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.[Level of evidence: II] 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.[2,3,4][Level of evidence: III]
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.