Clinical Management of Patients With Substance Abuse Histories
Involve a Multidisciplinary Team
Set Realistic Goals for Therapy
Evaluate and Treat Comorbid Psychiatric Disorders
Prevent or Minimize Withdrawal Symptoms
Consider the Impact of Tolerance
Apply Appropriate Pharmacologic Principles to Treat Chronic Pain
Recognize Specific Drug Abuse Behaviors
Utilize Nondrug Approaches as Appropriate
Taking a Substance Use History
The population of patients with substance abuse histories is extremely
heterogeneous. The most difficult issues in palliative care typically present
in those who are actively abusing alcohol or other drugs. Although the
principles in this section can also apply to patients who are in drug-free
recovery and those who are in methadone maintenance programs, they are likely
to be most helpful in the treatment of the active drug abuser.
The clinical assessment of drug-taking behaviors in medically ill patients with
pain is complex. Aberrant drug-taking behavior in cancer pain management is
generally related to premorbid history of drug addiction and the likelihood of
other pain treatment. A pilot questionnaire was used to characterize drug-related behaviors and attitudes in cancer and AIDS patients. Despite
limitations, this study highlights wide potential variation in different patient
populations in patterns of past and present aberrant drug-taking behaviors and
the need for a clinically useful screening approach.[1] The implications for
psychosocial and pharmacological management of symptoms such as pain, as well
as any aberrant behavior, remain unclear.
Recommendations for the long-term administration of potentially abusable drugs
such as the opioids to patients with histories of substance abuse are based
solely on clinical experience. Studies are needed to determine the most
effective therapeutic strategies and to empirically define patient subgroups
that may be most amenable to different approaches. The following guidelines
broadly reflect the types of interventions that might be considered in this
clinical context.
Involve a Multidisciplinary Team
In the population of patients with progressive medical illness and substance
abuse, palliative care often must contend with multiple medical, psychosocial,
and administrative problems. A team approach can be very useful in addressing
these problems. The most knowledgeable team may involve one or more physicians
with expertise in palliative care, nurses, social workers, and, if possible, one
or more mental health care providers with expertise in addiction medicine.
[2-4]
Set Realistic Goals for Therapy
Drug abuse and addiction often remit and relapse. The risk of relapse is
likely to be enhanced because of the heightened stress associated with life-threatening disease and the ready availability of centrally acting drugs
prescribed for symptom control. Preventing relapses may be impossible in such
a setting. Conflict with staff may be lessened if there is a general
understanding that unerring compliance is not a realistic goal of management.
Rather, the goal might be the creation of a structure for therapy that includes
sufficient support and limit-setting to contain the harm done by occasional
relapses.
A small subgroup of patients may be incapable of complying with the
requirements of therapy because of severe substance abuse and
associated psychiatric comorbidities. To establish the intractability of the
problem, clinicians must re-establish limits and attempt to develop an
increasing variety and intensity of supports. Frequent team meetings and
consultations with other clinicians who have expertise in palliative care and
addiction medicine may be needed. Ultimately, appropriate expectations must be
clarified, and therapy that is failing cannot be continued in the same way. The
success rate for converting highly problematic therapies into those that can be
managed over time is unknown.
Evaluate and Treat Comorbid Psychiatric Disorders
The comorbidity of depression, anxiety, and personality disorders in alcoholics
and other patients with substance abuse histories is extremely high.[5] The
treatment of anxiety and depression can increase patient comfort and possibly
diminish the likelihood of relapse.
Prevent or Minimize Withdrawal Symptoms
Clinicians must be familiar with the signs and symptoms associated with
abstinence from opioids and other drugs. Many patients with histories of drug
abuse consume multiple drugs. A complete drug use history must be elicited to
prepare for the possibility of withdrawal. Delayed abstinence syndromes, such
as may occur following abuse of some benzodiazepine drugs, may pose a
particular diagnostic challenge.
Consider the Impact of Tolerance
Patients who are actively abusing drugs may have sufficient tolerance to
influence the use of prescription drugs subsequently administered for an
appropriate medical indication. Tolerance is a complex phenomenon, and its
impact on clinical management in this context is likely to be highly
variable.[6,7] A prospective open-label study compared morphine dosage and
effectiveness in AIDS patients with and without histories of substance use. Results
demonstrated that both groups benefited, but patients with histories of drug use
required higher morphine doses to achieve stable pain control.[8] This
study should increase confidence in providing patients with histories of
drug use with appropriate pain management.
Apply Appropriate Pharmacologic Principles to Treat Chronic Pain
Individualization of the dose without regard to its size is the most important
guideline for long-term opioid therapy and can be problematic in patients with
histories of substance abuse. Although it may be appropriate to exercise
caution in prescribing potentially abusable drugs to this population, the
decision to forego the principle of dose individualization without regard to
absolute dose may increase the likelihood of undertreatment.[9,10] The
resulting unrelieved pain can lead to the development of aberrant drug-related
behaviors. Although these behaviors might be best understood as
pseudoaddiction, their occurrence confirms clinicians’ fears and encourages
even greater caution in prescribing.
This cycle must be recognized and openly acknowledged to the patient and the
staff. The request for dose escalation should not by itself be viewed as
aberrant drug-related behavior, but the concerns it generates should be
discussed. If the clinician perceives that limits on prescribing are necessary
to assess or manage a problematic therapy, frequent monitoring and alternative
approaches to pain control might be offered. The patient should be given clear
guidelines for responsible drug-taking with the expectation that responsible
drug-taking on the part of the patient will reassure the physician that dose
escalation is appropriate.
Recognize Specific Drug Abuse Behaviors
All patients who are prescribed potentially abusable drugs must be carefully
monitored over time for the development of aberrant drug-related behaviors.
The need for this monitoring is especially strong when patients have a remote
or current history of substance abuse, including alcohol abuse. If there is a
high level of concern about such behaviors, monitoring may require relatively
frequent visits and regular assessment by significant others who can provide
observations about the patient’s drug use.
To facilitate the early recognition of aberrant drug-related behaviors in patients who have been actively abusing drugs in the recent past, regular
screening of urine for illicit or licit-but-unprescribed drugs may be
appropriate. The patient should be informed about this approach, which should
be explained as a method of monitoring that can be reassuring to the clinician
and can provide a foundation for aggressive symptom-oriented treatments.
Presented in this manner, screening is a technique that enhances a therapeutic
alliance with the patient. Patients who protest excessively may be unwilling,
or unable, to enter a collaborative relationship with the clinician in which
the clinician can be confident of responsible drug-taking by the patient.
Similarly, the patient can be confident that the clinician will respond to
unrelieved symptoms with aggressive therapies. Such patients cannot be treated
with the same willingness to use potentially abusable drugs for symptom
control.
Utilize Nondrug Approaches as Appropriate
A variety of nondrug interventions may be useful in helping patients cope with
the rigors of medical treatments. These include educational interventions
designed to assist patients in communicating with staff and negotiating the
complexities of the medical system, as well as numerous cognitive techniques
that enhance relaxation and aid coping.
Taking a Substance Use History
Clinicians often avoid asking patients about drug abuse (and other socially
undesirable behaviors) out of fear that patients will be offended or will
become angry or threatened. Often there is the expectation that the patient
will not respond truthfully. These attitudes are self-defeating and may reduce
the likelihood of truthful communication and increase the problems associated
with the monitoring of therapy over time.
The clinician must be nonjudgmental when taking a patient’s history of
substance use. Adopting a professional and caring demeanor often necessitates
some degree of self-observation and exploration of one’s attitudes about
members of subcultures who hold different values.
The clinician should anticipate defensiveness on the part of the patient. It
can be helpful to mention that patients often misrepresent their drug use for
valid reasons: stigmatization, mistrust of the interviewer, or concern about
fears of undermedication. Clinicians must tell the patient that they need
accurate information about drug use to help keep the patient as comfortable as
possible by avoiding withdrawal states and prescribing adequate medication for
pain and symptom control.
The clinician must be inquisitive and knowledgeable about drug abuse. The use
of street names for drugs should be avoided unless the clinician has current
knowledge of the names in use. The interview should include a review of all
drugs taken, including the chronology of use over time, the frequency of use,
and triggers that initiate use. The so-called pyramid interview can be a
useful way to slowly introduce the subject of drug use. This style of
interviewing begins with broad and general questions about the role of
substances in one’s life, beginning with licit ones such as caffeine and
nicotine. It then proceeds to more specific questions about illicit
substances.
References
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Passik SD, Kirsh KL, McDonald MV, et al.: A pilot survey of aberrant drug-taking attitudes and behaviors in samples of cancer and AIDS patients. J Pain Symptom Manage 19 (4): 274-86, 2000.
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Crowther J, Fainsinger R: Incorrect diagnosis and subsequent management of a patient labeled with cholangiocarcinoma. J Palliat Care 11 (4): 48-50, 1995 Winter.
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Lawlor P, Walker P, Bruera E, et al.: Severe opioid toxicity and somatization of psychosocial distress in a cancer patient with a background of chemical dependence. J Pain Symptom Manage 13 (6): 356-61, 1997.
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Foley KM: Clinical tolerance to opioids. In: Basbaum AI, Besson JM, eds.: Towards a New Pharmacotherapy of Pain. Chichester, NY, John Wiley and Sons, 1991, pp 181-203.
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Ling GS, Paul D, Simantov R, et al.: Differential development of acute tolerance to analgesia, respiratory depression, gastrointestinal transit and hormone release in a morphine infusion model. Life Sci 45 (18): 1627-36, 1989.
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Kaplan R, Slywka J, Slagle S, et al.: A titrated morphine analgesic regimen comparing substance users and non-users with AIDS-related pain. J Pain Symptom Manage 19 (4): 265-73, 2000.
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Breitbart W, Rosenfeld BD, Passik SD, et al.: The undertreatment of pain in ambulatory AIDS patients. Pain 65 (2-3): 243-9, 1996 May-Jun.
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