Much like deprescribing, we plan to revisit certain high impact and dynamic topics frequently. Substance use disorder is one of those complex issues in which clinical practice is changing rapidly. You can listen to our prior podcasts on substance use disorder here, here, here, and here.

Today we talk with experts Janet Ho, Sach Kale, and Julie Childers about opioid use disorder and serious illness. We address:

Why is caring for patients with this overlap so hard? Inspired by Dani Chammas’s paper in Annals of Internal Medicine titled, “Wishing for a no show” we talk about countertransference: start by asking yourself, “Why am I having difficulty? What is making this hard for me?”
Sach Kale set up an outpatient clinic focused on substance use disorder for patients with cancer. Why? How? What do they do? Do you need to be an addiction medicine trained physician to start such a clinic (no: Sach is not). See Sach’s write up about setting up this clinic in JPSM.
What is harm reduction and how can we implement it in practice? One key tenet of harm reduction we return to multiple times on this podcast: Accountability without termination (or, in more familiar language, without abandonment).
When to consider bupenorphine vs methadone? Why the field is moving away from prescribing methadone to bupenorphine; how to manage patients prescribed methadone for opioid use disorder who then develop serious and painful illness - should we/can we split up the once daily dosing to achieve better pain control?
Who follows the patient once the cancer goes into remission? Who will prescribe the buprenorphine then? Or when it progresses - will hospice pay?
And so much more: maybe not the oxycodone for breakthrough; when the IV dilaudid is the only thing that works; pill counts and urine drug tests; the 3 Ps approach (pain, pattern, prognosis); stimulant use disorder; a forthcoming VitalTalk section…

Thanks to the many questions that came in on social media from listeners in advance of this podcast. We all have questions. We addressed as many of your listener questions as we could. We could have talked for 4 hours and will definitely revisit this issue!

Sometimes the drugs don’t work.

-Alex: @alexsmithmd.bsky.social

#30: Gardens of the Moon, chs 17-End (Malazan #1)