Outpatients who are currently abusing drugs may require special services to help manage substance abuse issues during treatment. Occasionally, these services can be coordinated with referral to a drug rehabilitation program. Patients with advanced medical illnesses, however, may find it difficult to obtain entry into such programs. Often the outpatient management of drug abuse is left to the clinician, who is also attempting to optimize palliative care and to offer whatever primary disease-oriented treatments remain.

The use of a written contract that clearly defines the roles of treatment team members and the rules and expectations for the patient can be helpful in structuring outpatient treatment. The contract should explicitly state the consequences of aberrant drug use. It is best to tailor the contract to the level of concern about a patient’s behavior.

Patients must be given detailed instructions about the parameters of responsible drug taking. The goal is to prevent the use of illicit drugs, if possible, and to eliminate or prevent abuse of the prescribed drug regimen. The actively abusing patient must be seen frequently in the outpatient department; weekly visits are common. Frequent visits help establish close ties with staff and allow evaluation of both symptom control and addiction-related concerns. Frequent visits also allow the prescription of small quantities of drugs that may diminish the temptation to divert from the dosing schedule and provide the patient with an incentive for keeping appointments. The clinician’s response to lost prescriptions, requests for early refills, and other aberrant behaviors should be decided in advance, to the extent possible, and explicitly explained to the patient.

Some patients can be referred to a 12-step program to help curtail drug abuse during palliative treatment of a progressive medical disease. Patients can document their attendance at groups to further reassure clinicians about their efforts to comply with therapy. Patients may allow physician contact with a sponsor (if the patient has entered a program that requires a sponsor). This sponsor may also help to support the clinical plan. This type of contact also helps to prevent a patient’s ostracism by others in the program when the patient attends meetings while receiving controlled prescription drugs.

To promote patient compliance and detect the concurrent use of illicit substances, most patients with substance abuse histories should be asked to submit periodic urine specimens for drug screening. The patient should be informed at the start of outpatient therapy that this request will be made from time to time. The patient should also be informed of the clinician’s response to positive screening. This response usually involves increasing the guidelines for continued treatment, including greater frequency of visits, smaller quantities of prescribed drugs, and other measures. In the case of repeated violations, referral for concurrent drug rehabilitation may be the most appropriate course.

Many drug-abusing patients come from dysfunctional families. Family meetings may identify family members who are using alcohol or illicit drugs. Referral of family members to drug treatment can be offered and portrayed as a way of marshaling support for the patient. The patient should be prepared to cope with friends or family members who may try to buy or steal prescribed drugs. Identifying reliable individuals who can be sources of strength and support for the patient can be extremely valuable.

In many settings, outpatient management begins with the individual practitioner as the sole caregiver. For some patients, this treatment model may be sufficient, at least for a time. The individual prescriber must be able to coordinate multimodality treatment designed to address palliative care needs and the potential for substance abuse.

The complexity of both palliative care and substance abuse treatment suggests the value of a treatment team. The isolated clinician is often a poor substitute for an interdisciplinary model of care. The treatment team for the active drug abuser with a progressive medical disease may include a specialist in addiction medicine as well as others who can address diverse palliative care needs.

The provision of optimal palliative care to patients with remote histories of alcoholism or drug addiction may present special needs for patient support and education. These patients may harbor concerns about the power of drugs in their lives. They may be rightly proud of their ability to remain drug-free and have great fear that the use of drugs for pain or other symptoms could re-addict them and lead to cravings for illicit or licit drugs. They may worry that family or friends could view the use of therapeutic drugs as abusive. This perception could jeopardize family or social support. Some patients may fear that friends or others who are actively using drugs will attempt to gain access to their prescribed drugs.

The clinician should acknowledge these concerns, offer reassurance, and attempt to address practical matters such as the security of prescribed drugs in the home or the need for contact between the treatment team and family members. The social context in which palliative care is offered differs strikingly from that which surrounds substance abuse. The re-addiction concern expressed by some patients appears to be a very uncommon phenomenon among patients with remote histories of drug abuse who receive prescribed drugs under medical guidance for the control of symptoms associated with progressive medical disease. Indeed, it is sometimes observed that addicts in recovery express the opinion that the opioids given for pain control produce an entirely different subjective experience (e.g., no euphoria, even with intravenous injection) than the opioids taken during a period of addiction. These reports may reflect the power of social forces, the physiologic or psychologic effect of the painful lesion, the influence of the clinician, or other factors that somehow change the nature of drug use for such patients.

Regardless of these facts, some patients are so concerned about the potentially adverse effects of opioids or other potentially abusable drugs that compliance with therapy is threatened. It may be helpful to emphasize nonpharmacologic means of symptom control and offer the patient a detailed structure for the administration of prescribed drugs. It is ironic that some patients prefer rigid guidelines because of an enhanced sense of control over drugs. In discussing the need for compliance, it is also important to have the patient realize that there may be a risk of re-addiction associated with uncontrolled pain or other symptoms. Counseling can also help patients to identify possible triggers of drug and alcohol abuse that might be encountered during treatment and to develop strategies for avoiding illicit drug use or uncontrolled use of prescribed drugs at those times.[1,2]

References

1. Passik SD, Portenoy RK, Ricketts PL: Substance abuse issues in cancer patients. Part 1: Prevalence and diagnosis. Oncology (Huntingt) 12 (4): 517-21, 524, 1998.  [PUBMED Abstract]
   
   
2. Passik SD, Portenoy RK, Ricketts PL: Substance abuse issues in cancer patients. Part 2: Evaluation and treatment. Oncology (Huntingt) 12 (5): 729-34; discussion 736, 741-2, 1998.  [PUBMED Abstract]
   
   

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