The majority of Palliative Care (PC) clinicians report recently caring for a person with a Substance Use Disorder (SUD). The impact of an untreated SUD is associated with significant suffering but many PC clinicians report a lack of confidence in managing this population.
Objective:
This paper aims to demonstrate existing PC skills that can be adapted to provide primary SUD treatment.
Methods:
A comprehensive literature review was conducted on quality PC domains and core SUD treatment principles. To demonstrate the shared philosophy and skills of PC clinicians and SUD treatment, the National Consensus Project Clinical Practice Guidelines for Quality Palliative Care and resources outlining core Addiction Medicine and Nursing Competencies were used.
Results:
There is an abundance of overlapping domains in PC and SUD treatment. This paper focuses on the domains of communication, team-based care, quality of life considerations, addressing social determinants of health, and adherence to ethical principles. In each section, the shared domain in PC and SUD treatment is discussed and steps to expand PC clinician's skills are provided.
Conclusion:
PC clinicians may be among the last healthcare touchpoint for persons with SUD, by naming the shared skills required in PC and evidenced-based SUD treatment, we challenge the field to undertake primary SUD treatment as part of its constant pursuit to better serve people living with serious illness.
ChildersJWArnoldRM. “I Feel Uncomfortable ‘Calling a Patient Out’”: educational needs of palliative medicine fellows in managing opioid misuse. J Pain Symptom Manage. 2012;43(2):253–260.
2.
MerlinJSPatelKThompsonN, et al.Managing chronic pain in cancer survivors prescribed long-term opioid therapy: a national survey of ambulatory palliative care providers. J Pain Symptom Manage. 2019;57(1):20–27.
3.
MerlinJSYoungSRArnoldR, et al.Managing opioids, including misuse and addiction, in patients with serious illness in ambulatory palliative care: a qualitative study. Am J Hosp Palliat Care. 2019:1049909119890556.
4.
PassikSDTheobaldDE. Managing addiction in advanced cancer patients: why bother?J Pain Symptom Manage. 2000;19(3):229–234.
5.
LarochelleMRBernsteinRBernsonD, et al.Touchpoints—opportunities to predict and prevent opioid overdose: a cohort study. Drug Alcohol Depend. 2019;204:107537.
6.
ParsonsHADelgado-GuayMOEl OstaB, et al.Alcoholism screening in patients with advanced cancer: impact on symptom burden and opioid use. J Palliat Med. 2008;11(7):964–968.
7.
GabbardJJordanAMitchellJCorbettMWhitePChildersJ.Dying on hospice in the midst of an opioid crisis: what should we do now?Am J Hosp Palliat Med®. 2018;36(4):273–281.
8.
EbenauADijkstraBter HuurneCHasselaarJVissersKGrootM. Palliative care for people with substance use disorder and multiple problems: a qualitative study on experiences of patients and proxies. BMC Palliat Care. 2019;18(1):56.
9.
MerlinJSYoungSRStarrelsJL, et al.Managing concerning behaviors in patients prescribed opioids for chronic pain: a Delphi study. J Gen Intern Med. 2018;33(2):166–176.
10.
CagleJGMcPhersonMLFreyJJ, et al.Estimates of medication diversion in hospice. JAMA. 2020;323(6):566–568.
11.
TemelJSGreerJAMuzikanskyA, et al.Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010;363(8):733–742.
12.
SchenkerYMerlinJSQuillTE. Use of palliative care earlier in the disease course in the context of the opioid epidemic: educational, research, and policy issues. Jama. 2018;320(9):871–872.
13.
FiscellaKWakemanSEBeletskyL.Buprenorphine deregulation and mainstreaming treatment for opioid use disorder: X the X Waiver. JAMA Psychiatry. 2019;76(3):229–230.
14.
D’OnofrioGO’ConnorPGPantalonMV, et al.Emergency department–initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial. JAMA. 2015;313(16):1636–1644.
15.
EbenauADijkstraBter HuurneCHasselaarJVissersKGrootM. Palliative care for patients with substance use disorder and multiple problems: a qualitative study on experiences of healthcare professionals, volunteers and experts-by-experience. BMC Palliat Care. 2020;19(1):8.
16.
WakemanSE. Medications for addiction treatment: changing language to improve care. J Addict Med. 2017;11(1):1–2.
17.
EmmaE.McGintyEMSKennedy-HendricksABachhuberMABarryCL. Medication for opioid use disorder: a national survey of primary care physicians. Ann Intern Med. 2020;173(2):160–162.
18.
LagisettyPARossRBohnertAClayMMaustDT. Buprenorphine treatment divide by race/ethnicity and payment. JAMA Psychiatry. 2019;76(9):979–981.
19.
GeeGCFordCL. Structural racism and health inequities: old issues, new directions. Du Bois Rev. 2011;8(1):115–132.
20.
WakemanSELarochelleMRAmeliO, et al.Comparative effectiveness of different treatment pathways for opioid use disorder. JAMA Netw Open. 2020;3(2):e1920622–e1920622.
21.
MartinSAChiodoLMBosseJDWilsonA. The next stage of buprenorphine care for opioid use disorder. Ann Intern Med. 2018;169(9):628–635.
2018 National Consensus Project for Quality Palliative Care (NCP). National Coalition for Hospice and Palliative Care. Accessed December 1, 2020. nationalcoalitionhpc.org on
24.
WakemanSEMetlayJPChangYHermanGERigottiNA. Inpatient addiction consultation for hospitalized patients increases post-discharge abstinence and reduces addiction severity. J Gen Intern Med. 2017;32(8):909–916.
25.
AhluwaliaSCChenCRaaenL, et al.A systematic review in support of the national consensus project clinical practice guidelines for quality palliative care, Fourth edition. J Pain Symptom Manage. 2018;56(6):831–870.
26.
FinnellDSTierneyMMitchellAM. Nursing: addressing substance use in the 21st century. Subst Abus. 2019;40(4):412–420.
27.
FerrellBRTwaddleMLMelnickAMeierDE. National consensus project clinical practice guidelines for quality palliative care guidelines, 4th edition. J Palliat Med. 2018;21(12):1684–1689.
28.
AyuAPEl-GuebalyNSchellekensA, et al.Core addiction medicine competencies for doctors: an international consultation on training. Subst Abus. 2017;38(4):483–487.
29.
PastranaTWenkRDe LimaL.Consensus-based palliative care competencies for undergraduate nurses and physicians: a demonstrative process with Colombian universities. J Palliat Med. 2016;19(1):76–82.
30.
GamondiCLarkinPPayneS.Core competencies in palliative care: an EAPC white paper on palliative care education—Part 1. Eur J Palliat Care. 2013;20(2):86–89.
31.
TemmeLJKopakAM. Maximizing recovery through the promotion of mindfulness and spirituality. J Rel Spiritual Soc Work: Soc Thought. 2016;35(1-2):41–56.
32.
ArnoldRMBackALBaileWFEdwardsKATulskyJA. The oncotalk/vitaltalk model. Oxford Textbook of Communication in Oncology and Palliative Care. 2017:363.
33.
BotticelliMPKohHK. Changing the language of addiction. JAMA. 2016;316(13):1361–1362.
34.
BroylesLMBinswangerIAJenkinsJA, et al.Confronting inadvertent stigma and pejorative language in addiction scholarship: a recognition and response. Subst Abus. 2014;35(3):217–221.
35.
RosenbaumMLobasJFergusK. Using reflection activities to enhance teaching about end-of-life care. J Palliat Med. 2005;8(6):1186–1195.
36.
FrankLENagelSK. Addiction and moralization: the role of the underlying model of addiction. Neuroethics. 2017;10(1):129–139.
37.
PollakKIJonesJLumHD, et al.Patient and caregiver opinions of motivational interviewing techniques in role-played palliative care conversations: a pilot study. J Pain Symptom Manage. 2015;50(1):91–98.
38.
ChildersJArnoldRPollakK. Communication as a dance: what palliative care providers can learn from motivational interviewing (426). J Pain Symptom Manag. 2012;43(2):395–396.
39.
PollakKChildersJArnoldR. Applying motivational interviewing techniques to palliative care communication. J Palliat Med. 2011;14(5):587–592.
40.
MartinoSZimbreanPForrayA, et al.Implementing motivational interviewing for substance misuse on medical inpatient units: a randomized controlled trial. J Gen Intern Med. 2019;34(11):2520–2529.
WeimerMBTetraultJMFiellinDA. Patients with opioid use disorder deserve trained providers. Ann Intern Med. 2019;171(12):931–932.
44.
PasareanuAROpsalAVederhusJKKristensenØClausenT. Quality of life improved following in-patient substance use disorder treatment. Health Qual Life Outcomes. 2015;13(1):35.
45.
ManningVGarfieldJBBLamT, et al.Improved quality of life following addiction treatment is associated with reductions in substance use. J Clin Med. 2019;8(9):1407.
46.
SpinolaSParkAMaistoSAChungT. Motivation precedes goal setting in prediction of cannabis treatment outcomes in adolescents. J Child Adolesc Subst Abuse. 2017;26(2):132–140.
47.
LallyKTuya FultonADucharmeCScottR. Using nurse care managers trained in the serious illness conversation guide to increase goals-of-care conversations in an accountable care organization. J Palliat Med. 2020;23(1):112–115.
48.
SnowRLSimonREJackHEOllerDKehoeLWakemanSE. Patient experiences with a transitional, low-threshold clinic for the treatment of substance use disorder: a qualitative study of a bridge clinic. J Subst Abuse Treat. 2019;107:1–7.
HenryBDosaniNHuynhLAmiraultN. Palliative care as a public health issue: understanding disparities in access to palliative care for the homeless population living in Toronto, based on a policy analysis. Curr Oncol. 2017;24(3):187–191.
51.
Smith-HowellERHickmanSEMeghaniSHPerkinsSMRawlSM. End-of-life decision making and communication of bereaved family members of African Americans with serious illness. J Palliat Med. 2016;19(2):174–182.
52.
StarrLTUlrichCMAppelSMJunkerPO’ConnorNRMeghaniSH. Goals-of-care consultations are associated with lower costs and less acute care use among propensity-matched cohorts of African Americans and whites with serious illness. J Palliat Med. 2020;23(9):1204–1213.
53.
ReeseRLClementSASyedaS, et al.Coordinated-transitional care for veterans with heart failure and chronic lung disease. J Am Geriatr Soc. 2019;67(7):1502–1507.
54.
BakitasMLyonsKDHegelMT, et al.Effects of a palliative care intervention on clinical outcomes in patients with advanced cancer: the Project ENABLE II randomized controlled trial. JAMA. 2009;302(7):741–749.
55.
ChildersJWBackALTulskyJAArnoldRM. Remap: a framework for goals of care conversations. J Oncol Pract. 2017;13(10):e844–e850.
JoostenEde WeertGSenskyTvan der StaakCde JongC. Effect of shared decision-making on therapeutic alliance in addiction health care. Patient Prefer Adherence. 2008;2:277–285.
58.
HuangHLTsaiJSYaoCAChengSYHuWYChiuTY. Shared decision making with oncologists and palliative care specialists effectively increases the documentation of the preferences for do not resuscitate and artificial nutrition and hydration in patients with advanced cancer: a model testing study. BMC Palliat Care. 2020;19(1):17–17.
59.
LewisM. Brain change in addiction as learning, not disease. N Engl J Med. 2018;379(16):1551–1560.
60.
FriedrichsASpiesMHärterMBuchholzA.Patient preferences and shared decision making in the treatment of substance use disorders: a systematic review of the literature. PLoS One. 2016;11(1):e0145817.
ChoiNGDiNittoDMMartiCN. Treatment use, perceived need, and barriers to seeking treatment for substance abuse and mental health problems among older adults compared to younger adults. Drug Alcohol Depend. 2014;145:113–120.
63.
Caruso BrownAE. Treating addiction as a terminal disease. N Engl J Med. 2020;382(3):207–209.
64.
LorenAW. Harder to treat than leukemia-opioid use disorder in survivors of cancer. N Eng J Med. 2018;379(26):2485–2486.
65.
SagerZBBussMKHillKPDriverJASkarfLM. Managing opioid use disorder in the setting of a terminal disease: opportunities and challenges. J Palliati Med. 2020;23(2):296–299.
66.
The 2019 and 2021 Annual assembly of hospice and palliative care. Published February 1, 2021. Accessed February 26, 2021. aahpm.org/meetings/assembly
MahmoudKFFinnellDSavageCLPuskarKRMitchellAM. A concept analysis of substance misuse to inform contemporary terminology. Arch Psychiatr Nurs. 2017;31(6):532–540.
