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Erin Bagwell, MSW, LCSW Palliative Care Social Worker Rush University Medical Center

“We’re Not Trained for This” The Role of Social Workers in Enhancing Palliative Care Practices for Patients with Substance Use Disorders. Erin Bagwell, MSW, LCSW Palliative Care Social Worker Rush University Medical Center Chicago, Illinois. Objectives.

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Erin Bagwell, MSW, LCSW Palliative Care Social Worker Rush University Medical Center

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  1. “We’re Not Trained for This”The Role of Social Workers in Enhancing Palliative Care Practices for Patients with Substance Use Disorders Erin Bagwell, MSW, LCSW Palliative Care Social Worker Rush University Medical Center Chicago, Illinois

  2. Objectives • Review the foundations of social work training that provide our discipline with the tools to navigate complex dynamics that exist in managing substance use disorders within a palliative care setting. • Propose a framework for utilizing our therapeutic skill set and for training other clinicians on the management of substance use disorders. • Apply tangible methods to assess for and navigate through substance use issues in the palliative care population, contrasting the variability in processes between malignant disease and cancer survivorship.

  3. Disclosure I have no conflicting interests to disclose.

  4. Why do we talk about this? • Broad spectrum- prior or concurrent addiction, active opioid addiction, substance misuse, and pseudoaddiction • Limitations of mental health/substance use training on palliative teams • 83% of new MD fellows with training compared to 47% of existing staff • Average of 0.4 SW staffing per palliative teams in Chicago as of 2014 • Reality: substance misuse is not likely why we got into palliative care 1 2 1. Tan, PD, Barclay, JS, Blackhall, LJ. Do Palliative Care Clinics Screen for Substance Abuse and Diversion? Journal of Palliative Medicine. June 2015. 2 . O’Mahony, Sean, MBBCh, BAO, MS. Palliative Workforce Development and a Regional Training Program. Journal of Hospice and Palliative Medicine. Vol. 35(1) 138-143. 2016.

  5. Scope of the problem City of Chicago: • “High Intensity Drug Trafficking Area” • Heroin tied with alcohol for substance-related ED visits • Heroin is the most common reason people seek inpatient treatment • Lack of treatment availability • Introduction of Fentanyl-laced heroin • Overdose deaths involving opioids in Chicago rose from 426 deaths in 2015 to 741 deaths in 2016 Data Source: Illinois Department of Public Health, Cook County Medical Examiner’s Office, US Census Bureau

  6. Lake Michigan Reese, C., Pederson, T., Avila, S., Joseph, K., Nagy, K., Dennis, A., et al. (2012). Screening for traumatic stress among survivors of urban trauma. The Journal of Trauma and Acute Care Surgery, 73(2), 462–7– discussion 467–8. City of Chicago Department of Public Health, Chicago-Cook Task Force on Heroin. (2016) Chicago-Cook Task Force on Heroin Final Report. https://www.cityofchicago.org/content/dam/city/depts/cdph/tobacco_alchohol_abuse/HeroinTaskForceReport_Final_10.6.16.pdf

  7. Lake Michigan City of Chicago Department of Public Health, Chicago-Cook Task Force on Heroin. (2016) Chicago-Cook Task Force on Heroin Final Report. https://www.cityofchicago.org/content/dam/city/depts/cdph/tobacco_alchohol_abuse/HeroinTaskForceReport_Final_10.6.16.pdf

  8. Scope of the problem 1 • Palliative Care Study (2017): • 28% of palliative care inpatients experiencing some form of alcohol misuse • Validated assessment (CAGE, AUDIT) • Review of palliative program screening policies (2015) • 38 programs surveyed • 40.5% have policy to screen patients for substance misuse • 16.2% have a policy to screen families • 27% have a policy to address diversion • 32% use a validated screening tool 2 • MacCormac, Aisling, MBChB. Alcohol Dependence in Palliative Care: A Review of the Current Literature. Journal of Palliative Care. October 2017. • Tan, PD, Barclay, JS, Blackhall, LJ. Do Palliative Care Clinics Screen for Substance Abuse and Diversion? Journal of Palliative Medicine. June 2015.

  9. Impact on care • Effects opioid prescribing habits • Impacts insurance coverage • More work for providers • Increases tension in a group practice setting • Creates challenge for independent providers • “Am I doing the right thing?” • Rush palliative clinic: • 61% of patients at outpatient meeting discussion with moderate to high risk ORT scores*

  10. Social work skills • Strength based assessment • Non-judgmental presence • Resource navigation • Care plan development • Liaisons between community providers • Education on inaccurate or potentially disparaging chart documentation • “Drug-seeking behavior” • “Opioid use disorder” without DSM criteria • “Addiction” vs “misuse”

  11. Social Work Skills • Knowledge of harm reduction strategies • Elucidating patient and family goals • Ability to provide perspective • How is the patient receiving information provided? • Identification of countertransference • Education on “helping” versus “enabling” • Protocol and/or policy development

  12. Harm Reduction 1 • Harm reduction approaches- improve utilization of palliative care (Canada study) • Examples: • Needle exchange programs • Methadone & buprenorphine clinics • Naloxone prescribing • Safe opioid injection sites (Canada, Philadelphia) • Opioid prescribing to reduce street drug use • Long acting = often less street value • Use of medical cannabis • Law in 29 states, as well as D.C., Guam and Puerto Rico  2 McNeil, Ryan, et all. Harm reduction services as a point-of-entry to and source of end-of-life care and support for homeless and marginally housed persons who use alcohol and/or illicit drugs: a qualitative analysis. BMC Public Health. May 2012. National Conference of State Legislatures. http://www.ncsl.org/research/health/state-medical-marijuana-laws.aspx

  13. Case study #1 • 48 y/o man with stage IV lung cancer with brain metastases • Married, 6 y/o son • 20-year history of heroin and cocaine abuse • Uses $60 per day’s worth of heroin • 6 palliative medicine clinic visits, 5 physicians • Extent of use not discovered until 4 months into pt’s care • Urine drug screen • + opiates + cocaine • - benzodiazepines (prescribed lorazepam)

  14. Social work interventions • Assessed patient and family’s perspective • Completed opioid treatment agreement* • Recommended resources to wife (Nar-Anon) • Connected son to child life services • Educated providers on qualifications for Methadone clinics • Joint visits with MD to help mitigate distress • Coordinated referral to hospice care

  15. Case study # 2 • 49 y/o woman with HIV and rectal cancer • 20+ year history of cocaine use • Cancer treatable with surgery but surgeons refusing until HIV & cocaine use better controlled • Limited health literacy • Poor social support • 6 children, mother is POA, but always presents to visits alone • Lives with two aunts and an uncle, all whom per patient misuse various substances

  16. Case study # 2 • Frequent no shows with our clinic • Screaming in pain upon arrival • Frequent hospital admissions • Limited follow up with HIV doctor • No consistent follow up with PCP • No mental health care despite Bipolar Disorder diagnosis in her record • UDS consistently positive for cocaine • Verbalizes desire to quit • Relapses due to social stressors, desire for pain control

  17. Social Work Interventions • Joint visits with provider for rapport building, continuity, and distraction • Taught simple breathing techniques • Identified housing resources and coordinated with CM during hospital stays • Explored readiness for sobriety • Educated providers on barriers to sobriety • Willing to go to NA but did not have transportation • Disease prevented her from being able to sit on the bus • No consistent phone or Internet access

  18. Social Work Interventions • Assessed overall literacy • Coordinated appointments with HIV physician • Set up psychiatry appointment • Rush dual diagnosis clinic • Discussed nursing home placement within the context of patient’s goals • Coordinated hospice, as disease progressed quickly • Managed provider distress with this case

  19. Opioid Agreements Pros Cons Enforcement in the malignant pain population is challenging Health literacy limitations Patients can feel “singled out” when asked to complete one Standardize- helpful • Help set expectations • Serve as a guide for difficult conversations • Create boundaries with other providers (i.e., oncologists, PCPs) who may also be dually prescribing opioids • Good assessment tool for literacy, psychosocial needs, etc.

  20. Case study #3 • 34 y/o male dx with Hodgkin’s Lymphoma • Disease is curative with treatment • 3 children (2 different mothers) • Big stressor- cut off from seeing the two youngest • Primary social support- mother • Works as a plumber- currently not employed • Depression, anxiety (situational)- no SI hx • Initially resistant to treatment efforts

  21. Case study #3 • Drinking 1 pint of vodka daily • Cut back to 2-3 mixed drinks 2-3 times weekly • Daily marijuana use since age 16 • Initially for relaxation • Since cancer dx, used as appetite stimulant • Missing appointments, including chemotherapy • Transport resources offered, but declined • “I just need to prioritize my money” • Mother expressing distress over sporadic chemotherapy

  22. Social Work Interventions • Opioid risk survey tool (score of 12 = high risk) • More in-depth psychosocial assessment • Medical cannabis • Exploration of adherence concerns • Family meeting • Education on clinic processes and protocols • Pt with very limited exposure to healthcare • Identification of an insurance case manager • Normalized mental health follow up

  23. Case study #4 • 32 y/o married male • Diagnosed with leukemia at age 21 • BMT, full treatment course, cured at age 23 • GVHD which has caused ongoing knee pain • Graduated college with a degree in business but has not had any formal employment • Volunteers for his church’s music program and is a talented pianist • Voices some anxiety, depression and social isolation • Taking Norco 10/325 4-6 x daily for knee pain

  24. Case study #4 • Conversations begin re: tapering Norco • Met with worsening anxiety, frustration • Begin to see patterns: • 9 early Norco refills within 2 years (many more requests) • Agrees to psychology- 4 no shows in 6 months • 5 ED visits in 6 months with requests for IV pain meds • Prescribed Fentanyl but toxicology negative • Resistant to multiple counseling efforts re: medication safety • Wife called psychologist expressing concerns

  25. Social Work Interventions • Opioid treatment agreement • Mental health evaluation • Coordinated psychiatry, psychology appointments • Care conference organization • Education on addiction • Empowerment/goal setting • Coordinated eventual dismissal from clinic • Team decision- Norco not indicated • Refusing other treatment options

  26. Cancer Survivorship • Few formalized programs • Limited emphasis on pain management • Needs more complex for patients with greater psychosocial concerns • Every pain is a fear of the cancer returning • Palliative care training scope is limited for this population • What happens when our patients don’t die?

  27. Standardizing practice • New patient protocols: • Opioid risk tool • Opioid agreement • UDS • Flag for palliative SW consult for patients that screen as moderate to high risk • Assess for need for linear provider • Joint SW/MD visits for higher risk patients • Integrating debrief sessions for providers to help mitigate distress

  28. Screening tools • CAGE • Have you ever felt you should cut down on your drinking?  • Have people annoyed you by criticizing your drinking?  • Have you ever felt bad or guilty about your drinking?  • Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (eye opener)? • DAST-10 • 10 questions, specific for drug use • AUDIT-C • 3 questions, scoring range 0-12 American Psychiatric Association. 2002.

  29. Screening Tools • SOAPP-R • Specific for opioid risk assessment • Long- 24 questions • Opioid Risk Survey Tool • Used by our team • Short- self-survey component • Best validation- administered by MD/SW/behavioral health clinician

  30. Opioid risk survey tool Webster, L. R., & Webster, R. M. (2005). Predicting aberrant behaviors in opioid-treated patients: preliminary validation of the Opioid Risk Tool. Pain Medicine (Malden, Mass.), 6(6), 432–442.

  31. Opioid risk survey tool

  32. Conclusion Ways that social workers can help navigate these complex cases: • Assist in developing and implementing policies to: • Standardize substance use assessments • Manage cancer survivors on opioid treatment • Develop resource guides for patients and staff • Facilitate completion of the opioid agreement • Utilize joint visits to model creating non-judgmental presence • Educate providers on countertransference • Create opportunities for staff to debrief on challenging cases • Have confidence in our abilities

  33. Questions? Please do not hesitate to email me: Erin Bagwell, LCSW Erin_Bagwell@rush.edu

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