switch to a totally different strategy, which is to switch people to buprenorphine, which certainly, if you think that they have an opioid use disorder, is the treatment for opioid use disorder, and that should, you know, one of the treatments for opioid use disorder, so that should be considered. But you might even decide to switch people who don't have an opioid use disorder off-label to buprenorphine because it's a lower-risk opioid and a lot of us are starting to explore that with our patients on long-term opioid therapy, particularly those who are at high risk, so those people on high-dose opioids, co-prescribed meds, and JCPs, et cetera. So I'm gonna move now to opioid misuse. Does anybody have any questions about that first section they wanna throw into the chat? Okay. Okay, I will keep an eye on the chat. And we'll just go from there. Okay. So when I say, oh, would you recommend methadone for opioid use disorder? That is a great question. So, you know, there are three FDA-approved medications to treat opioid use disorder, buprenorphine, methadone, and naltrexone. In patients who have comorbid pain, it stands to reason, even though in studies of naltrexone, people's pain seemed to be a bit better, it stands to reason that using an opioid makes sense, so that leaves you with buprenorphine and methadone. You know, the challenge with methadone, and Dr. Plamek can speak to this very well as she is the director of a methadone clinic, but the challenge with methadone is that if you're treating opioid use disorder with methadone, you really have to be in a methadone treatment program with a licensed methadone treatment program. I can't do it in my primary care clinic or my outpatient, you know, addiction clinic. So that often limits people's access. The other thing that can be challenging too is if somebody has chronic pain, you might wanna give them dosing multiple times a day, which can be challenging, though not impossible in the setting of a methadone treatment program. So a lot of the reasons why we wouldn't use methadone have to do with the logistics of methadone treatment programs, but they can be, methadone is a really effective drug and methadone treatment programs can be really effective modalities for folks. So personally, I end up reaching a lot for buprenorphine because I can prescribe it. And so I can give somebody a strip before they leave the office for something that I know is gonna reduce their mortality. And so for that reason, I find myself often recommending buprenorphine and buprenorphine, you can dose, you can split dose it. People can take it multiple times a day as well. So that may be better for their pain. I hope, Teresa, that I answered your question. If not, please put another one in. Oh, and here's another one from Teresa. For patients who've been on chronic oxycodone who would like to taper oxycodone. I don't know if there's more to that question, Teresa. If you have somebody who is on oxycodone or any full agonist opioid that wants to come off, what I normally do is I give them two options. One is to taper from the full agonist. So to say, okay, let's start by going down some manageable amount. It's really important if you're gonna do that, that you choose a pretty small amount to start with and you make sure people really build their self-efficacy for tapering so that they feel like, okay, I've got this. This wasn't so bad, I can do this. And then go at a slow patient directed rate. There's a great systematic review that Joe Frank wrote about this a few years ago now in 2017 that really showed that if you're doing that so-called voluntary tapering, that the thing that makes the most difference in terms of success is having psychosocial support. And so for somebody like that, I would also be thinking about referring them, for example, for cognitive behavioral therapy to help with their pain. So thinking about how to manage their pain in some way that's not an opioid, thinking about do they have other comorbid psychiatric conditions that should be managed at the same time that will improve their pain like depression and anxiety that maybe have been skipped over in the past. And then just psychosocial support specifically for the taper because it can be really challenging. The other thing that you can do, the other option I offer people is to switch them to buprenorphine for the taper with the idea that it's probably safer to taper people from buprenorphine because if they overtake their meds during the taper, buprenorphine, as you probably know, has a ceiling effect in terms of its overdose potential. It's very hard to overdose and get respiratory depression or severe sedation on buprenorphine. And so often I will suggest to them that they switch over to buprenorphine and we taper from the buprenorphine. And then if the taper doesn't, can't taper the person all the way off, which is very often the case, then they're left on a much safer medication at whatever dose. So I hope that answered your question, Teresa. Those were really great questions. Okay. I did see another question. It was in the chat and it says, for buprenorphine patients that are on greater than 20 milligram morphine equivalents per day, is there a higher risk for an MBA or motor vehicle accident? Oh, for people on buprenorphine? Is that the question? Yeah. You know, I guess I don't specifically know the literature about motor vehicle accidents. I know that in terms of the things that we worry about that are the root cause of those types of things like sedation and respiratory suppression, overdose, that the risk for buprenorphine is dramatically lower than it's in fact, like very, very difficult to overdose on buprenorphine because it has that ceiling effect. Meaning that you can take more and more and more and more and the risk of respiratory suppression and overdose levels out. And unlike things like oxycodone, where you take more and more and more and you get more sedated and respiratory depression and overdose. So I think the root of your question is probably like, is buprenorphine really safer? And the answer is definitely yes. I don't know specifically the literature on motor vehicle accidents, but it is definitely a safer medication. And I hope that answered that person's question. Were there any other questions, Julie, in the chat? I didn't see any. Okay, great. Thank you so much. So opioid misuse, what do we mean when we say opioid misuse? So these are behaviors that are potentially associated with increased risks of opioid related harms. Like things like, you know, missing appointments, taking opioids for symptoms other than pain, using more opioids than prescribed, repeatedly asking for an increase in opioid dose, aggressive behavior related to the opioid and concurrent substance, other substances. So in the literature and also sort of colloquially, you'll hear people use these other terms. So like red flag behaviors, aberrant behaviors. In the palliative care literature, a lot of people use the term chemical coping, which just makes my skin crawl. I really hate that term because these are all kind of like, chemical coping is kind of like a euphemism. Like, oh, our patients with cancer can't possibly really have a problem with their opioids. But the rest of these like red flag, aberrant, those are kind of stigmatizing language. And so I would just suggest that you avoid those terms and just stick with either opioid misuse, which is, you know, pretty widely used or concerning behaviors, which I've kind of migrated a bit to, or just describe what you're seeing. Like this person has missed five appointments in a row, whatever it is. So I'd love to know if you could just throw in, in the Q&A or the chat, you know, what are the opioid misuse behaviors that you see that are most challenging? Oh, and now I actually have the chat up. I figured out how to actually do that. So I can actually see the chat now, sorry. Um, but what do you see in practice? You are not seeing any opioid misuse behaviors. Diversion, I don't treat opioid misuse, fair enough. Missing appointments. Yeah, it's really hard to care for somebody when you're not seeing them, right? So I often will, and I often will say that to patients. Friday after I was complaining that they ran out of meds, right, so somebody running out early and then it happens at a time when it's a, puts more strain on the system for sure, but running out early, taking more than prescribed, great. So one thing that I wanted to point out about diversion, so diversion, the technical and continued use, I see somebody say continued, continued use of, I'm assuming other substances, particularly opioids. So one thing about diversion, which is something I didn't mention on the prior slide. So diversion, the technical definition is basically moving from the medical channel to a non-medical channel. So whether that's somebody stealing meds from a pharmacy, which is something that we see a lot less, but is actually the predominant form of diversion in this country, or folks giving or selling their opioids to someone else. The thing about diversion is it's really hard to know whether that's actually happening. In my 10 plus years of practice in this area, I would say that I've only felt like I knew for sure that an opioid was being diverted once. And that was a situation where the patient called the PA that I was working with and tried to sell him her methadone thinking he was someone else. That's a very bizarre and unusual situation. I think most of the time, somebody's urine might be negative for an opioid, for example, and then there's a question of what is the differential diagnosis for that finding? And certainly diversion is on that list, but there are a lot of other things on that list, right? It might be some of these other things that people were mentioning in the chat, like running out early. It might be things like poor health literacy or health numeracy. And so you just wanna make sure that when you see a behavior or there's a finding, like a urine drug test, that you're considering the full scope of that differential diagnosis. I saw somebody ask a question about cannabis, and I'm gonna return to that. I wanna put that on the shelf for a second because that's a really important question and one that I really wanna give full attention. All right. So how common is opioid misuse in individuals with serious illness? So studies in oncology palliative care settings have found that it's really common. The rates vary by study, but it's certainly substantial. And we did a survey of ambulatory palliative care clinicians where we found that 53% of them spent at least 30 minutes a day managing opioid misuse behavior. So this is a big thing. So I kind of foreshadowed this a minute ago about predicting the risk of misuse. So there's been this traditional approach. And if you're working in an opioid treatment setting, you might not be as familiar with this because this is something that would occur in like a primary care setting or a pain clinic, where the traditional approaches, there are these tools that you can use to predict opioid misuse risk. They're often embedded in electronic medical records. And as a result, these tools are really widely available, but they're very low quality. So just to give you a couple of ideas, the names, there's the opioid risk tool or the ORD, there's the SOAP, there's the Dyer. And what we know about these tools, and Roger Chowdhury did a really nice systematic review of them in 2011, that the studies that initially investigated their properties were very low quality. They found that these tools have poor sensitivity and specificity, basically no better than the flip of a coin. And there are really no studies evaluating their effectiveness for misuse opioid use disorder overdose. So they really don't do what they are intended to do. And another problem with them is that they are often, because we have so few concrete tests in this area of medicine, people start using the results of these tools for things that they were not even originally designed for, like predicting the risk of opioid use disorder or overdose. The other thing about some of these tools that I'll just encourage you to think about is that some of them include things like history of incarceration, race. And so these things are obviously going to bias the results in such a way that individuals who are black, individuals who are poor are going to be found to be at higher risk. And so as a result of that, these tools really reinforce bias, which is something that clearly we don't wanna be doing. So the long story short is please stay away from these tools and the more recent approach that is the approach that I recommend and I have adopted is to think about factors that we know are predictive of high opioid use disorder risk. So things like history of opioid use disorder, non-opioid substance use disorders, certain mental health diagnoses, particularly personality disorders, certain psychiatric meds. If one or more of these factors are present, just be aware that this person is at increased risk and incorporate that into your shared decision-making with the patient, incorporate that into your communication with the patient. But as I always say to patients, opioid misuse, use disorder, overdose, these are side effects of opioid medications. You might be at higher risk for getting it, but even if you're not at higher risk for getting it, you still might get it. And so, and we know that there are no symptom signs or tools that can identify truly low risk individuals. So I assume that everybody is at some risk and I counsel accordingly. How do we identify and then manage misuse behaviors? So in order to identify misuse behaviors, you have to be seeing people frequently enough. I see people running into this issue a lot where they're really just not seeing the patient that often. And so there are issues there where you can't really detect a problem if you're not monitoring for it. The other thing is universal precautions are really recommended in people in long-term opioid therapy. So you're in drug testing, which the CDC recommends annually or more, opioid treatment agreements annually or more, checking the state database, which a lot of states actually require with every script and doing this universally, right? We know that when we cherry pick who are going to your own drug test, for example, that we end up here in drug testing more people who are black than people who are white. And so we really wanna make sure to avoid those biases and just do that universally. And then there are management algorithms. We published in the Journal of General Internal Medicine in 2018 for management of opioid misuse behaviors that include things like increased monitoring, education, looking for a pattern of misuse behaviors and using that to try to identify, diagnose opioid use disorder and other substance use disorders if they're present. And management of misuse behaviors rarely involves stopping opioids abruptly. It might involve tapering if you feel like the risk of continued prescribing is greater than the benefit. And clearly serious illness makes this all that much more complex because you have people with limited prognoses, you have people who are undergoing active treatment and all of those things in subsequent slides. So just looking at the time here, sorry, I'm having, I see that we're 55 minutes in, which probably means that we are pretty- It's actually 1244. Is it? Yeah, I think it's just when the- Oh, I see it, 1244, actually I have it. Okay, good. All right, good. Not sure what happened there with my slides. Okay, excellent. So yeah, we can go through these cases. So here's an opioid misuse case for us. So Ms. H is a 60-year-old woman with breast cancer with meds to the spine and low back pain. She's been seeing a colleague in clinic who's on medical leave and you are now seeing her for the first time. She's been getting regular prescriptions of oxycodone 10-QID to treat her back pain. You also notice that she's had four year drug tests in the past year. One in your office, three during ED visits when she's presented for chest pain or back pain. And two of these tests have been positive for cocaine. We do another drug test at your visit which is also positive for cocaine. The patient doesn't have a history of opioid use disorder. She has no other misuse behaviors. She's coming to her appointment. She's not run out early and her urine is positive for the oxycodone. So it seems that she's taking that. She reports good pain control and requests that her current regimen be continued. And the review of her oncologist notes suggest that her prognosis is likely years. So what would you do? Continue her opioids, increase monitoring, taper her opioids, or transition her to buprenorphine and naloxone. So go ahead and just throw that in chats or the Q&A whichever is easier for you. I can see both. You've got B, D, lots of Bs and Ds. You got one vote for A. I like it. I like it. So we did what's called a Delphi study which is basically a study where we recruited experts. So palliative care clinicians and also addiction clinicians and presented this exact case to them and basically used some strategies to help them come to a consensus or determine if there was consensus on how to manage this patient. And they were pretty similar to you all which is not a surprise given your expertise. So they felt that continuing opioids and increasing monitoring was appropriate, that tapering opioids was inappropriate and were uncertain about the transition to buprenorphine. And I think those of us who do this work a lot, this comes up a lot. This patient, the way that I presented this patient, she does not have an opioid use disorder. So there's not a very simple cut and dried indication for buprenorphine, but I think a lot of us would say that this person's cocaine use is causing her risk of adverse outcomes to be increased. And so as a result of that, we would at least contemplate switching to buprenorphine. And I think more times than not, I sort of pushed to switch folks like this to buprenorphine. Interestingly, we gave folks this exact same case but switched it to having a poor prognosis less than a year and folks felt that buprenorphine, switching to buprenorphine was inappropriate in that situation which I can only imagine it's probably because somebody is doing okay-ish on their opioids and the main issue is cocaine use. You might not wanna kind of upend their opioids and suggest a really big change. So it's a good question Katie's asking in the chat where the patient has to have a diagnosis of OUD to switch to buprenorphine. So the FDA indication for buprenorphine naloxone which is probably what this person would be switched to because she's on a pretty high dose of opioids and things like the buprenorphine patch with these tiny doses are not going to do it for her. So folks like this, you would wanna switch into buprenorphine naloxone and the FDA indication for using buprenorphine naloxone is opioid use disorder. But I don't think any of us are strangers to prescribing off-label. And so you can certainly treat people with buprenorphine naloxone off-label for being on opioids for a long time and wanting to switch them to a safer opioid or in this case kind of a version of that which is cocaine use that increases their risk. So you don't have to have an OUD diagnosis to prescribe buprenorphine. And yeah, Denise wants to explore her cocaine use more which absolutely you would. I totally think Denise you would wanna do and think about treatment for, if she has a cocaine use disorder, it's not clear that she does, but if after talking to her about her cocaine use she does, you wanna think about how to talk to her about whether she's wanting to stop and whether she's wanting to change her use and kind of what would come next. So behavioral treatments are really most effective for cocaine use disorder. The other thing that I feel like in 2022 I can't not mention is that cocaine is often contaminated with fentanyl. We see that very frequently. And so whenever I see somebody using cocaine I also talk to them about harm reduction. So whether it's using fentanyl test strips or making sure that they don't use a loan, there's that 1-800 line, never use a loan line, making sure that there's somebody available to give them Narcan should they need it and making sure they have Narcan. All of those things are really important in people using cocaine as well. So just a little sidebar there. Okay, using more opioid than prescribed. So a lot of you mentioned this as an important behavior that you see in the chat. So this is for you all. So Mr. F is a 76 year old male with a history of alcohol and tobacco use, but not opioid use disorder, who develops laryngeal cancer and has a resection and is thought to be cured. He has residual post-radiation neck pain in the six months after his definitive treatment. He's prescribed morphine and oxycodone at about 120 MMEs. And on several occasion, his urine is negative for the opioids that you're prescribing and he reports taking more. So when you explore that, right, there's always a differential diagnosis for behavior like that. And this is great because you're like, okay, your urine's negative, like help me understand what the reason might be. And he says, well, I've been taking more than prescribed. And so I always run out several days early and I didn't want to bother you by calling you and asking you for, you know, an early refill or something. So, or I was ashamed and didn't want to go there. So assume that you're ex-waivered and that his insurance will cover buprenorphine naloxone and tell me what you would do. Would you continue his opioids, increase monitoring, taper opioids or transition to buprenorphine naloxone? We've got a vote for D. There's A, B and D. Yeah. Repeat the drug screen, test specifically for the oxycodone. That's a good point. So just as a sidebar, when you're doing urine drug testing, you really need to make sure that the drug that you think you're testing for is actually in the panel. I've seen this happen before where somebody's like, the urine's negative for oxycodone. And then you realize that actually the panel does not include oxycodone. It's not that it's negative, it's just not included in the panel because these panels that we run are amino assays and they contain this like set compliment of substances and every institution, clinic, whatever, has the one that they've picked from the manufacturer. So you just, you really wanna make sure of that. So thank you, Joseph, for reminding me of that. So what I love about people's responses is that nobody said C. So, yeah, you don't wanna just go ahead and taper his opioids. I mean, you want to really figure out what's going on by increasing monitoring during which time you're continuing his opioids. And yeah, so, and again, this is from the StelFy study, there was some uncertainty around transitioning to buprenorphine. And I would say that like, the times when I would switch somebody like this to buprenorphine are, so let's say I increased monitoring and oftentimes what that looks like is giving people short prescriptions. So maybe this person, like I said before, has low health numeracy or just is cognitively impaired or is just not good at numbers or not good at kind of regulating things, pill counts. So like if you give somebody a short supply, it's sort of a built-in pill count in the sense that if they come in next, if you give them a week supply and they come in next week and they ran out a day early, then you sort of have a sense of how much they're taking extra. And that also gives you a sense of, whether they might meet the opioid use disorder criteria that this behavior most often represents, which is loss of control, right? So it might just be that they're not good with numbers or it might be that you tell them, okay, I'm giving you a week supply, do you not take more than this number of pills a day? Have your spouse help you with the counting if you're having issues with that and they cannot control their use, right? So I think it's in those kinds of situations where the transition to buprenorphine becomes less uncertain and more certain. But switching somebody from a full agonist opioid to buprenorphine, in my opinion, is never the wrong thing to do. It's always kind of a patient-oriented conversation. Shared decision-making with the intent to reduce risk. And certainly in this case, when someone's running out early and they lose tolerance in those days when they are not getting their opioid. And so it's very risky for folks like that because then they restart at their old dose and that really increases their risk for overdose. And so switching to buprenorphine is never sort of wrong in this place. Yeah, so an electronic pill dispenser, I think thinking about, I think that's a great idea. I think thinking with patients about sort of like problem solving with patients about what is the issue here and what are the potential solutions. And sometimes patients will come up with amazing solutions or identify problems that you could never have imagined. So for example, I had a guy who was referred to me specifically for running out early and it turned out that he would go to work and put pills in his pants and to take with him to work. And then he would get home from work and if he hadn't used all the pills yet, he would take off his pants and his wife would wash the pants. And so the opioids ended up getting the washing machine someplace. And so like, that was one of those things where you sort of have to talk to the person and be like, so like the electronic pill box probably would, I don't know if that would have been the right choice for him, but he immediately was like, I just shouldn't put my pills in my pants. And you're like, well, that's a great solution. So having patients come up with their own solutions can often be really good, but those types of tools can be great for sure. Yeah, so great question about methadone versus buprenorphine for pain. So there've been no head-to-head studies of methadone versus buprenorphine for pain. There is definitely sort of, I don't know what to call it, like folklore believes that methadone is better, but I will say that I manage, because I'm not a methadone clinic, I don't prescribe methadone for people with comorbid opioid use disorder and pain. And I will say that my folks on buprenorphine, I have a whole clinic of patients who are being, their pain is being managed with buprenorphine and they're doing well. Sometimes you have to add prolaginus to the buprenorphine in patients with cancer-related pain. And there's a case about that a little bit later, but which is something that we usually only do in patients who have a pretty short prognosis. But, you know, so you might have to do that, but that's also true of methadone. We often end up in that same situation with methadone. So I think that was a long way of saying that bup works for pain and there's no reason in my mind to think that methadone would be better. There's just not evidence to support it. Oops, okay. So we have three minutes left. Yeah, I think maybe we can wrap up now for today and then finish up on next Wednesday when our webinar is going to be at 12 o'clock noon Eastern again on September 7th. And Dr. Merlin's going to continue her presentation and answer questions on this webinar. You can also post cases for Dr. Merlin that you would like her opinion on. And what you would do is go to the AOAAM education page and enter your questions under the discussion tab. So you can put your cases in there, any questions you have from today, and we'll pass those on to her for next week's webinar. So I'd just like to thank you, Dr. Merlin, for presenting today. This has been an excellent webinar and very interactive, and I know our participants appreciate it. So we're looking forward to seeing you again next week at 12 noon Eastern. Great, I look forward to seeing all of you again. This was a really great discussion. Thanks for all of your engagement. I really appreciate it. So thanks for inviting me, Dr. Kmec. All right, take care, everybody.

opioid complexity

serious illness

long-term opioid therapy

opioid misuse

identification

management strategies

individualized treatment plans

shared decision-making

comprehensive approach