An Organizational Framework for Approaching Patients with OUD and Painful Serious Illness

Safely navigating the management of pain for patients with opioid use disorder (OUD) and serious illness is complex. Balancing the risks and harms of opioid treatment for pain are even more complex in the context of the ongoing drug overdose epidemic and persistent gaps in access to medications for OUD treatment (MOUD). These challenges are only expected to grow as patients survive longer with chronic life-limiting disease due to advancements in disease-directed treatment therapies, like novel immunotherapies for cancer. 80% of patients with cancer are exposed to opioids during their course of treatment, and 40% of survivors continue to live with chronic pain related to cancer or its treatments. As a result, the long-term exposure to opioids further heightens the risks for developing unhealthy opioid use or OUD among patients with serious illness. Despite this, there is limited guidance in the literature on treating pain with opioids in these situations, as most studies exclude patients with cancer and patients with OUD. This, combined with a lack of primary addiction skills training for most palliative care clinicians contributes to one survey finding that the majority of palliative care clinicians report a lack of confidence in managing patients with OUD, despite spending over 30 minutes daily doing so. Therefore, while addiction specialists are not expressly trained to treat pain, they increasingly face the likelihood of being asked to consult on cases of complex opioid management for patients with concurrent pain, serious illness, and OUD. What factors should addiction specialists consider when consulted for the management of pain in a patient with OUD and serious illness? How do we put together the risks and benefits of full-agonist opioid treatments versus opioid agonist treatment in cases of painful serious illness? This session will present a 7P organizational framework with which to guide medical decision making in these situations by consolidating the risks and benefits of various treatment options. The considerations include: pain characteristics, prognosis, physical function/ performance status, patterns of substance use (e.g., substance use history), psychosocial factors, partnerships with other providers, and parity in care (would different treatment options be offered if the patient did not have OUD). Taught by physicians who are board certified in both palliative medicine and addiction medicine, this interactive, case-based session will identify considerations at the intersection of both to care for individuals with painful serious illness and OUD or risky opioid use. We will describe the model, summarize available evidence behind recommended considerations, and practice its application in various case scenarios. By having tools to help organize the total risks and benefits of opioids as analgesia and/ or MOUD, addiction clinicians will be better prepared to provide peer training in primary addiction medicine skills and advise colleagues on comprehensive approaches to these challenging cases.