(68) Change the Conversation: Addiction Mentoring is Key in Palliative Care Training

Introduction/

Background:
Hospice and palliative care (HPC) clinicians lack strategies, confidence, and mentorship in caring for patients with substance use disorders (SUD). HPC training focuses on pain and symptoms of serious illness, as well as on communication with patients and family. Insufficient time is spent on managing concurrent substance use or SUD. Expert recommendations are emerging on the management of cancer pain with substance use. Most recommendations refer to risk mitigation, prescription monitoring, and pharmacology, with generalized attention to communication and harm reduction principles. Recommendations still include referral to addiction specialists in very high risk patients. However, care collaboration amongst pain, addiction, and HPC providers is challenging due to patient barriers (symptom burden, functional status, caregiver strain), system barriers (insurance), and provider barriers (appointment burden, staff and time constraints). Additionally, lack of specialty access in resource limited areas compounds healthcare disparity. Extension for Community Healthcare Outcomes (ECHO) informal meetings may be a place for specialist practice change.

Methods:
Routine meetings of addiction and HPC clinicians occurred 2018-2021 with regional service updates, journal article review, and case discussions. 77 individual participants were identified from both in person and online meetings over the 3 years, including multiple disciplines, specialties, and healthcare organizations, mainly based in Appalachian states (KY, OH, WV, and SC). Online REDCap survey was emailed to 100 people on the meeting distribution list. The survey questionnaire consisted of Likert scales, multiple choice, and open comment answers regarding perception of knowledge, confidence, and practice changes in treating patients with concurrent pain, SUD, and serious illness. Demographic characteristics included: training background, specialties/ subspecialties, disciplines, and years in practice.

Results:
17 total respondents (17% of 100 invited participants) included 12 physicians (7 HPC, 1 HPC/addiction, 1 psychiatrist, 1 PM&R, 1 neurosurgery, 1 oncology), 1 HPC APP, 1 Psychologist, 2 HPC nurses and 1 SW. 1 palliative respondent did not identify their discipline. Most participants attended 1-5 sessions (76%, n=13), 18% (n=3) attended >5 sessions, and 6% (n=1) never attended a session. Of those clinicians that ever attended a session (n=16), they felt the following impact: 100% (n=16) learned something new, 94% (n=15) felt more comfortable talking to their patients about substance use, 88% (n=14) felt more supported managing patients with serious illness and substance use or diversion, 75% (n=12) felt more comfortable managing substance use in their patients. Importantly for past session attendees, most 88% (n=14) made a practice change; 94% (n=15) were less likely to discharge patients for substance use, 81% (n=13) consider buprenorphine more often for their patients, 69%(n=11) refer more patients to non-pharmacologic therapies. The one respondent, an oncologist with 30 years in practice, never attended a live session, and would have only received journal articles. This respondent felt they had no change in knowledge, confidence, nor practice. They did not prescribe buprenorphine to their patients.

Conclusions:
This addiction and palliative collaborative network increased HPC comfort in managing their patients with substance use. Practice change required not only dissemination of knowledge, but also peer led coaching and opportunities for in depth conversation with all interdisciplinary team members.

References: Morrison, Laura J., et al. "Launching the Next Steps to Improve Hospice and Palliative Medicine Fellow Performance

Assessment: A Look Back to the Initial Toolkit of Assessment Methods." Journal of pain and symptom management 61.3 (2021): 613-627.

Childers, Julie W., and Robert M. Arnold. "“I feel uncomfortable ‘calling a patient out’”: educational needs of palliative medicine fellows in managing opioid misuse." Journal of pain and symptom management 43.2 (2012): 253-260.

Merlin, Jessica S., et al. "Managing opioids, including misuse and addiction, in patients with serious illness in ambulatory palliative care: a qualitative study." American Journal of Hospice and Palliative Medicine® 37.7 (2020): 507-513.

Zhou, Carrol, et al. "The impact of project ECHO on participant and patient outcomes: a systematic review." Academic Medicine 91.10 (2016): 1439-1461.