Fast Facts and Concepts # 127; Substance Use Disorders In the Palliative Care Patient

Author(s): Gary M. Reisfield, MD, Gabriel Paulien, MD, and George R. Wilson, MD

The spectrum of substance use disorders (SUDs) are characterized by increasing degrees of craving, compulsive use, loss of control, and continued use despite harm (see FF #68). Addiction is understood to be a disease with complex genetic, neurobiological, psychosocial, and behavioral determinants. If not properly managed, a SUD can: 1) complicate the diagnosis and treatment of psychological (e.g. depression) and physical (e.g. pain) symptoms; 2) compromise compliance with the palliative treatment plan; 3) impair a stressed social support network; 4) weaken trust in patient-physician/nurse relationships; and 5) promote “chemical coping” strategies during periods of stress and decision-making.

Data on the prevalence SUDs in palliative care is unknown, but likely reflects the general population in which alcoholism and abuse of prescription and non-prescription drugs is common. Bruera reported a prevalence of alcoholism of 27% in patients admitted to a tertiary care palliative medicine unit. Far from being a source of pleasure, SUDs are more commonly a source of tremendous suffering for affected individuals and their loved ones. Addressing addiction may allow for: 1) preservation/restoration of damaged social supports; 2) restoration of self-respect and dignity; 3) accomplishment of end-of-life work through recovery; and 4) improvement in quality of life for patients and families.

Substance Use Disorders and Pain Management

Patients with a current or past history of an SUD are particularly challenging. Patients who are in “recovery” are often fearful of using opioids, even in the setting of severe pain near the end-of-life. Conversely, the ability to complete a pain assessment and use opioids effectively is challenging in patients with an active SUD, especially an opioid addiction. Listed below are suggested management techniques in patients with a past or current SUD.

1. Complete a thorough substance use history. Distinguish between those who have active SUDs from those who are at-risk or in recovery. Explain to patients why your knowledge of this information is important for their care. Be empathic and nonjudgmental.
2. Encourage participation in recovery (e.g. 12-step) programs if the patient is willing and physically able. Consider consultation with an addictions/mental health professional.
3. Formalize a treatment plan and coordinate it with all other involved health professionals.
4. Consider use of a written opioid agreement with carefully defined patient and provider expectations; this may give motivated individuals a sense of control over their SUD. Components of an opioid agreement include: establishing a single opioid prescriber, using a single pharmacy, periodic urine drug testing.
5. Treat pain aggressively; poorly treated pain can increase substance abuse behaviors. (See FF#69-Pseudoaddiction)
6. Use non-opioid analgesics and non-pharmacological measures to their full potential.
7. Use opioids at appropriate doses and at appropriate intervals. Titrate long-acting opioids to minimize the need for short-acting opioids. Note: Opioid-tolerant patients may need larger than “usual” doses.
8. Monitor closely; frequent contact allows for close patient observation and prescription of limited quantities of opioids. Careful monitoring will usually distinguish whether deteriorating function is due to substance abuse or disease progression.
9. Recognize that addiction is a chronic, relapsing illness – and respond with increasing structure and compassion.

References:

1. Bruera E, Moyano J, Seifert L, et al. The frequency of alcoholism among patients with pain due to terminal cancer. J Pain Symptom Manage 1995;10(8):599-603
2. Passik SD, Theobald DE. Managing addiction in advanced cancer patients: why bother? J Pain Sympt Manage 2000;19(3):229-234
3. Passik SD , Portenoy RK, Ricketts PL. Substance abuse issues in cancer patients. Part 1: prevalence and diagnosis. Oncology 1998;12(4):517-521
4. Passik SD , Portenoy RK, Ricketts PL. Substance abuse issues in cancer patients. Part 2: evaluation and treatment. Oncology 1998;12(5):729-734

Copyright/Referencing Information : Users are free to download and distribute Fast Facts for educational purposes only. Citation for referencing: Reisfield GM, Paulien G, and Wilson, GR. Fast Facts and Concepts #127: Substance use disorders in the palliative care patient. December 2004. End-of-Life/Palliative Education Resource Center www.eperc.mcw.edu.

Fast Facts were edited by David Weissman MD, Palliative Care Center, Medical College of Wisconsin until January 2007.  For comments/questions write to the current editor, Drew Rosielle MD: drosiell@mcw.edu. The complete set of Fast Facts is available at EPERC: www.eperc.mcw.edu

Disclaimer: Fast Facts provide educational information, this information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Fact information cites the use of a product in dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.

Creation Date: 12/2004

Format: Handouts

Purpose: Instructional Aid, Self-Study Guide, Teaching

Audience(s)

ACGME Competencies: psychiatric disorders

Specific Disease and Organ System Category(s): Psychiatric Disorders