Involve a multidisciplinary team
Set realistic goals for therapy
Treat related psychiatric disorders
Prevent or minimize withdrawal symptoms
The impact of tolerance
Treat chronic pain
Recognize drug abuse behaviors
Use nondrug approaches
Taking a substance abuse history

The following issues refer to palliative care for patients who are actively abusing alcohol or other drugs, or who are in a drug-free recovery or methadone program.

Patients with histories of substance abuse are best treated for progressive medical illness by a team of health care providers. A team of one or more physicians, nurses, social workers and, if possible, an expert in addiction medicine, will address the many medical, psychosocial, and administrative problems that patients with drug histories and progressive illness may have.

Patients who have drug abuse and addiction problems experience periods of recovery and relapse. The risk of relapse is increased when patients have a life-threatening disease and have access to pain medication. In this situation, the goal of treatment may not be the complete prevention of relapse, but may be to provide a structure that will limit any harm done by abuse of the drugs. Some patients who have severe substance abuse and related psychological problems may never be able to use therapeutic drugs as prescribed. The health care team should monitor and revise treatment goals for these patients as often as necessary to avoid treatment that is not successful.

Alcoholics and patients with substance abuse histories are very likely to also suffer from depression, anxiety, and personality disorders. The risk of relapse may be decreased if the patient also receives treatment for anxiety and depression.

Many patients with a history of drug abuse consume multiple drugs. The health care provider must be made aware of all drug use so the patient may be effectively monitored to prevent withdrawal symptoms.

Patients who are actively abusing drugs may have developed a tolerance that limits the effectiveness of drugs prescribed for a medical condition.

Opioid regimens used for long-term control of medical symptoms are individualized for each patient so that the dosage is large enough to control symptoms. In patients with substance abuse histories, prescribing dosages that are not large enough may result in undertreatment of the symptoms. The undertreatment does not relieve the patient's pain, and may encourage drug abuse in an effort to control the symptoms. This behavior may cause the physician to become more cautious in prescribing opioids. The physician and patient must work together closely to determine the necessary dosage and to agree on guidelines for responsible use of therapeutic drugs.

While all patients who are prescribed drugs that may be abused must be monitored closely, monitoring is especially important for people who have a history of substance abuse. The patient may be reassessed frequently, and the patient's significant others may be asked to provide observations about the patient's drug use. The physician may find it appropriate to test the patient's urine for illegal or unprescribed drugs. If a patient is agreeable to drug testing and monitoring and uses prescribed drugs responsibly, a trusting relationship may be established with the physician. A physician who is confident that the patient will not abuse drugs is more likely to adjust therapies to control symptoms.

The patient may benefit from nondrug approaches, such as learning about the complexities of the medical system, communicating with the medical staff, and learning relaxation and coping techniques.

To avoid offending a patient, a health care provider may choose not to ask about drug abuse. The health care provider may assume that the patient may become offended, angry, threatened, or may not tell the truth. Such attitudes are not helpful in establishing truthful communication between health care provider and patient and may cause problems in monitoring therapy.

A patient may withhold information about his or her drug use because of negative attitudes the health care provider may have about drug users. The patient may not trust the health care provider, or the patient may fear that if his/her drug abuse history is known, inadequate medication may be prescribed to control symptoms. The physician must know the patient's drug use history in order to control symptoms and to keep the patient comfortable by prescribing adequate medication to prevent withdrawal symptoms and reduce pain. The physician needs to know which drugs the patient has taken, the length of time drugs have been used, the frequency of drug use, and the situations that cause the patient to use drugs.

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