Outpatient Management Plan
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
-
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]
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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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