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UDS on the 82 oncology patients at high risk for substance misuse were frequently positive (46%) for non-prescribed opioids, benzodiazepines or potent illicit drugs such as heroin or cocaine, and 39% had inappropriately negative UDS, raising concerns for diversion.

Context Inpatient palliative care is associated with reduced costs, but the optimal model for providing inpatient palliative care is unknown. Objectives To estimate the effect of palliative care consultations (PCC) and care in a palliative care unit (PCU) on cost of care, in comparison with usual care (UC) only and in comparison with each other. Methods Retrospective cohort study, using multinomial propensity scoring to control for observed confounding between treatment groups. Participants were adults admitted as inpatients between 2009 and 2015 with at least one of seven life-limiting conditions who died within a year of admission (N=6,761). Results Palliative care within 10 days of admission is estimated to reduce costs compared to UC in the case of both PCU (−$6333; 95% CI: −7871 to −4795; p<0.001) and PCC (−$3559; −5732 to −1387; p<0.001). PCU is estimated to reduce costs compared to PCC (−$2774; −5107 to −441; p=0.02) and LOS compared to UC (−1.5 days; −2.2 to −0.9; p<0.001). The comparatively larger effect of PCU over PCC is not observable when the treatment groups are restricted to those who received palliative care early in their admission (within six days). Conclusions Both PCU and PCC are associated with lower hospital costs than usual care. PCU is associated with a greater cost-avoidance effect than PCC except where both interventions are provided early in the hospitalization. Both timely provision of palliative care for appropriate patients and creation of more PCUs may decrease hospital costs.

There is literature demonstrating that the N-methyl-d-aspartate (NMDA) receptor antagonist ketamine has analgesic properties that can be used as an adjuvant to opiates for pain relief in multiple various conditions and pain states. However, there is a lack of published information on ketamine used in persons with sickle cell disease in acute pain crises. The Virginia Commonwealth University Palliative Care team was consulted on a 38-year-old African American female with sickle cell thalassemia in severe acute pain crisis overlying chronic pain related to her disease. Pain control was unable to be achieved with escalating doses of opiates and other adjuvant medications. The patient responded well to an intravenous test dose of ketamine and was subsequently placed on an oral regimen of ketamine in addition to opiates. In the 24-hour period following ketamine initiation, the patient's pain was able to be controlled on decreased amounts of opiates. She was eventually transitioned to an oral opiate and ketamine regimen, which allowed her to be discharged home with pain levels close to her baseline and the ability to function and perform all activities of daily living.

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