Substance use disorder (SUD) is characterized by increasing degrees of craving, compulsive use, loss of control, and continued use despite harm.
If not properly managed, SUD can make it difficult to diagnosis and treat psychological and physical symptoms, and can reduce compliance with the palliative treatment plan.
The prevalence of SUDs in palliative care patients (alcoholism of 27%, chemical coping 18%) probably reflects that of the general population in which alcoholism and abuse of prescription and nonprescription drugs is common.
Patients with a current or past history of an SUD are particularly challenging.
The following is a list of recommended management techniques in patients with a past or current SUD.
1. Complete a thorough substance use history. Distinguish between those who have active SUD from those who are at-risk or in recovery. Validated tools are available for risk stratification.
2. Encourage participation in recovery programs if the patient is willing and physically able. Consider consultation with an addictions/mental health professional.
3. Formalize a treatment plan and coordinate it with all other involved health professionals.
4. Consider use of a written opioid agreement with carefully defined patient and provider expectations. Components of an opioid agreement include: establishing a single opioid prescriber and pharmacy, making regular pill counts and, if possible, using urine drug testing and an electronic drug monitoring database.
5. Use non-opioid analgesics and non-pharmacological measures to their full potential.
6. Use opioids at appropriate doses and at appropriate intervals. Titrate long-acting opioids to minimize the need for short-acting opioids.
7. Address anxiety with counselling and antidepressants.
8. Recognize that addiction is a chronic, relapsing illness.
See reference for more information.
Adapted from Reisfield GM, Paulian GD, and Wilson GR. Substance use disorders in the palliative care patient. Palliative Care Network of Wisconsin. Fast facts and concepts #127. Internet. Accessed on May 6, 2019.