PC for Patients with Substance Use Disorder: Janet Ho, Sach Kale, Julie Childers
Feb 27, 2025
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In this engaging discussion, Janet Ho, Sach Kale, and Julie Childers tackle the intricate overlap of substance use disorders and serious illness. Janet shares insights on why treating these patients is so challenging, while Sach details his successful outpatient clinic for cancer patients facing addiction. They explore harm reduction strategies, such as accountability without abandonment, and debate the merits of using buprenorphine versus methadone. The trio also candidly addresses the emotional complexities clinicians face, emphasizing the need for effective communication and tailored care.
Understanding countertransference is essential for clinicians to improve their comfort and effectiveness in caring for patients with substance use disorders and serious illnesses.
Implementing harm reduction strategies, such as co-management with addiction specialists and using buprenorphine, enhances patient care in palliative settings.
Establishing specialized outpatient clinics fosters collaboration among interdisciplinary teams, ultimately improving outcomes for patients facing both cancer and substance use disorders.
Deep dives
Understanding Substance Use Disorder in Palliative Care
Caring for patients with serious illnesses who also have substance use disorder presents unique challenges for healthcare providers. Clinicians often feel uncomfortable in these situations due to the impulsive behavior commonly associated with substance use disorders. The feelings of moral distress and personal inadequacy can enhance this discomfort, making it essential for providers to reflect on their countertransference during patient interactions. Recognizing these dynamics can help clinicians develop more effective communication strategies and enhance the therapeutic relationship.
Harm Reduction Approach in Palliative Care
Implementing a harm reduction approach is crucial for managing patients with cancer and substance use disorders within palliative care settings. This framework focuses on reducing the potential negative consequences of substance use while prioritizing the patient's overall well-being. For instance, clinics may incorporate strategies such as offering co-management with addiction specialists or using medications like buprenorphine to address both pain relief and substance use disorders simultaneously. By advocating for additional resources and following specific harm reduction principles, healthcare teams can significantly improve care for this vulnerable population.
Integrative Care Models for Substance Use in Cancer Patients
The establishment of specialized clinics has transformed the way palliative care providers manage patients with both serious illnesses and substance use disorders. Such clinics offer a collaborative environment where interdisciplinary teams, including addiction specialists and palliative care providers, work together to address the multifaceted needs of patients. This model allows for tailored care that takes into account the patients’ cancer treatment and any ongoing substance use. The approach not only improves patient outcomes but also helps providers develop confidence in managing these complex cases.
Buprenorphine and Opioid Management Strategies
Buprenorphine is increasingly recognized as a first-line medication for treating pain in patients with a history of substance use disorders. Its unique properties reduce the risk of respiratory depression and provide a safer alternative to traditional full agonist opioids. When managing acute pain or chronic conditions, clinicians must assess the type of pain, the patient’s history with substances, and their prognosis to determine the most appropriate treatment approach. Shared decision-making is vital, as the patient's willingness to adhere to the treatment plan plays a significant role in achieving effective pain management.
Challenges in Prescribing to Patients with Substance Use Disorder
Prescribing opioids for patients with substance use disorders requires careful consideration and an understanding of the unique psychological and physiological challenges they face. Clinicians are encouraged to start with a harm reduction strategy, which includes lower doses and a thorough evaluation of the patient’s overall health status. Additionally, having detailed discussions around medication agreements and expected outcomes can help set appropriate boundaries. Taking into account the history of substance use, providers should be prepared for potential non-adherence and have alternative care plans in place to ensure continued support for these patients.
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!
