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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:
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
Passik SD, Theobald DE. Managing addiction in advanced cancer patients:
why bother? J Pain Sympt Manage 2000;19(3):229-234
Passik SD , Portenoy RK, Ricketts PL. Substance abuse issues in cancer
patients. Part 1: prevalence and diagnosis. Oncology 1998;12(4):517-521
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 Physician Education Resource Center
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)
Training: Fellows, PGY1 (Interns), PGY2-6, Physicians in Practice
Specialty: Anesthesiology, Emergency Medicine, Family Medicine, General
Internal Medicine, Geriatrics, Hematology/Oncology, Neurology, OB/GYN,
Ophthalmology, Pulmonary/Critical Care, Pediatrics, Psychiatry, Surgery
Non-Physician: Nurses
ACGME Competencies: Patient care; Medical Knowledge and Systems based
practice
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