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Background: Growing clinical interest in psychedelic-assisted therapies has led to a second wave of research involving psilocybin, lysergic acid diethylamide (LSD), 3,4-methylenedioxymethamphetamine (MDMA) and other substances. Data suggests that these compounds have the potential to treat mental health conditions that are especially prevalent in older adults such as depression, anxiety, existential distress, and posttraumatic stress disorder. Aims: The goal of this study was to quantify the prevalence of older adults enrolled in psychedelic clinical trials and explore safety data in this population. Methods: A systematic review was conducted following the 2020 PRISMA guidelines. Search criteria included all trials published in English using psychedelic substances to treat psychiatric conditions, including addiction as well as existential distress related to serious illness. Articles were identified from literature searches on PubMed, EBSCO, and EMBASE. Results: 4376 manuscripts were identified, of which 505 qualified for further review, with 36 eventually meeting eligibility criteria. Of the 1400 patients enrolled in the 36 studies, only 19 were identified as 65 or older, representing less than 1.4% of all trial participants. For 10 of these 19 older adults, detailed safety data was obtained. No serious adverse events (AEs) occurred in any older adults and only transient mild-to-moderate AEs related to anxiety, gastrointestinal upset, and hypertension were reported during the psychedelic dosing sessions. Conclusions: While existing data in older adults is limited, it suggests that psychedelic-assisted psychotherapy can be safe and well tolerated in older adults. Therefore, psychedelic-assisted psychotherapy should be more rigorously investigated for the treatment of psychiatric conditions in this population. [ABSTRACT FROM AUTHOR]

Background: Eliciting life stories is an important component of person‐centered care that may aid in understanding how an individual's unique background and narrative impacts their health. Such life stories, especially when gathered from older military Veterans, may include traumatic events, raising the urgency that clinicians be prepared to provide care that is trauma‐informed and ensure Veteran's experiences are acknowledged and treated effectively. Methods: We examined the prevalence and type of potentially traumatic and/or adverse life events spontaneously shared by 231 older Veterans participating in a life story intervention while receiving care within the U.S. Veterans Health Administration system. Veteran life stories were extracted from the electronic medical record and deductive qualitative content analysis was used to code potentially traumatic or adverse life experiences based on a codebook adapted from the Brief Trauma Questionnaire and Adverse Childhood Experience questionnaire. Results: A majority (71.0%) of Veterans described at least one traumatic disclosure in their life story. Among narratives with a disclosure of any type, more than half (53.0%) included descriptions of combat trauma, 21.5% noted a history of life‐threatening illness, and 9.5% reported having been in a serious accident. Fewer noted adverse childhood experiences (19.5%). Conclusions: Elicitation of life stories among older Veterans may advance person‐centered care and life stories frequently include disclosure of potentially traumatic and/or adverse life events. These findings underscore the normative experience of traumatic events among older Veterans and highlight the importance of developing age‐sensitive trauma‐informed care competencies. [ABSTRACT FROM AUTHOR]

1. Identify patients who would benefit from a trial of buprenorphine low-dose initiation. 2. Review approaches to performing a buprenorphine low-dose initiation to decrease total opioid use in patients with cancer and non-cancer-related pain. Buprenorphine low-dose initiation is a novel approach that harnesses the unique pharmacological profile of this partial-opioid agonist to reduce both risk of precipitated opioid withdrawal and need for prolonged opioid tapers in vulnerable patients. Buprenorphine low-dose initiation is a novel approach that harnesses the unique pharmacological profile of this partial-opioid agonist to reduce both risk of precipitated opioid withdrawal and need for prolonged opioid tapers in vulnerable patients (1). A 65-year-old man with metastatic bladder cancer and significant non-cancer-related orthopedic spine concerns is followed in the palliative care clinic for both cancer and non-cancer-related pain. He was being treated with a multimodal pharmacologic approach, involving opioid therapy (hydromorphone 8mg every 4 hours), neuropathic agents (amitriptyline and pregabalin), muscle relaxants (baclofen), and anti-inflammatory agents (celecoxib). With this, he had recently noted improvement in his pain level and had a desire to wean opioids due to bothersome side-effects of fatigue, cognitive fogging, and occasional myoclonus. Given his chronic opioid use, a rotation to buprenorphine was performed using a low-dose initiation protocol with subutex (buprenorphine tablets). The patient successfully weaned his opioid use from 48mg oral hydromorphone daily to 12mg oral subutex with resolution of his opioid side-effects. Buprenorphine low-dose initiation involves adding increasing low-dose formulations of buprenorphine to an amount where the opioid receptors are nearly fully occupied, then reducing the frequency and dose of full-agonist opioids. In patients with both chronic non-cancer-related and cancer-related pain, this strategy can provide relief from opioid-related side effects, while still achieving good pain control. Evidence supports the use of buprenorphine rotation to reduce chronic pain, without precipitating opioid withdrawal or other serious adverse side effects (2). Managing Suffering and Distress / Pharmacotherapeutics / Pharmacopalliation [ABSTRACT FROM AUTHOR]

Psychedelic-assisted therapy (PAT) is a burgeoning treatment with growing interest across a variety of settings and disciplines. Empirical evidence supports PAT as a novel therapeutic approach that provides safe and effective treatment for people suffering from a variety of diagnoses, including treatment-resistant depression, substance use disorder, and post-traumatic stress disorder. Within the palliative care (PC) field, one-time PAT dosing may lead to sustained reductions in anxiety, depression, and demoralization—symptoms that diminish the quality of life in both seriously ill patients and those at end of life. Despite a well-noted psychedelic renaissance in scholarship and a renewed public interest in the utilization of these medicines, serious illness-specific content to guide PAT applications in hospice and PC clinical settings has been limited. This article offers 10 evidence-informed tips for PC clinicians synthesized through consultation with interdisciplinary and international leading experts in the field with aims to: (1) familiarize PC clinicians and teams with PAT; (2) identify the unique challenges pertaining to this intervention given the current legalities and logistical barriers; (3) discuss therapeutic competencies and considerations for current and future PAT use in PC; and (4) highlight critical approaches to optimize the safety and potential benefits of PAT among patients with serious illness and their caregivers. [ABSTRACT FROM AUTHOR]

Background: Despite the association between chronic pain and post-traumatic stress disorder (PTSD), little is known about the longitudinal course of pain and PTSD during cancer treatment. Objectives: We examined the prevalence of PTSD and chronic pain at three time periods in veterans with a diagnosis of cancer, and the relationship between the experience of pain and PTSD. Methods: Participants (N = 123) with oral-digestive cancers were recruited from the Veterans Healthcare System (age M = 65.31 and SD = 9.13; 98.4% male) and completed face to face interviews at 6, 12, and 18 months post-diagnosis. Measures included the Post-traumatic Stress Disorder Checklist-Stressor-Specific version (PCL-S), Primary care PTSD (PC-PTSD), and the Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Impact Scale. Results: About one-third (26.8%) of the sample had chronic pain, defined as elevated pain at two time periods. About one-fifth (20.3%) endorsed symptoms of combat-related PTSD at 6 months, and 22.8% endorsed symptoms of cancer-related PTSD, exceeding a clinical cutoff for older adults (12 months = 21.1%, 18 months = 23.1%). Changes over time were observed for cancer-related PTSD symptom clusters of hyperarousal (F = 3.85 and p = 0.023) and emotional numbing (F = 4.06 and p = 0.018) with a statistically significant quadratic function increasing at 18 months. In logistic regression, individuals with both combat and cancer-related PTSD symptoms at six months had 8.49 times higher odds of experiencing chronic pain (χ2 = 25.91 and p < 0.001; R2 = 0.28). Conclusions: Persisting pain may be a concern in veterans with cancer. Individuals who have experienced traumatic events with persisting PTSD symptoms may be at elevated risk for chronic pain. Veterans with PTSD symptoms from both cancer and combat are at the highest risk to experience chronic pain. [ABSTRACT FROM AUTHOR]

Opioids have long been a mainstay of symptom management in palliative care (PC), allowing patients with terminal illnesses to have an improved quality of life. Unfortunately, these same medications have contributed to the explosion of the opioid epidemic. This article explores the case of a patient with opioid use disorder (OUD) and pancreatic cancer. We share our experience of managing his symptoms and treating OUD in the setting of an outpatient PC clinic. We explore the challenges and joys of this case while reflecting on the need for more research investigating best practices for individuals where opioids serve as both a pain reliever and contributor to further suffering from their OUD. [ABSTRACT FROM AUTHOR]

The article focuses on revisiting the roots of palliative care (PC). Topics discussed include mental health clinicians addressing the psychological needs of patients frequently marginalized in the care of dying patients; supporting the psychological and psychiatric needs of patients recognized as a cornerstone of high-quality PC; and mental health professionals in PC offering many advantages to patients and their families.

The delivery of psychiatric care via video-teleconferencing (VTC) technology is thought to have reached a tipping point. As a medical speciality with relatively few material or technical requirements for service delivery, psychiatry has been one of the earliest to embrace the possibility of providing evaluations and treatment at a distance. Such technical infrastructure as is necessary can often be found in the institutions already in existence. It was natural therefore that institutionally based telepsychiatry would lay the foundation for the development of the field. In this article we review the history and development of institutional VTC in a wide variety of clinically supervised settings such as hospitals, outpatient clinics, and forensic settings. We cite evidence supporting institutionally sponsored use and expand on key takeaways for the development and expansion of videoconferencing in these settings. We also speculate on the future direction and development of psychiatric care provided by these arrangements. [ABSTRACT FROM PUBLISHER]

Identifying and attending to the existential needs of persons with serious illness and their care partners are integral to whole-person palliative care (PC). Yet, many PC clinicians, due to individual factors and wider systemic barriers, are ill-prepared and under-resourced to navigate the existential dimension. In this article, written from clinical, research, and lived experiences, we offer tips to empower PC clinicians to understand, recognize, and respond to patients' and care partners' existential experiences by leveraging their existing skills, collaborating closely with colleagues, exploring their own existential experience, and implementing evidence-based interventions. We propose that by prioritizing existential care within PC, we can shift the culture of health care to better affirm the humanity of both patients and clinicians. [ABSTRACT FROM AUTHOR]

Context: Hospice and palliative care (HPC) clinicians increasingly care for patients with concurrent painful serious illness and opioid use disorder (OUD) or opioid misuse; however, only a minority of HPC clinicians have an X-waiver license or actively use it to prescribe buprenorphine as medication treatment for OUD.Objectives: To understand barriers for HPC clinicians to obtaining an X-waiver and prescribing buprenorphine as medication treatment for OUD.Methods: We performed content analysis on 100 survey responses from members of the national Buprenorphine Peer Support Network, a group of HPC clinicians interested in buprenorphine, on X-waiver status, barriers to obtaining an X-waiver, and barriers to active prescribing.Results: Of 100 HPC clinicians surveyed, only 26 of 57 HPC clinicians with X-waivers had ever prescribed. Prominent barriers included discomfort managing concurrent pain, buprenorphine, and OUD; concerns about impacts on practice; unsupportive practice culture; insufficient practice support; patient facing challenges; and cumbersome regulatory policies.Conclusion: Despite HPC clinicians' interest in buprenorphine prescribing for OUD, several steps are needed to facilitate the practice, including clinician education tailored to pain and to clinical challenges faced by HPC clinicians, mentorship on buprenorphine use, and cultural and practice changes to dismantle systemic stigma towards addiction. We propose evidence-based steps derived from our survey findings that individual clinicians, HPC leaders, and national HPC organizations can take to improve care for patients with painful serious illness and OUD. [ABSTRACT FROM AUTHOR]

AbstractPurposeMethodsResultsDiscussionTraumatic experiences are ubiquitous and associated with negative impacts on health and wellbeing in patients, students, and clinicians. Trauma-informed care (TIC) is a harm reduction framework that aims to minimize re-traumatization and the negative health impacts of trauma. TIC is increasingly being incorporated into undergraduate medical education (UME) curricula; however, to date, there is no standardized curriculum to support faculty in precepting TIC clinical skills.We created a series of five educational modules in an asynchronous online format to support faculty in the instruction and precepting of TIC clinical skills in UME. The modules instruct on trauma epidemiology, trauma-informed clinical skills, trauma-informed precepting, and trauma-informed self-care (TISC). The modules are interactive and utilize multimedia content.Fifty-three faculty members of the primary care clerkship participated in the modules. After the modules, faculty demonstrated increased knowledge of TIC, though their comfort in applying principles with patients and students was unchanged.We present a novel, standardized curriculum to support faculty in the practice and precepting of TIC clinical skills. The intervention is shown to promote knowledge surrounding TIC. In the future, pairing these asynchronous modules with in-person training may be necessary to improve comfort with the application of these skills. [ABSTRACT FROM AUTHOR]

The article presents the discussion on Fast Fact providing guidance on initiation using the traditional method through buprenorphine/naloxone sublingual (SL) film. Topics include patients being developed opioid misuse behaviors or opioid use disorder (OUD) such that the harms of LTOT with full l-agonist opioids; and Buprenorphine being safely initiated in the inpatient setting, outpatient clinic, or in the patient's home.

Background: The present study explored the acceptability of psilocybin‐assisted group therapy from the perspective of patients with cancer and depression who participated in a clinical trial assessing the safety and efficacy of this novel intervention. Methods: Guided by the conceptual framework of acceptability, the authors conducted semi‐structured interviews with participants of the psilocybin trial. Data were analyzed using template and thematic analyses. Results: Participants' (n = 28) perspectives on the acceptability of the group and simultaneous sessions was generally positive, both in terms of safety and efficacy: first, the groups contributed to increase participants' sense of safety and preparedness as they were engaging in the therapy; and second, the groups fostered a sense of connection and of belonging, which served to enrich and deepen the meaning of participants' experience, ultimately opening a dimension of self‐transcendence and compassion. Other subthemes related to factors influencing the acceptability of the group approach included: 1) the importance of the therapeutic framework, 2) the complementary value of individual sessions, 3) disruptive factors related to the group and/or simultaneous setting, and 4) opportunities and challenges related to group size and how to structure interactions. Conclusions: This study enhances understanding of what promotes acceptability of the psilocybin‐assisted therapy group model for the treatment of MDD in cancer patients. Plain Language Summary: We conducted exit interviews with participants of a phase 2 trial of psilocybin‐assisted therapy (PAT) conducted in a community cancer center, to assess the acceptability of a novel psilocybin delivery model combining simultaneous individual therapy and group sessions.Our findings support the acceptability of this intervention and suggest that in addition to being feasible, it might also enhance participants' perceived safety and efficacy compared to uniquely individual or group delivery models of PAT.Our analysis highlights critical factors conditioning acceptability and suggests new ways PAT may be scaled and integrated into cancer care. Psilocybin‐assisted group therapy to treat depression in patients with cancer is acceptable and might enhance safety and efficacy. The findings of this study highlight critical factors conditioning acceptability of the group model and suggest new ways psilocybin‐assisted therapy may be scaled and integrated into cancer care. [ABSTRACT FROM AUTHOR]

In this narrative medicine essay, a geriatric and palliative care physician shares his understanding that the patience, flexibility, humility, and presence required to grow a garden are entirely appropriate for end-of-life patient care. [ABSTRACT FROM AUTHOR]

The article discusses the health care stigmatization of patients who abuse drugs or have addictions and proposes languages to de-stigmatize addiction, respect personhood, and support recovery. Also cited are how stigma occurs in health care through labeling, stereotyping and discrimination, and some preferred languages like substance use disorder (SUD), opioid use disorder (OUD), and alcohol use disorder.

Background: Recent and preprohibition studies show that patients with serious illness might benefit from psychedelic-assisted therapies for a range of symptoms, physical, psychosocial, and existential. Objective: To explore the potential roles and research priorities of these therapies in patients with serious illness. Design, Setting, and Participants: Qualitative study based on semistructured interviews with 17 experts in serious illness care and/or psychedelic research from the United States and Canada. Measurements: The interview guide elicited participants' perspectives on (1) the potential roles of psychedelic-assisted therapies in this setting, (2) research priorities relevant to this population, and (3) the potential for integrating psychedelic-assisted therapies into existing delivery models of serious illness care. We used thematic analysis until thematic saturation. Results: Domain I: Participants had polar views on the therapeutic potential of psychedelic-assisted therapies, ranging from strong beliefs in their medical utility to reluctance about their use in this patient population. They shared concerns related to the risks of adverse effects, such as delirium or worsening of psychological distress. Domain II: Research priorities primarily concerned patients with clinically diagnosed psychosocial distress, such as depression, anxiety, or demoralization. Participants also articulated potential roles extending beyond traditional medical diagnosis. Domain III: Participants emphasized essential safety and efficacy guidelines relevant to the integration of these therapies into existing models of care. Conclusion: This qualitative study highlights issues and priorities for research on psychedelic-assisted therapies in patients with serious illness and proposes a conceptual framework for integrating these therapies into existing delivery models of serious illness care. [ABSTRACT FROM AUTHOR]

Posttraumatic stress disorder (PTSD) may emerge or re-emerge at end of life (EOL), increasing patient suffering. Understanding factors associated with PTSD at EOL may assist clinicians in identifying high risk veterans. To determine rates of and variables associated with PTSD-related distress at EOL. Retrospective observational cohort study including veterans who died within a Veterans Affairs (VA) inpatient setting between October 1, 2009 and September 30, 2018 whose next-of-kin completed the Bereaved Family Survey (BFS; N = 42,474). Our primary outcome was PTSD-related distress at EOL, as reported by veteran decedents' next-of-kin on the BFS. Predictors of interest included combat exposure, demographic variables, medical and psychiatric comorbidity, primary serious illness, and palliative care support. Veteran decedents were majority male (97.7%), non-Hispanic white (77.2%), 65 years or older (80.5%), without combat exposure (80.1%). Almost one in ten (8.9%) veteran decedents experienced PTSD-related distress at EOL. In adjusted analyses, combat exposure, younger age, male sex, and non-white race were associated with PTSD-related distress at EOL. High overall medical comorbidity, dementia, and psychiatric comorbidities including both substance use disorder and depression, were also associated with PTSD-related distress at EOL. Palliative care consultation and emotional support were associated with decreased odds of PTSD-related distress, while pain was associated with increased odds of PTSD-related distress at EOL. Trauma and PTSD screening, pain management, and providing palliative care and emotional support at EOL, particularly in at-risk groups such as veterans from racial/ethnic minority backgrounds and those with dementia, are critical to decreasing PTSD-related distress at EOL. [ABSTRACT FROM AUTHOR]

Pain management in palliative care (PC) is becoming more complex as patients survive longer with life-limiting illnesses and population-wide trends involving opioid misuse become more common in serious illness. Buprenorphine, a generally safe partial mu-opioid receptor agonist, has been shown to be effective for both pain management and opioid use disorder. It is critical that PC clinicians become comfortable with indications for its use, strategies for initiation while understanding risks and benefits. This article, written by a team of PC and addiction-trained specialists, including physicians, nurse practitioners, social workers, and a pharmacist, offers 10 tips to demystify buprenorphine use in serious illness. [ABSTRACT FROM AUTHOR]

At the end of life, individuals may re-engage with earlier life trauma as they reflect on life experiences and confront their mortality. As such, posttraumatic stress disorder (PTSD) symptoms at the end of life may worsen the quality of death experience. This is a concern for military veterans, who tend to have more trauma exposures and higher rates of PTSD, and particularly for veterans receiving care in rural areas where access to PTSD specialty services is limited. To better understand this issue, we conducted 10 focus groups with clinicians serving veterans in rural communities across five U.S. states. The aims of this project were to evaluate: (1) do hospice and palliative care providers/staff observe PTSD symptoms in veterans at the end of life? (2) if so, how are symptoms similar to and different from existing DSM-5 criteria for PTSD? We used qualitative content analysis with mixed deductive and inductive approaches to code 151 anonymized statements. Analyses found descriptions of PTSD symptoms aligned broadly with existing diagnostic nomenclature, but descriptions revealed specific presentations relevant to the end of life setting such as resistance to care, agitation, restlessness, and effects of delirium. In addition, some veterans expressed pride in service and openness to discussing military experiences. Further, clinicians noted that PTSD symptoms were relevant to family dynamics. Future research should further characterize these symptom differences through direct patient assessment and develop resources to improve quality of death experience for veterans with PTSD symptoms. [ABSTRACT FROM AUTHOR]

The article discusses the low-dose initiation method in which there is a period of concomitant high affinity partial mu-opioid agonist buprenorphine and full agonist opioid administration. It mentions that with a low-dose initiation, full agonist opioids should be continued until buprenorphine titration reaches a threshold of opioid receptor activity to minimize the risk of opioid withdrawal symptoms.

Persons without family or friends to serve as healthcare agents may become "unrepresented" in healthcare, with no one to serve as healthcare agents when decisional support is needed. Surveys of clinicians (N = 81) and attorneys/guardians (N = 23) in Massachusetts reveal that unrepresented adults experience prolonged hospital stays (66%), delays in receiving palliative care (52%), delays in treatment (49%), and other negative consequences. Clinicians say guardianship is most helpful in resolving issues related to care transitions, medical treatment, quality of life, housing, finances, and safety. However, experiences with guardianship are varied, with delays often/always in court appointments (43%) and actions after appointments (24%). Policy solutions include legal reform, education, and alternate models. [ABSTRACT FROM AUTHOR]

The intent of this research project was to improve upon current nondestructive evaluation techniques for predicting the burst pressures of Kevlar/epoxy pressure vessels from acoustic emission (AE) data. AE data were recorded during the first step of hydro-burst testing of twelve unfilled and eleven inert-propellant-filled Kevlar/epoxy pressure vessels. These vessels were first impact damaged to varying degrees, after which the initial part of AE data up to 25% of the burst pressure was input to a back-propagation neural network (BPNN) capable of predicting the vessels' burst pressures. This raw AE amplitude distribution histogram data resulted in worst case predictions of 19.04% for the unfilled bottles and 5.70% for the inert propellant filled bottles. A Kohonen self organizing map (SOM) neural network was subsequently used to classify the raw AE data into the four distinct failure mechanisms typical of filament-wound composite pressure vessels. Using the matrix cracking only amplitude histogram data as input to the BPNN improved the worst case burst pressure predictions from 19.04% to 8.81% for the unfilled bottles and 5.70% to 3.85% for the inert propellant filled bottles, respectively. The greater than ±5% worst case error for the unfilled bottles was attributed to the scarcity of AE data available up to 25% of the expected burst pressure for BPNN processing. Thus, by inputting the amplitude histogram for the matrix cracking only data into a BPNN rather than the entire amplitude distribution histogram, the technique for predicting burst pressures in impact-damaged filament-wound Kevlar/epoxy pressure vessels was made significantly more accurate in spite of a scarcity of AE data. [ABSTRACT FROM AUTHOR]

There are growing calls to broaden palliative care access to more populations, diseases, and care settings and to earlier in the disease process; yet, supply of specialty palliative care is not likely to keep pace with demand. This article discusses possible solutions by which to bridge the gap between limited palliative care supply and demand. The proposed solutions include: (1) specialist workforce development; (2) alternate models of care; (3) triaging systems; and (4) telemedicine. Education/training, research, and policy mechanisms could operationalize these solutions. With the solutions in hand, the field may be able to increase the reach, sustainability, and equity of palliative care, thereby improving access and enabling a multitude of positive patient, family, and health care system outcomes. [ABSTRACT FROM AUTHOR]

An editorial is presented on buprenorphine as a treatment for OUD with and without co-occurring pain. Topics include essential for all palliative care clinicians in applying for the DEA X waiver and acquiring basic competencies; and patients prescribing longterm opioids being at increased risk for opioid-related harms.

1. Construct low-dose buprenorphine initiation protocols using local formularies (patch, sublingual, buccal, IV) appropriate for the inpatient setting. 2. Provide education, support, and guidance to primary teams and patients on full-agonist opioids when recommending a low-dose buprenorphine initiation. Hospice and palliative care (HPC) clinicians are increasingly caring for patients who are living longer with serious illness, pain, and concurrent substance misuse or use disorder, prompting the field's rapidly growing interest in buprenorphine. And yet, clinicians new to buprenorphine may be hesitant to incorporate it into practice given its unique partial-agonist pharmacology that can cause precipitated opioid withdrawal when added to a patient already maintained on full-agonist opioids. Traditional methods of rotation to buprenorphine therefore require a patient on full agonist to first enter supervised opioid withdrawal, which often precludes its use in painful serious illness. Low-dose initiation methods ("microdosing") have become standard of care to rotate opioid-tolerant patients to buprenorphine successfully, safely, and with minimal risk of experiencing opioid withdrawal in the inpatient setting. Confidence integrating buprenorphine into specialty HPC is critical to delivering patient-centered, accessible, and equitable care for patients often stigmatized by health care for challenging pain, chronic cancer pain, substance use, or opioid misuse. While the low-dose initiation method is customizable to various formularies and clinical scenarios, this flexibility can be daunting and confusing for clinicians new to the method. "What is a safe buprenorphine starting dose? How fast can I titrate buprenorphine? What about patients on high doses of methadone? What about the full agonist? What if the patient feels worse? What support should my team provide patients?" Using case studies from inpatient settings, an interdisciplinary group of HPC and addiction medicine clinicians (pharmacy, nurse practitioner, physicians) with experience in buprenorphine initiation will guide participants through frequently asked questions and common pitfalls of low dose initiation in the inpatient setting. Participants will leave with resources, clinical skills practice, peer networks to support practice change, and sample low-dose initiation protocols appropriate for their inpatient buprenorphine formulary. [ABSTRACT FROM AUTHOR]

Outcomes 1. Discuss advances in psychedelic-assisted therapy science relevant to palliative care settings 2. Explain implications of psychedelic-assisted therapy from myriad disciplinary perspectives with the goal of advancing collaboration and the field more broadly 3. Reflect on palliative care practice models as exemplars for relationship-based psychedelic-assisted therapy integration within the health system In 2021, two landmark randomized controlled studies of psychedelic-assisted therapy generated intense public and scientific interest as well as speculation that MDMA and psilocybin may be granted federal regulatory approval within the next several years for a wide array of mental health indications. Potential applications pertinent to palliative care extend well beyond management of anxiety and depression among those with serious illness to include demoralization, existential distress, grief, meaning making, and life completion. Unlike other drug therapies where efficacy can be reduced to the biochemical action of the drug, the clinical benefit (or harm) of psychedelic medicines is highly contingent on the mindset of the patient and the physical and emotional setting in which they are used. The quality of presence and skills of the therapist are paramount to establish a trusting relationship and safe environment fostering healing. In many traditions, the therapeutic relationship is considered the "medicine," and psychedelics act to catalyze and deepen the relational aspects of care that may ease suffering and allow each patient's innate healing processes to unfold. Training clinicians and therapists skilled in this modality presents a major bottleneck to this developing field and limitation to widespread accessibility, not simply because clinical infrastructure must be converted or developed but because the safety and efficacy of the intervention uniquely depend on the preparation of the clinician. To meet this need, several training programs have developed over the last 5 years. We present a diverse panel of palliative care and hospice clinicians training and working in psychedelic-assisted therapies to share their experiences of training and clinical care and how the interdisciplinary, intensively relationship-centered approach of palliative care may serve as a model for the successful implementation of psychedelic medicines more broadly across society. [ABSTRACT FROM AUTHOR]

Outcomes 1. Describe contemporary, evidence-based understanding of opioid use disorder (OUD) as a chronic condition with effective medication treatment in an environment of ongoing healthcare stigma, access inequities, and shifting policies 2. Analyze the common psychosocial and neurobiologic pathways between pain and OUD that limit the use of a dichotomous approach to caring for patients with coexisting pain and opioid misuse or OUD 3. Practice developing comprehensive pain management plans using a risk/benefit analysis of opioid prescribing through interactive case-based discussion in situations such as patients with serious illness and pain who use stimulants or other nonprescribed substances, self-titrate opioids prescribed for serious illness pain, have preexisting OUD and actively use, have preexisting OUD in remission on methadone or buprenorphine treatment, or have residual disease-related chronic pain on high-dose opioid use in survivorship This preconference will enhance the skills and preparedness of hospice and palliative care clinicians to treat pain in patients with serious illness and opioid use disorder (OUD). Participants will learn both evidence-based best practices and emerging treatments while honing their skills through interactive sessions and case discussions led by an interdisciplinary team of clinicians with expertise at the intersection of palliative care and OUDs. Presenters will discuss topics such as the chronic disease model of addiction, diagnosis of OUD, and evidence for office-based medication treatment of OUD. Presenters will also examine the shared neurobiologic and psychosocial threads between pain and OUD and introduce approaches to jointly managing both through the principles of harm reduction. Additionally, presenters will establish buprenorphine as a crucial medication in the palliative care and hospice toolbox for the treatment of patients with concurrent pain, OUD, and serious illness through review of evidence for buprenorphine as analgesia and as first-line office-based treatment of OUD. Participants will practice risk/benefit analysis of opioid prescribing in pain management through discussions of cases such as patients who use nonprescribed substances, self-titrate opioids prescribed for serious illness pain, have preexisting OUD and actively use or are in remission, or are survivors with chronic pain on high-dose opioids. Throughout, presenters will cultivate awareness and self-reflection on the sociocultural and political environment underlying stigma toward OUD and pain, impacts of healthcare stigma on inequities in care, and strategies to promote culture change. Lastly, presenters will prepare attendees to prescribe buprenorphine for up to 30 patients as permitted by the Notice of Intent by reviewing protocols of buprenorphine initiation with microdosing for patients on full agonists, addressing common concerns, and answering questions about the recent April 2021 X-waiver reform removing standardized education. Participants will leave with new networks of peers and mentors for ongoing support. [ABSTRACT FROM AUTHOR]

Context: Guardians are surrogate decision makers appointed by a court when other health care decision-makers are unable, unwilling, or unavailable to make decisions. Prior studies suggest that persons under guardianship may experience delays in transitions of care.Objectives: To compare quality of end-of-life care for persons under guardianship to a matched group on objective indicators and to identify narrative themes characterizing potential obstacles to quality end-of-life care.Methods: One hundred sixty-seven persons under guardianship who died between 2003 and 2019 within the Veterans Healthcare Administration in Massachusetts and Connecticut matched on a 1:1 basis to persons without guardians. The groups were compared on treatment specialty at death, days of hospice and intensive care unit care, and receipt of palliative care consultation. Additionally, patient narratives for those under guardianship with extended lengths in intensive care unit were subjected to qualitative analysis.Results: Overall, <1% were under guardianship. Within this sample of persons who died within the Veterans Health Administration, persons under guardianship were as likely as patients in the comparison group to receive palliative care consultation (odds ratio [CI] = 0.93 [.590-1.46], P = .359), but were more likely to have ethics consultation (odds ratio [CI] = 0.25 [0.66-0.92], P = .036) and have longer lengths of ICU admission (β = -.34, t = -2.70, P = .009). Qualitative findings suggest that issues related to family conflict, fluctuating medical course, and limitations in guardian authority may underlie extended lengths of stay.Conclusion: Guardianship appears to be rare, and as a rule, those under guardianship have equal access to hospice and palliative care within Veterans Health Administration. Guardianship may be associated with health-care challenges in a small number of cases, and this may drive perceptions of adverse outcomes. [ABSTRACT FROM AUTHOR]