Good afternoon, everybody. Sorry for the technical difficulties. We're still trying to resolve them. But today, we're going to continue with Dr. Jessica Merlin on her talk on managing opioid complexity in adults with serious illness. So my name is Julie Kimmick. I'm going to be your moderator for the session. And this is the fourth of a six-hour webinar series on hot topics in the treatment of opioid use disorder and stimulant use disorders. So as you know, Dr. Merlin's 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 PIT's Challenges in Managing and Preventing Pain Clinical Research Center. She's also a board certified in internal medicine, infectious disease, palliative care, and addiction medicine. She's a PhD-trained behavioral scientist and NIH-funded clinician investigator. Her program of research focuses on the intersection of chronic pain and opioid misuse slash use disorder across populations and settings, especially in individuals with serious illnesses like advanced cancer. To that end, she is the MPI of an NIH-funded tailored retention and engagement for equitable treatment of opioid use disorder and pain clinical research center, which is called TREATOP, one of the four NIH-funded centers focusing on the intersection of pain and opioid use disorder in the U.S. She's also the MPI on 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 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 or use disorder. She's been recognized nationally with the 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'm hoping that we're able to start on the rest of her slides now. Dr. Merlin, can you hear us? Yes, I can hear you. Can you hear me okay? Yes, can you guys see the slides? Yep, we just talked to Dr. Merlin. If you could follow along with your slides, I'm on slide one, and then if you can all hear us, then we can just proceed. Sounds great. Is that okay? Can I proceed? Yes, proceed please. Thank you. Absolutely. Well, thanks everyone for bearing with the technical difficulties. I'm really not sure what happened here, but I'm really glad that I'm able to join you this way. So if you were with us last week, I was keeping an eye on the chat. I'm not able to do that now, so I'll just ask Dr. Kamek or any of her colleagues to shout out any questions that appear in the chat that seem like they should be answered in a timely manner. Sounds good. I have a cold, so I hope everybody can hear me okay. I'm sorry for the coughing. If we can go to slide 32. Last time we covered everything up until there, we covered... Could you stop for one second? Yes, sure. I have the slides. That is the slides for the show one. Hannah, do you have Dr. Merlin's slides or Dr. Kamek? Because I just realized I don't have Dr. Merlin's slides. I will look for them, but I also just sent another link to try again, so if you could check your inbox. Dr. Kamek, could you check your inbox and see if you can get on that way? Yes, I'm in my inbox now. I will also send you... Send me your slides. Thank you. What is your email address? I found it. Yeah, just reply to the one that I have. I think I have them as well. I'm just trying to... Yeah, there's 82 of them, so let me just... Okay, go ahead and you can share your screen, Dr. Kamek. I just sent that. Okay. I'm looking still for the link. Did you send it? It's okay. Let's just go ahead and if Dr. Kamek can share her screen. Dr. Kamek, you're the host. Do you want to share your screen? Yeah, it's just one second. Okay, sure. I don't see any email. All right, don't worry about the link. Just Dr. Kamek is going to share her screen and then we'll proceed. I apologize. I don't know what happened here. Fine, it happens. Yeah. Okay, so I'm going to go to 82 and then I'm going to... Or sorry, 30. What slide do you want to start on? Oh, slide 32. It's an outline slide. Okay, so I'm going to get to that and then I just have to get this down. What is it? Oh, it's this. Okay. Okay, so I think... Because I'm there too. Do you want me to go? You've got it? Okay. Yeah, I'm not sure why. Hang on. My mouse is kind of like... Maybe something else could happen that goes wrong on this. Oh, okay. Wait, actually I think it's getting shared. Do you have it? Yeah. Okay. Okay, so I think we just got one. This is slide 32. Slide 32. Do you see it, Dr. Merlin? Yeah, we can see it. Okay, Dr. Merlin, we got slide 32. You can go ahead and go. Okay, great. So as I was saying last week, we gave kind of an overview of opioid-serious illness and talked about prescribed long-term opioid therapy and opioid use disorder. So this week I wanted to pick up with opioid use disorder. If you weren't here last week, that's fine. You'll be able to dive right into this as new content. So, yeah. And Dr. Kimmick, can you let me know if there are questions? I will. Thank you. I don't see any so far. Fantastic. So next slide. So key terms, and I'm probably preaching to the choir here given what call we are on, but just to make sure we're on the same page. We think about addiction as a treatable chronic medical disease involving complex interactions among brain circuits, genetics, the environment, and an individual's life experience. And so just to put it out there and say that addiction is not a choice, addiction is not a lifestyle, addiction isn't a moral failing, addiction is a treatable chronic disease. So entering this content with that in mind. And it involves an alteration of the pleasure-reward system, really resulting in what we would call compulsive use, also loss of control. Those are really two of the key features of substance use disorders is compulsive use and loss of control. With one or multiple substances, and really polysubstance use is the norm rather than the exception. And we know that treatment works, and we're going to be talking mostly about treatment for opioid use disorder. We have some really powerful tools in our toolbox, particularly for opioid use disorder. Next slide. So I wanted to just introduce you to this concept called complex persistent dependence. This has a couple of different names in the literature, but basically the idea is, if you are a clinician who treats patients who are in long-term opioid therapy, you know what I'm talking about here. The idea is that, as some have described it, it's the gray area between opioid dependence and addiction. So basically people who remain on long-term opioid therapy, maybe they don't meet criteria for opioid use disorder by DSM criteria, but they continue to be on high-dose opioid therapy, they may have trouble tapering, and they're not doing well. They're having continued pain, their function continues to be poor. If you try to taper them, not only does it not work and that they feel like they can't taper, they have worse pain with tapering, but they have worse in psychiatric and medical instability. And, you know, the question here really, this conundrum of, is this a new clinical entity or just opioid use disorder by another name? And this has been a topic that's been pretty robustly debated, I would say, in the national literature and in national meetings. And, you know, I think it's an interesting question and an important question, but I would say that the treatment, regardless of whether you view this as its own separate thing or just somewhere on the OUD spectrum, is the same. So the treatment for this, I would argue, is just the same as treatment for opioid use disorder, which is consideration of switching over to buprenorphine. This is not an FDA-approved indication for buprenorphine. This is kind of the cutting edge of the field. And so, you know, a lot of times, folks like this, we try to taper them and it doesn't work, so we switch them over to buprenorphine. And, you know, there have been some case theories published that suggest that this is effective, that people find that they have less pain and their function improves, etc. So in a patient like this, I think it's reasonable to at least think about switching them over to buprenorphine, and then you can decide if you want to taper the buprenorphine or not. But tapering from buprenorphine is definitely a bit easier and probably safer than tapering from opal agonist, because if somebody takes more buprenorphine than you want them to, because of the sealing effects that we talked about last time, it's unlikely to cause them any trouble in terms of respiratory suppression or somnolence. So next slide. The other thing that I hear a lot is, does this patient have pain or do they have a substance use disorder? And so I just wanted to really put it out there that this is a false dichotomy. So pain and substance use disorders are really, really closely related to one another. And so if somebody says they have pain, I think we should all take that at face value. That does not mean that their pain should be treated with opioids. That's a separate and related question. But if they say they have pain, they have pain. And they may also have an opioid use disorder. So we know that there's a high prevalence of pain in people with opioid use disorder. And we also know that a lot of patients who are on long-term opioid therapy for chronic pain, somewhere between 10 and 30%, depending on the study you look at, will develop an opioid use disorder. So these things are by far not mutually exclusive. And then what is the optimal treatment for pain if opioid use disorder is co-occurring? I think that is a major question for the field. In fact, we have a center grant here that is one of four in the country that is specifically looking at answering that question. And so there really isn't a lot of data on this. But I think those of us who do this a lot clinically would say that you want to think about using the medications that you use for opioid use disorder, which we'll talk about in a second, optimally for pain. So for example, if they're on buprenorphine, thinking about not just titrating to their cravings, but also titrating to their pain, splitting up multiple times to do dosing. And also thinking about making sure that you're doing everything you can to treat not only their opioid use disorder, but also their pain directly. So things like cognitive behavioral therapy for pain in addition to counseling for their substance use disorder can be really important and helpful. And hopefully in the next several years, there'll be lots more published on this because of these four centers that are working on developing more data on how to do this. Next slide. So I think all of you are probably familiar with what the DSM is, basically the psychiatry Bible, the diagnostic criteria for psychiatric disorders. And look at this slide. I think this distills the 12 diagnostic criteria for substance use disorders into something that you can easily remember as a mnemonic, which is the four Cs. So it's certainly worth looking up the DSM criteria when you're seeing a patient that you think has an opioid use disorder so that you can determine whether it's mild, moderate, or severe. And that helps you kind of understand what symptoms they're having and what might improve with therapy. And also technically speaking, moderate and severe opioid use disorder are the criteria that sort of qualify you for the FDA indication for buprenorphine. But just thinking about these four Cs that are really hallmarks of any substance use disorder. So cravings, so usually patients know what that means if you ask them about cravings, because cravings are something that all of us experience in some way, shape, or form in life. Cravings for food, cravings for substances. So I think that's pretty straightforward. Loss of control, I find, especially when we're talking about a prescribed opioid, is something that sometimes we as clinicians pick up before a patient would. So maybe you realize that you're trying to taper somebody and you tell them, okay, I want you to only take four oxycodone this week, and they're just unable to do that. Or maybe they come to you because they're taking more than prescribed and they're not able to control it. Consequences, so continued use despite problems socially, interpersonally, or medically, and getting some corroborating information from family members can be really helpful. Sometimes certainly patients can recognize it themselves. And compulsive use as well, I think is pretty self-explanatory. So next slide. So here's a case, just like last time, we have some cases. So Mr. R is a 50-year-old male with early stage laryngeal cancer undergoing curative intent radiation. He also has opioid use disorder on buprenorphine, naloxone, and a stable dose of 16 milligrams daily for many years. He has pain related to his radiation. How would you best address his pain? So next slide. So I will not be able to see how people are voting. So maybe Julie or one of the staff can clue me in. But what would you do? Would you continue the buprenorphine naloxone and divide it into three times daily dosing? Would you continue the buprenorphine naloxone and add a polygonist opioid to the picture? Discontinue the buprenorphine and start methadone. Discontinue the buprenorphine and start polygonist opioids other than methadone or refer to a methadone treatment program. And you can select more than one of these. And I'll be monitoring for some answers here. I'm sorry? I'll be monitoring and let you know what people vote for. Great. I'll give people a second. Do you want them to put that in the chat? Oh, yeah. Oops. Sorry. Okay, put it in the chat then. Yeah. So if people could put the numbers and the letters in the chat, that'd be great. We've got an A. I see another A. Oh, yeah. People can enter into the Q&A box if you can't get into the chat. A, okay, good. Sounds like a lot of people are liking A. Yeah, a lot of A's popping up here. Yeah, that's everybody. Everybody said A. I got one B, E, I think there's some concern sometimes that being on a phylogenist and BUPE at the same time will make the BUPE less effective. I think those of us who do this work see that that is a theoretical concern, but most of the time it's perfectly possible to add a phylogenist on top of BUPE, and there have been studies in the surgical literature post-op pain to support that, but sometimes there may be a doubt that the BUPE is causing some difficulty, and in that case discontinuing BUPE could potentially be an option weighing the risks and benefits of the patient. Next slide. Okay, so we're going to talk about some very specific skills, buprenorphine, prescribing, and tapering. Before I do that, I'll just pause and ask you, are there any questions in the chat? None right now. Great. Next slide. Hopefully everybody here knows this, but if you don't, I'm going to catch everybody up to speed and let you all know that as of April 27, 2021, it has become much more possible to prescribe buprenorphine. In fact, all you have to do is scan this QR code, so we'll leave this light up for a hot second, scan this QR code, and it'll take you to a website where you can sign up. If you have a DEA, you can do this. All it asks you for basically is your address and your DEA, your name, and it allows DEA licensed clinicians to apply for a waiver without any additional training and without attesting to the ability to refer for counseling. It will give you a waiver of up to 30 patients. The vast majority of people who have a waiver prescribe for far less than 30 patients. This will allow you to, as I put on this slide, and this is not my catchphrase, somebody wrote an opinion piece that said this, I thought it was really nice, to become a buprenorphine dabbler. I know some of you work in opioid treatment programs, some of you don't, but for those of you who don't work in the opioid treatment setting, if you're in primary care, just do this for your patients. You don't have to set up a shingle and advertise that you're going to do this for the next 500 patients with opioid use disorder. You can just start somewhere and every little bit, every new waiver clinician helps. Next slide. I just wanted to comment. There is a comment in the chat here that said somebody works as a hospice physician, and the main reason that they don't use buprenorphine is costs and the hospice formulary due to Medicare per diem for hospice, and the methadone is so cheap. I think I heard part of that. I think what you're saying is that buprenorphine is not on the Medicare hospice formulary. Correct, because of the per diem, I guess. I'm sure whoever is making this comment probably knows better about this than I do, but my understanding is that it's like any other medication in hospice that's expensive. The way that hospices work is that they are given a capitated per diem payment, and so when they're expensive treatments like chemotherapy or radiation or whatever, then some hospices can afford to do that, and some hospices cannot afford to do that. If it's not a medication that's covered under the hospice formulary, then it's a question of can the hospice afford to do this or can the hospice not afford to do this, and some hospices have money and some do not, and so it becomes kind of a case-by-case consideration, and so I think that's a really good point. Methadone is pennies. Buprenorphine is a monthly supply. I don't want to misstate this, but it's much more than ... I don't want to give a number because I'm probably going to get it wrong, but it's certainly much more than pennies, and so that's a very good point about why that happens. Right, and somebody just commented. I'm sorry my mic is kind of odd today, but somebody just commented that generic buprenorphine monoproduct without the naloxone is about a dollar each for cash pay. Generic buprenorphine monoproduct is a dollar? That's, yeah, a dollar each is what one of our attendees had mentioned. That's great. I was not aware of that. That's really great to know, and I mean, that's interesting, actually. I mean, so yeah, I'll just leave that there. I was not aware, so that's great information to share. Are we on the slide that says preparation? Yes. Okay, so I think I'm preaching to the choir here too, but just in case there are some folks who are less familiar, there are ways that if you're just starting to prescribe buprenorphine, you can get help. So there's a program called Professional Support System that you can, if you Google it, you can get a longitudinal mentor. I'm a mentor for PCSS. I'm sure many other people on this call are mentors for PCSS. There's also a warm line at PCSS that you can contact for specific questions. And I'll just say that it's finding other kind of champions of practicing this way and using buprenorphine in your context so that you're not the only one is really important. I'll leave that there because I know we have so many people work at OTPs. That's not really applicable. Next slide. So when to use buprenorphine? So I think it's pretty clear in patients without serious illness, in patients with opioid use disorder, buprenorphine, there's always an indication for medication for opioid use disorder, including buprenorphine. I think that in patients with opioid misuse that doesn't resolve and for whom you have a high suspicion for opioid use disorder, it's reasonable to start buprenorphine. The newer approach that I talked about a few minutes ago, if you're tapering somebody and it's not working very well, switching into buprenorphine for the taper. And sometimes in patients with pain who are at high risk for opioid side effects in that situation, we see a lot of folks appropriately using things like the buprenorphine patch called Butrans because it's a low dose buprenorphine that because of slow dissociation of buprenorphine from the receptor is thought to be the reason why such a low dose of buprenorphine in the microgram order of magnitude would help with pain. And that can be really good in somebody where you're really worried about malignant opioid side effects or somebody who's had a lot of malignant side effects, like somebody who's a frail elder who is having falls. And then uncharted territory, but makes sense. Patients with complex persistent dependence, we talked about that before. And then patients from opioids are being considered, but are high risk of patient. Do you think that somebody would benefit from an opioid, but they have a history of a substance use disorder, whether it's opioids or something else, they're not getting buprenorphine as treatment for their substance use disorder, but maybe they have in the past, or maybe they just never saw treatment before and you want to treat pain, it's reasonable to start them on buprenorphine for pain. So that's kind of in general. I think in patients with serious illness, I think we can take all of these same approaches, just kind of moderated by expected course of illness, functional expectations and practices. So if somebody has complex persistent dependence, but they're in the last three months of their life, does it really make sense to switch to buprenorphine? Probably not. So that's something that you do to improve sort of long-term functional benefits and sort of long-term adverse outcomes like mortality from malignant opioids. And there's very little literature about the intersection of buprenorphine and serious illness, but my colleague listed here and I are trying to add to it. And so hopefully in the next years, there will be more. So I'm actually going to skip the next two slides because we've covered a lot of it and because I think we've covered a lot of how buprenorphine works. So I'll skip that and just go to slide 48 to say that I just want to make sure everybody is aware that there are newer protocols for initiating buprenorphine that you should be aware of because the traditional method is somebody's using heroin or fentanyl, they come to you, they're in withdrawal, they stopped their opioids. So that's why they're in withdrawal and you can give them a bunch of buprenorphine up to 12 milligrams the first day starting at four milligrams increments. The benefit to this is it's a more rapid transition. You can get somebody on buprenorphine away. The burdens of this are that the person has to be in withdrawal. And the reason for that is we all know about precipitated withdrawal, right? If you just, if somebody's on a bunch of a filagginous opioid and you just dump a boatload of buprenorphine on them, the buprenorphine binds more tightly to the receptor, knocks off the filagginous and they go into precipitated withdrawal. So there's another way of doing this called low-dose initiation where there are protocols that have been published. It's at the level of case series. There haven't been large randomized trials of this, although there is one that's about to start. But where you slowly introduce the buprenorphine at a level of, you know, a 20 might be trans patch. If you're in the inpatient setting or in the outpatient setting, you can use a two milligram strip and cut it into quarters to get a point milligram dose. A person does not need to be withdrawal for this, but this can take about a week to get somebody up to a therapeutic dose of buprenorphine. But, you know, the other benefits of this as well is if you want someone to remain on their filagginous opioid, like let's say somebody who, you know, is on a filagginous opioid for their cancer treatment and comes to you because they want to get back on their buprenorphine to treat their opioid use disorder, this is the way to do it. So next slide. You all are going to get a copy of my slides, but this is just, you know, you can Google and find this. The American Academy of Addiction Medicine and AFAM have, there's a million of them out there, like protocols for initial, for traditional initiation. And then the next slide, low dose initiation, this is just what I said, written out in table form. This is the, like I said, there's been a bunch of case theories that have protocols in them, and this is my favorite because it includes my, it was written by my colleague Will Becker, but again, starting with half a milligram dose a day. And in this case, this person stopped their filagginous opioid day four, which is about when we would do it in this situation, but they could have just continued it if that's what, you know, is appropriate. Next slide. All right, we can spend a couple minutes talking about tapering. So this goes back to people who are on, I'm going to talk specifically about tapering from filagginous opioids. I'm not talking here about tapering buprenorphine because buprenorphine for opioid use disorder, we know that if you taper it with methadone, that it increases people's risk of mortality. And so we generally do not recommend tapering. Certainly if a patient wants to taper off of their methadone or buprenorphine, we can support them in doing that, but it's really a shared decision-making type thing where you're explaining to the patient what the risks are. Here, I'm kind of getting back to people who are on filagginous opioids. So there's a systematic review that Joe Frank wrote in 2017 that still really holds up. And what he found was that pain function and quality of life may improve with voluntary tapering supported by a multidisciplinary team. So if this is somebody who comes to you and says, I really want to get off of these meds or somebody for whom you say, hey, here are the risks of these medications in the long-term. I usually like to talk to all my patients about considering either tapering or switching to buprenorphine. And the patient says that they're interested in tapering. So what I take from this is that I try to provide them with as much support as I can through counseling, help them identify people in their personal life that they can identify as folks who can support them. And then also let them know that actually in studies of voluntary tapering, pain function, and quality of life, many of those studies have showed that those things have actually improved. Next slide. So again, tapers work best when combined with psychosocial support, as the Frank study showed, and a couple of other sort of pearls. So I give patients control over the rate whenever possible. So because there is no evidence base for how fast you should taper somebody, we know that you shouldn't taper somebody by more than 25 to 50% because that will cause them to go into withdrawal. But that's a pretty slow bar, just avoiding withdrawal. We want people to actually have success. And so what I do is I ask them what they think would be a reasonable amount to taper. And I try to encourage them if they're trying to be a little more ambitious, then they probably ought to be. I encourage them to go in pretty small increments. I'm talking like 5% of total daily dose so that they can have initial success with it. So they can build some self-efficacy and realize that, hey, this isn't going to be that bad. And then there is an example from a pain clinic that Beth Sarnell published where they gave the patients an education. Their approach was to go slow. They did a 5% reduction twice in a month, and then no more than 10% per week. And most of the people who completed the study were at a reduced dose with minimal or no change in pain. The other thing about tapering is, I will say anecdotally, it's hard to get people totally off of high-dose opioids. But just even reducing their dose seems like it ought to have a survival benefit, and so it's reasonable to contemplate that. And then we talked before that switching to BuP may be useful as a tapering tool. Okay, next slide. So a disclaimer here is that high-quality evidence on the harms of opioid tapering are being limited. There's definitely a lot of concern that tapering people specifically and especially involuntary tapers where you just have a pain clinic that closes or a clinician says, like, I don't like the fact that you're on high-dose opioids, so I'm just going to tell you to taper it. There is a lot of concern that this leads to opioid withdrawal, psychological distress, increased pain, and may unmask an opioid use disorder. There's some fairly recent studies that have looked at this, including from Marc LaRochelle, which is cited here. So given those concerns, I think the jury's still out on how harmful tapering really is, but I think to reduce people's potential of harm during tapering, having frequent check-ins with them. This isn't something you set and forget. Short prescriptions, so say, all right, we're going to taper. I'm going to give you a two-week supply. We'll come back in two weeks, see how everything went. Making sure they have Narcan available in case they do overtake and their body is no longer as tolerant of the opioid as it once was. And so just making sure that, I mean, everybody on high-dose long-term opioids should have Naloxone on hand, but just double-checking that and making sure people engage in interdisciplinary multimodal care so they do have that support, like I mentioned before. If somebody starts exhibiting opioid use disorder criteria, treat it like you would anybody else. And again, this is a new area where research is emerging, and policies make it challenging to provide individualized care. I know, you know, sometimes clinics or health systems are insuring everybody down to 90 milligrams of colds and morphine a day or something like that. And that just is not consistent to good care. Next slide. This is a flowchart that I think is actually pretty useful. It kind of summarizes some of what we've already said, but it was published in JAMA and it's basically guidance from DHS about how to taper. So you assess benefits and risks of continuing opioids at the current dose, and if on the right-hand side the benefits outweigh the risks, you document that and you re-evaluate that periodically. That's the key, is re-evaluating it periodically, not just saying, okay, I thought about it and I'm never going to think about it again. If the risks outweigh the benefits, you discuss, educate, often taper, start a slow taper, and taper down until the benefits outweigh risks. And then once the benefits start outweighing the risks again, you re-evaluate those benefits and risks quarterly, like we did on the right-hand side of this chart. If you can't taper down, you know, I'll help break things when you're trying to taper a person, you know, starts on the left-hand side meeting criteria for opioid use disorder. You obviously want to treat that. You don't need to add criteria for opioid use disorder, but the patient just says, I can't do this. I don't want to do this. You could slow the taper down or stop the taper or go back up. That's totally fine. You could try to transition them to buprenorphine as a safer opioid, like we talked about before, and then just continue to re-evaluate those benefits and risks. Next slide. So, as we all can appreciate here, we are at the forefront of an important problem. So, I think particularly as folks who work at OTPs, you know, many of you are already engaged in the hard work of treating patients with opioid use disorder. What I would love to see more of is that clinicians who treat patients with serious illness gain the skills that you have in treating opioid use disorder and that people at OTPs gain the skills in treating opioid use disorder and patients with serious illness, which really isn't, you know, now that you've heard this talk, I think that's, you know, perfectly sufficient to, you know, the literature is not that deep and we need more people to be willing to do this. And so, I hope that this talk has kind of spurred some people to consider taking on more patients with serious illness in their opioid treatment programs. Yes, we have the skills for this. We can make a difference. And for those of you who are not wavered, just do it. So, that is, and here's the next slide is another QR code to get wavered and those are literally the bags that it takes on the website to get wavered. That is not, and that's it. So, I think we are ready for more discussion. Okay. I, while we were talking earlier about the costs of buprenorphine versus methadone, somebody had also mentioned too that substance use disorder is not usually a primary or secondary hospice diagnosis. So, it can be covered outside the hospice benefit, they think. So, that's a good point too. Sorry, there's a lot of speaking. Oh, there we go. Yeah. So, I mean, you're, you have to, you know, have a, you have to, to name it, the primary diagnosis for the hospice that somebody's being referred to hospice for and other conditions can continue to be covered outside the hospice benefit. So, that's how sometimes people continue to remain on dialysis in hospice, for example, because they're, you know, hospice diagnosis is cancer, but, you know, they want to continue to remain on dialysis for a variety of very understandable reasons. So, that's another very good point. You can think about that with substance use disorder. If you do have a question or comment, just enter them into the Q&A box, everyone. Somebody had also mentioned that they're here for your lecture today because they've been thinking about the overlap between treating pain and serious illness in their hospice practice, as well as addiction. So, very happy to be here for your talk today. Oh, that's great. Thank you very much. I appreciate that comment very much. Yeah, and just commenting on what you had mentioned about the payment situation and everything. If we're treating pain, the hospice is responsible for everything related to that. It would be a gray area that would freak most hospices out, they think, but regulations are moving towards the hospice covering everything. Yeah, good point. You know, it strikes me that there are so many people here with hospice expertise. I think maybe I was aware of this before. It seems to be jogging something in my mind, or maybe not, but there's an overlap between people who work at OTPs and run OTPs and also run hospice programs. That's great. That's an overlap that our field desperately needs, and it's clear that that exists on this call, so that's great. If there's any other questions, please enter them into the Q&A box. Dr. Merlin, I was just wondering, I know you were focusing on serious illnesses and opioid treatment. How often are you seeing people with just chronic pain problems? So for example, I have somebody at the OTP who is on methadone maintenance and she had what she describes as a failed back surgery. And so she has high levels of chronic pain, has tried everything basically when I went through things with her. She is starting physical therapy. So that's something new that she didn't try, but she tried chiropractic care as well as non-opioid medications. And I was just wondering what your approach is to these other kinds of chronic pain conditions when somebody does have an opioid use disorder, if you do see that in your practice. Yeah, so that's a really good question. So I think this is an illustration to how fragmented care can be. Like I have a practice that just focuses on patients with advanced cancer. I used to have a practice that focused on sort of chronic pain, quote unquote, chronic non-malignant pain. So I think generally speaking, the things to think about, and also I think speaks to the fact that most opioid treatment programs that I'm aware of, even though more than half of patients with in the methadone clinic are likely to have chronic pain, don't necessarily, and I'm not picking on you in any way, shape or form, please don't interpret it that way, but true for the OTP that I work in, like we don't have anything for patients with chronic pain. That's not part of the discussion. It's not part of, we do HIV screening, we treat hep C, but chronic pain is not, even though it's so common, it's just not part of our offering. But I think the things that should be thought of in somebody like that are treating the chronic low back pain the way that you would treat chronic low back pain in anybody. So exactly as you said, physical therapy, cognitive behavioral therapy for pain, those are probably the things with best evidence. There are lots of potential pharmacologic therapies that you can try. You wanna make sure you don't get into too much off-label stuff that doesn't have any evidence base. This person has already experienced that, which is low back surgery. So surgery for low back pain is essentially a non-evidence-based approach to treatment of low back pain. And so you wanna make sure that you're not sort of contributing to that. There's also pretty minimal evidence for injections. Hopefully there's, if there's an anesthesiologist on this call who wants to fight me for it, I'm okay with that. But that's just true is that the people might feel benefit from that, but there have been meta-analyses that show that it doesn't really help. So there aren't a lot of great treatments for chronic pain. Sometimes I will give people very low risk off-label treatments, things like topical NSAIDs and finding more and more that insurance will cover topical lidocaine, even though there's really no evidence base for that aside from post-traumatic neuralgia, but people tend to like that, whether it's in a 3% cream or a patch, you can get some of that over the counter as well, which depending on whether the insurance covers it, maybe cheaper. And then there are things like the American Chronic Pain Association. Well, I should say things like there's the American Chronic Pain Association, which has amazing support groups everywhere in the country. So I highly recommend that people look that up and have their, if you call, it's one of those few things that in 2022, if you call their main number, you get a human, you don't get a telephone tree and you get a very nice human on the other end of the phone who can help direct you to your local support group. And so that can be also a very valuable resource. So those are the types of things that I try to direct people to. And I think in the context of a methadone program, the other thing you could consider doing, obviously depending upon how the patient is doing is split dosing. My understanding is that when people get take-homes, a lot of times they split dose those anyway. So if somebody is getting take-homes, that might be something to explicitly recommend to them, but it's just something to think about. Right, yeah. I think those are all great, great ways to tackle the problem or try to address it. We did have another comment here in relation to what you had mentioned about tapering. Somebody had said they start patients on split dosing because it's both behaviorally proactive, but also it's easier to wean them if they- You know what, I'm gonna stop you because I can't hear you. Oh, one second. Yeah, there was a siren. Okay, it's over. Okay. Somebody had mentioned that they behaviorally, proactively put people on split dosing in the beginning just because it's easier to wean later on. And also, if the patients feel like they have a little bit of control over the medication, it's helpful for them. And I'm sorry, I missed whether that was in the context of methadone. It was in the context of what you had talked about earlier about tapering. I'm sorry, I'm having a little trouble. Yeah, sorry, I said it was in the context of tapering that you had talked about. I see, yeah, that makes a lot of sense to me. I like, I mean, I'm not sure if they're, I'm assuming they're talking about buprenorphine and not methadone, but I would just say in the context of buprenorphine, I often slash always encourage people to split their dose. I feel like people do that naturally anyway, but I think it's, you know, because there's such a high comorbidity with chronic pain, I just see it working really well. We have one other question here. I think we have time for this, is do you have any recommendations for how to talk to patients who've been on long-term opioid treatment who are basically legacy patients who might be concerned about being diagnosed with an opioid use disorder? To elaborate, do you think a legacy patient could benefit from tapering and trying buprenorphine? Yes, that's a great question. I think there are a couple of questions in that question. So one is, you know, when you sort of inherit somebody who's been on long-term opioid therapy for a long time, or maybe it's one of your patients and you were the one who put them on it. I mean, you know, it wasn't that long ago that this was sort of standard of care. What I do is I tell people, you know, back when you were started on these medicines and when we increased the dose or whatever, that was standard of care. That's what we thought was the right thing to do. Since then, we've learned a lot, and you probably know that we've learned a lot because you've probably, you know, seen something about it in the news, you know, heard from friends that, you know, this is, we no longer serve people in your situation on opioids, but that doesn't help you that much because you're already on. And so now the question is like, how do we best work together to help you, you know, achieve your goals in life, maximize your function, minimize your risk, given the fact that now you have a new problem on your problem list, and that problem is, you know, being prescribed long-term opioid therapy. And then, you know, if I think somebody has an opioid use disorder through their long-term opioid therapy, then I have a discussion with them about how opioid use disorder is an expected complication of being prescribed long-term opioid therapy. So now they have two problems. They have their original pain that they were prescribed the opioid for, and now they have a new problem, which is their opioid use disorder. And so then I talk to them about treating that new problem that they have come into through no fault of their own, like anybody with an opioid use disorder, but I think it's important to say that because I think people feel somehow responsible like they did something wrong, which of course is not the case. If they don't have an opioid use disorder, and the question is just, what do we do now? Then I think, you know, what I generally do is I say, the current practice is that every so often we have a conversation about these medications and we think about the benefits you're getting from them, the risks from being on them, any harms you might've already experienced, and then think about, you know, whether it's reasonable to either try a totally different approach, and that would be for morphine, or not that it's totally different, but to try a bit of a different approach, which would be for morphine, or to try tapering. And I let them know, this is not something that I'm going to, if the person is not having misuse behaviors and doesn't have opioid use disorder, and it's really to prevent problems and improve their quality of life, I will say, this isn't something I'm going to force you to do, this is gonna be a decision we make together. You don't have to do this. We can, you know, you can think about it, you can consider it another time. I just want to talk to you about kind of what the, you know, what the options are. And then it becomes, you know, if you think that they would be better off not on opioids, but, you know, if they're morbidly obese and have sleep apnea, and, you know, just some things that you sort of think, you know, this would be better without the opioids, then it's like motivational interviewing over time, right? The behavior you're trying to get them to change is the opioid taking behavior for their chronic pain. Not because they have an opioid use disorder, but because this is how they've managed their chronic pain, and this is how the healthcare system told them to manage their chronic pain. So you work with them using motivational interviewing to try to, you know, if they have absolutely no interest at the beginning in tapering or switching to puke, you work with them on that. And then at the same time, you treat their pain. So oftentimes people in this situation have not really been offered directed treatments for their pain. So, you know, you find somebody who can do CBT for them, you know, maybe they're interested in acupuncture, there's some evidence to support that. You know, you do those other things so that maybe hopefully the tapering would be easier or where they wouldn't need the opioid as much. That's my, I know I took forever to say all that, but that's my long answer. Okay, thank you so much. I think we're running on the one o'clock hour. So I wanted to wrap up today and mention that Dr. Merlin's slides are going to be available on the website, the AOAAM website under the education tab. And remind you that next week, we have our last two set or our last set of talks starts next Wednesday, September 14th. And it's with Dr. Brandon Marshall, the state of harm reduction in the US, progress, barriers, and what's next. So I hope that you all can join us again next week, but it's going to be at 5 p.m. Eastern time for that webinar. And I'd like to thank Dr. Merlin for soldiering on today through all these technical difficulties, as well as to all of our attendees for coping with these problems that we've had technologically. I really appreciate it. And thank you again for an excellent couple of weeks of talks, Dr. Merlin. Thank you, this was really fun. And thanks to everybody for their excellent questions and comments.

opioid complexity

serious illness

buprenorphine

tapering

psychosocial support

chronic pain

substance use disorder

non-opioid treatments

interdisciplinary care