Julie W. Childers

Chronic Pain and Risk Factors for Opioid Misuse in a Palliative Care Clinic

Objectives: To describe the prevalence of chronic pain and the risk of opioid misuse in a palliative care clinic. Methods: We reviewed patient records for 6 months for source of pain, treatment status, opioid misuse risk (Cut down, Annoyed, Guilty, and Eye-opener [CAGE] and Screener and Opioid Assessment for Patients with Pain version 1.0—Short Form [SOAPP-SF] scores), and urine drug screens. Results: Of 323 patients, 91% had cancer, 56% undergoing cancer treatment, while 28% had no evidence of disease. Eighty-six (27%) patients had noncancer pain. In all, 46% of new patients had positive scores on the SOAPP-SF and 15% had a positive CAGE. Of the less than 5% of visits that included a urine drug screen, 56% had aberrant results. Conclusion: Chronic pain and indicators of opioid misuse risk were prevalent. Outpatient palliative care practices should develop policies to address these issues.

Applying motivational interviewing techniques to palliative care communication.

Palliative care relies heavily on communication. Although some guidelines do address difficult communication, less is known about how to handle conversations with patients who express ambivalence or resistance to such care. Clinicians also struggle with how to support patient autonomy when they disagree with patient choices. Motivational Interviewing (MI) techniques may help address these responses. Specifically, MI techniques such as reflective statements and summarizing can help reduce a patients resistance, resolve patient ambivalence, and support patient autonomy. Not all the MI techniques are applicable, however, in part because palliative care clinicians do not guide patients to make particular choices but, instead, help patients make choices that are consistent with patient values. Some elements from MI can be used to improve the quality and efficacy of palliative care conversations.

Chronic Pain in the Outpatient Palliative Care Clinic

Chronic pain is common. Many patients with cancer and other life-limiting illnesses have chronic pain that is related to their disease, and some have comorbid chronic nonmalignant chronic pain. As palliative care continues to move upstream and outpatient palliative care programs develop, palliative care clinicians will be called upon to treat chronic pain. Chronic pain differs from acute pain in the setting of advanced disease and a short prognosis in terms of its etiology, comorbidities—especially psychiatric illness and substance abuse—and management. To successfully care for these patients, palliative care providers will need to learn new clinical competencies. This article will review chronic pain management core competencies for palliative care providers.

Teaching the Teachers: Faculty Preparedness and Evaluation of a Retreat in Screening, Brief Intervention, and Referral to Treatment

ABSTRACT Effective clinical faculty are essential for disseminating substance abuse screening, brief intervention, and referral to treatment (SBIRT). The authors developed an 8-hour SBIRT training for internal medicine faculty preceptors. Trainers conducted SBIRT lectures and small-group communication practice sessions. The authors assessed participants’ (n = 27) knowledge, skills, and attitudes using an enhanced Alcohol and Alcohol Problems Perceptions Questionnaire (AAPPQ). Participants self-assessed their changes in SBIRT competence and comfort. Faculty trainees did not feel competent in SBIRT, particularly in intervention and referral to treatment. AAPPQ subscale scores were highest in Role Legitimacy and Motivation and lowest in Role Adequacy and Satisfaction. After training, faculty members reported greater likelihood of performing and teaching SBIRT. In some topic areas, faculty attending an SBIRT training reported limited knowledge and competence for treating drinkers; however, their interest and motivation for doing so was high. Ongoing faculty and organizational development efforts may help close these gaps.

Treatment of Pain in Patients Taking Buprenorphine for Opioid Addiction #221

1. Micromedex Healthcare Series [Internet database]. Greenwood Village, CO: Thomson Reuters (Healthcare) Inc. Updated periodically. 2. Chou R, Qaseem A, Snow V, Casey D, Cross JT Jr, Shekelle P, Owens DK; Clinical Efficacy Assessment Subcommittee of the American College of Physicians; American College of Physicians; American Pain Society Low Back Pain Guidelines Panel: Diagnosis and treatment of low back pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society. Ann Intern Med 2007;7:478–491. 3. Massey T, Derry S, Moore RA, McQuay HJ: Topical NSAIDs for acute pain in adults. Cochrane Database Syst Rev 2010; 6:CD007402. 4. Roelofs PD, Deyo RA, Koes BW, Scholten RJ, van Tulder MW: Nonsteroidal anti-inflammatory drugs for low back pain: An updated Cochrane review. Spine 2008;33:1766–1774. 5. Gotzsche P: NSAIDs. Clinical Evidence 2009;6(1108). 6. Prentice WM, Roth LJ, Kelly P: Topical benzydamine cream and the relief of pressure pain. Palliat Med 2004;18: 520–524. 7. Singh G, Triadafilopoulus G: Epidemiology of NSAIDinduced GI complications. J Rheumatol 1999;26:18–24.

Hepatic Encephalopathy in End-Stage Liver Disease #188

1. Gilbar PJ, Ridge AM: Inappropriate labelling of patients as opioid allergic. J Oncol Pharm Pract 2004;10:177–182. 2. Fisher MM. Harle DG. Baldo BA: Anaphylactoid reactions to narcotic analgesics. Clin Rev Allergy 1991;9:309–318. 3. Hermens JM: Comparison of histamine release in human skin mast cells induced by morphine, fentanyl, and oxymorphone. Anesthesiology 1985;62:124–129. 4. Kroigaard M, Garvey LH, Menne T, Husum B: Allergic reactions in anaesthesia: Are suspected causes confirmed on subsequent testing? Br J Anaesth 2005;95:468–41. 5. Tcheurekdjian H, Gundling K: Continuous hydromrphone infusion for opioid intolerance J Allergy Clin Immunol 2006;118:282–284. 6. Joint Council of Allergy Asthma and Immunology: Practice parameters for drug hypersensitivity. Ann Allergy Asthma Immunol 1999;83:S665–700.

Dying on Hospice in the Midst of an Opioid Crisis: What Should We Do Now?

The current opioid crisis in the United States is a major problem facing health-care providers, even at the end of life. Opioids continue to be the mainstay treatment for pain at the end of life, with the prevalence of pain reported in up to 80% of patients and tends to increase as one gets closer toward the end of life. In the past year, 20.2 million Americans had a substance use disorder (SUD) and SUDs are disabling disorders that largely go untreated. In addition, the coexistence of both a mental health and SUD is very common with the use of opioids often as a means of chemical coping. Most hospice programs do not have standardized SUD policies/guidelines in place despite the increasing concerns about substance abuse within the United States. The goal of this article is to review the literature on this topic and offer strategies on how to manage pain in patients who have active SUD or who are at risk for developing SUD in those dying on hospice.

“I Know I'm Going to Beat This”: When Patients and Doctors Disagree About Prognosis

As palliative care physicians who frequently discuss goals of care with seriously ill patients and their families, we often get called because the patient/family is in “denial.” In a common scenario, we are consulted by a medical team where team members want us to make sure the family “gets it” and then makes the “appropriate” decision for a do not resuscitate (DNR) order or for hospice care. Too often, from the consulting service perspective, the term “denial” is a substitute for “the patient won’t do what we think they should be doing.” In these cases, our first challenge as clinicians is to understand the patient beliefs that underlie the disagreement, including how the patient obtained them, how those beliefs function in their life and family, and their malleability. In their article, Blumenthal-Barby and Ubel (2018) delineate several reasons that patients and families may express disagreement with our predictions, which often involve an interplay between emotional and social factors. We agree that it is difficult it is to distinguish between denial, self-deception, and unrealistic optimism. In addition, we caution clinicians against seeing any of these states as static. Often, not “getting it” is a stage that patients go through as they adjust to their illness. For example, imagine a surgeon telling a young patient that he needs an above-the-knee amputation to save his life; the patient disbelieves the estimates, saying that he can heal better than the doctors think. It takes a few days for his view of himself to adjust to the sick role and accept the amputation. This is particularly common if the patient’s physical state does not appear to match the clinicians’ prognosis. Families may have trouble accepting a terminal prognosis if the patient is awake and interacting. Clinicians also should not be too quick to assume that what they call “denial” is irrational. Too often, we assume that our beliefs are the truth, while for patients, our information is one piece of data in larger picture. Patients talk to other people than doctors, and we should not assume that our information is the most accurate or trustworthy in their eyes. If my family member (who is a health care provider) tells me not to worry because she thinks I will get better, am I in denial or listening to a person I trust more than you? Anecdotal experience of a friend or family member who survived a similar illness provides more powerful data for many individuals than randomized controlled trials. The Internet is another way lay people gather and evaluate information, and patients may find doctors deficient if they have not heard about a treatment that came up when patients googled their disease. Finally, when predictions conflict with their experience, individuals typical believe their experience. We encounter this often in cases where a patient has come through a succession of critical illnesses and previous medical predictions of impending death have proven incorrect. In other cases, as Blumenthal-Barby and Ubel point out, “denial” may be part of a patient’s coping style; in these cases, rather than being a negative, it is something that helps the patient cope with a scary future. As with Blumenthal-Barby and Ubel’s example of Rodrigo, who has a 5% chance of surviving cancer but takes actions indicating expectation of a longer prognosis, many patients hold two perspectives of their prognosis simultaneously. Jacobsen and colleagues (2018) have described this as a “dual framework” in which the patient swings between expressions of optimism and realism, with the optimism allowing the patient to take a break from difficult realities when needed. Not wanting to “admit” one’s illness also may be the way the family unit copes with illness. This may be part of the culture (“In our family,

Opioids for Chronic Pain in Patients with History of Substance Use Disorders, Part 2: Management and Monitoring #312

Adherence checklists and individual/group counseling can reduce opioid abuse in high-risk patients. Only one clinician and pharmacy should be used in providing opioids. Regular follow-up visits should be scheduled to assess the ‘‘Four A’s of Pain’’ before and after every intervention: analgesia (pain relief), activities of daily living (functional status), adverse effects, and aberrant drug-taking behaviors. Aberrant Drug Behaviors are not all the same, each behavior should be evaluated based on the specific patient and situation. Clinicians should assess the degree of risk involved with the aberrant drug behavior. Considerations include the extent of the aberrant behavior, including whether it has persisted despite attempts to correct it, whether the patient is actively using, the type of substance (opioids, alcohol, methamphetamine, cocaine, and cannabis), and level of abuse (daily intoxication and binge use).

A pilot trial of early specialty palliative care for patients with advanced pancreatic cancer: Challenges encountered and lessons learned.

110 Background: Palliative care trials face implementation barriers. We describe challenges encountered in a pilot trial of early specialty palliative care for patients with pancreatic cancer. METHODS We conducted a mixed-methods pilot randomized controlled trial of early specialty physician-led palliative care in advanced pancreatic cancer. Recently diagnosed patients with borderline, locally-advanced, or metastatic pancreatic cancer and their caregivers (total N=60) were recruited from clinic at a comprehensive cancer center and randomized (2:1) to receive monthly specialty palliative care visits for 3 months in addition to standard oncology care vs. standard oncology care alone. Feasibility assessments included enrollment and intervention completion rates. Acceptability and perceived effectiveness were assessed via drop-out rates and semi-structured participant interviews. RESULTS The enrollment target was reached after 50 weeks, with a randomized: approached rate of 27%. Mean patient age was 63 (SD 11) and 50% were male. Mean caregiver age was 62 (SD 12), 47% were male, and 80% were the spouse or partner of a patient. 70% of participants in the intervention group completed at least one specialty palliative care visit and 15% completed 3 palliative care visits within the 3-month time period. Two patients and 3 caregivers withdrew, and 4 patients died prior to 3 months. Enrollment barriers included patients not planning to continue receiving care from a participating oncologist and feeling too overwhelmed at the time of diagnosis to consider research participation. In semi-structured interviews, patients and caregivers noted that long travel times to the cancer center, difficulty scheduling palliative care visits at a convenient time, and lengthy study assessments posed burdens. Oncologists and palliative care physicians recommended more in-person communication between clinicians and tailoring palliative care visit content and schedules to match patient needs. CONCLUSIONS Future palliative care intervention trials must consider implementation challenges related to recruitment, retention, intervention fidelity, and participant burden. CLINICAL TRIAL INFORMATION NCT01885884.