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.

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]

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.

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.

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.

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.

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.

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.

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.

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

1. 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.  [PUBMED Abstract]
   
   
2. Crowther J, Fainsinger R: Incorrect diagnosis and subsequent management of a patient labeled with cholangiocarcinoma. J Palliat Care 11 (4): 48-50, 1995 Winter.  [PUBMED Abstract]
   
   
3. 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.  [PUBMED Abstract]
   
   
4. McCorquodale S, De Faye B, Bruera E: Pain control in an alcoholic cancer patient. J Pain Symptom Manage 8 (3): 177-80, 1993.  [PUBMED Abstract]
   
   
5. Khantzian EJ, Treece C: DSM-III psychiatric diagnosis of narcotic addicts. Recent findings. Arch Gen Psychiatry 42 (11): 1067-71, 1985.  [PUBMED Abstract]
   
   
6. 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. 
   
   
7. 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.  [PUBMED Abstract]
   
   
8. 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.  [PUBMED Abstract]
   
   
9. 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.  [PUBMED Abstract]
   
   
10. Cleeland CS, Gonin R, Hatfield AK, et al.: Pain and its treatment in outpatients with metastatic cancer. N Engl J Med 330 (9): 592-6, 1994.  [PUBMED Abstract]
    
    

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