Caring Through Complexity: Developing a Palliative Care Opioid and Stimulant Use Disorder Workflow.

Abstract

Caring for individuals with serious illness and opioid or stimulant use disorder (OUD/STuD) is complex. Palliative care (PC) providers often lack addiction medicine training and report discomfort managing this population. This quality improvement project aimed to assess PC team comfort, provide targeted education, and create an institutional PC workflow around caring for individuals with OUD/STuD. This project was conducted within an academic health system's PC program. A preintervention survey assessed baseline comfort caring for individuals with OUD/StUD. The intervention included the development and dissemination of 1) an evidence-based, locally adapted workflow guiding opioid prescribing and clinic management protocols stratified by substance use risk and 2) educational sessions on buprenorphine for pain, substance use risk assessment, and safe opioid management. During implementation, the workflow was iteratively updated based on challenges identified in patient cases (i.e., diagnostic uncertainty, unexpected urine toxicology screens). A postintervention survey assessed changes in provider comfort after implementation. Of the 27 individuals who completed the presurvey (response rate 73%), 66% felt uncomfortable overall caring for individuals with OUD/StUD; among prescribers, only 19% felt comfortable managing opioids for this population. The workflow was applied to ten patients (ages 38-76; all with cancer). In the post survey (n = 23, response rate 62%), fewer respondents (35%) felt uncomfortable overall caring for individuals with OUD/StUD and a majority of prescribers (52%) felt comfortable managing opioids for this population. Developing evidence-based, locally adapted workflows and educational sessions can improve PC provider comfort around caring for patients with OUD/StUD.