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Substance Abuse Issues In Cancer (PDQ®)
- Prevalence Among the Physically Ill
- Conceptual Issues in Defining Terms for the Medically Ill
- Risk of Abuse and Addiction in Populations Without Drug Abuse Histories
- Risk of Abuse and Addiction in Populations With Drug Abuse Histories
- Clinical Management of Patients With Substance Abuse Histories
- Inpatient Management Plan
- Outpatient Management Plan
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Substance abuse in cancer patients who do not have histories of substance abuse is exceptionally rare. Opioids and other controlled substances can be prescribed judiciously for symptom management, without concern about misuse. When problematic drug-taking behavior is manifested by such patients, it is often the result of poor pain control. However, many people with cancer have a history of drug abuse or live among those who do. They have special needs that are often underappreciated because this problem is overlooked. Nearly one-third of the population of the United States has used illicit drugs, and an estimated 6% to 27% have a substance abuse problem of some type. The abuse of prescription opioids has grown rapidly since the mid-1980s and is now as frequent as the abuse of cocaine. Because of the prevalence of substance abuse and the association between drug abuse and some types of cancer, problems related to abuse and addictions are encountered in palliative care settings.
The population of patients who have histories of substance abuse or addiction is extremely heterogeneous, and the status of each patient will affect concerns central to his or her palliative care. Patients who are actively abusing alcohol, illicit drugs, or prescription drugs present problems distinct from those experienced by patients in drug-free recovery or patients in methadone maintenance programs. Appropriate diagnosis of substance abuse may be challenging because of the variability in abuse behaviors over time, the changes in comorbid physical and psychosocial factors that influence drug abuse, and the problems inherent in the nomenclature of drug abuse in the physically ill.
Patients who have histories of substance abuse present many clinical problems. Clinicians must control and monitor drug use in all patients. Compliance with treatments for the underlying disease may be so poor among cancer patients who are actively abusing drugs that the substance abuse actually shortens life expectancy by preventing the effective administration of primary therapy. Prognosis may also be altered by the use of drugs in a manner that negatively interacts with therapy or predisposes the patient to other serious morbidity.
Active or past substance abuse also may weaken social support networks. Among these supports is the patient’s relationship with the treatment team. Lack of mutual trust can characterize the relationships between substance-abusing patients and members of the treatment team. Concerns about drug abuse may lead clinicians to doubt the veracity of the history divulged by the patient, the report of symptoms, and compliance with therapy. A desire to build trust may lead clinicians to hide these concerns from the patient. Patients with histories of substance abuse may sense the mistrust, question the team’s good will, and have negative expectations that become self-fulfilling prophecies. Mistrust can disrupt assessment, management, and follow-up and can result in the failure of therapies intended to improve quality of life.
Thus, a history of substance abuse can undermine palliative care and increase the risk of morbidity or mortality among patients with progressive, life-threatening diseases. This potential can only be mitigated by a therapeutic strategy that addresses drug-taking behavior while implementing other therapies. To organize this strategy, clinicians who provide palliative care in the cancer setting must be knowledgeable about the basic concepts of addiction medicine.
In this summary, unless otherwise stated, evidence and practice issues as they relate to adults are discussed. The evidence and application to practice related to children may differ significantly from information related to adults. When specific information about the care of children is available, it is summarized under its own heading.1Weissman DE, Haddox JD: Opioid pseudoaddiction--an iatrogenic syndrome. Pain 36 (3): 363-6, 1989.2Colliver JD, Kopstein AN: Trends in cocaine abuse reflected in emergency room episodes reported to DAWN. Drug Abuse Warning Network. Public Health Rep 106 (1): 59-68, 1991 Jan-Feb.3Gfroerer J, Brodsky M: The incidence of illicit drug use in the United States, 1962-1989. Br J Addict 87 (9): 1345-51, 1992.4Regier DA, Myers JK, Kramer M, et al.: The NIMH Epidemiologic Catchment Area program. Historical context, major objectives, and study population characteristics. Arch Gen Psychiatry 41 (10): 934-41, 1984.5Kessler RC, McGonagle KA, Zhao S, et al.: Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Results from the National Comorbidity Survey. Arch Gen Psychiatry 51 (1): 8-19, 1994.6Substance Abuse and Mental Health Services Administration.: Results From the 2001 National Household Survey on Drug Abuse: Volume I. Summary of National Findings. Rockville, Md: SAMHSA, Office of Applied Studies, 2002. DHHS Publication No. SMA 02-3758.
Prevalence Among the Physically Ill
Substance abuse appears to be very uncommon among cancer patients. The reported prevalence of substance abuse issues in cancer patients is much lower than the prevalence in society at large, general medical populations, and emergency medical departments. This relatively low prevalence was also reported in a Psychiatric Collaborative Oncology Group study, which assessed psychiatric diagnoses in ambulatory cancer patients from several tertiary care hospitals. On the basis of structured clinical interviews, fewer than 5% of 215 cancer patients met the Diagnostic and Statistical Manual for Mental Disorders, 3rd Edition (DSM-III) criteria for a substance use disorder.
The relatively low prevalence of substance abuse among cancer patients treated in tertiary care hospitals may reflect institutional biases or a tendency for patient underreporting in these settings. Drug abusers who are poor or feel alienated from the health care system may not seek care in tertiary centers. Those who are treated in these centers may not acknowledge a history of drug abuse. The low prevalence of drug abuse in cancer centers, therefore, may not represent the true prevalence among the cancer population overall. A survey of patients who were admitted to a palliative care unit found indications of alcohol abuse in more than 25% of these patients; this, however, represents highly selected palliative care patients referred to a specialized inpatient unit.
Defining Abuse and Addiction in the Physically Ill
Epidemiologic studies and clinical management depend on an accepted, valid nomenclature for substance abuse and addiction. The pharmacologic phenomena of tolerance and physical dependence are commonly confused with abuse and addiction. Terminology is also strongly influenced by sociocultural considerations that may lead to the sending of mixed messages in the clinical setting. The definitions of addiction and abuse that are applied to patients who are physically ill have been developed from populations of addicts who do not have physical illnesses. The clarification of this terminology is an essential step in improving the diagnosis and management of substance abuse in the palliative care setting. The list below gives the proposed definitions for these terms.
- Proposed Terminology for Substance Abuse
- Physical dependence: Pharmacologic property of some drugs defined solely by the occurrence of abstinence syndrome following abrupt dose reduction, discontinuation of dosing, or administration of a pharmacologic antagonist.
- Tolerance: Diminishing of one or more of the drug effects (either favorable or adverse) that are caused by exposure to the drug; may be pharmacologic or the result of associative learning.
- Substance abuse: Use of a substance in a manner outside sociocultural conventions; according to this definition, all use of illicit drugs and all use of licit drugs in a manner not dictated by convention (e.g., according to physician’s orders) is abuse.
- Addiction: Commonly used term that does not appear in current psychiatric nosologies but can be taken to mean the aberrant use of a substance in a manner characterized by loss of control, compulsive or escalating use, preoccupation, and continued use despite harm.
Physical dependence is defined solely by the occurrence of a characteristic withdrawal or abstinence syndrome following discontinuation of dosing, abrupt dose reduction, or administration of a pharmacologic antagonist. Neither the dose nor duration of administration of opioids required to produce clinically significant physical dependence in humans is known. Most practitioners assume that the potential for abstinence syndrome exists after opioids have been administered repeatedly for only a few days.
Physical dependence is not apparent unless abstinence is induced. In the clinical setting, physical dependence on an opioid is not considered a problem as long as patients are told to avoid abrupt discontinuation of therapy and to avoid the inadvertent administration of an opioid antagonist (including an analgesic from the agonist-antagonist class).
There is often confusion among clinicians about the differences between physical dependence and addiction. Physical dependence, like tolerance, has been suggested to be a component of addiction, and the avoidance of withdrawal has been postulated to create behavioral contingencies that reinforce drug-seeking behavior. These speculations, however, are not supported by experience with opioid therapy for chronic pain. Physical dependence does not preclude the uncomplicated discontinuation of opioids during multidisciplinary pain management of nonmalignant pain. Opioid therapy is routinely stopped without difficulty in cancer patients whose pain disappears following effective antineoplastic therapy. Indirect evidence for a fundamental distinction between physical dependence and addiction is provided by animal models of opioid self-administration, which have demonstrated that persistent drug-taking behavior can be maintained in the absence of physical dependence.
Tolerance, a pharmacologic property defined by the need for increasing doses to maintain effects, has been a particular concern with opioid therapy. Clinicians and patients commonly express concern that tolerance to the analgesic effects of opioids may compromise the benefits of therapy and lead to a requirement for progressively higher and ultimately unsustainable doses. It has been speculated that the development of tolerance to the reinforcing effects of opioids and the consequent need to increase doses to regain these effects is an important element in the pathogenesis of addiction.
Despite these concerns, extensive clinical experience with opioid drugs given for medical reasons has not confirmed that tolerance causes substantial problems. Numerous surveys have demonstrated that most patients can attain stable opioid doses with a favorable balance between analgesia and side effects for prolonged periods.
Clinical observation does not support the conclusion that analgesic tolerance is a substantial contributor to the development of addiction. It is widely accepted that addicts who do not have a medical disorder may not have any of the manifestations of analgesic tolerance. Opioid-treated patients who present with analgesic tolerance typically do so without evidence of abuse or addiction.
Deficiencies in the Current Nomenclature
The definitions of tolerance and physical dependence highlight deficiencies in the current nomenclature applied to substance abuse. The terms addiction and addict are particularly troublesome. In common parlance, these labels are often inappropriately applied to describe both aberrant drug use (reminiscent of the behaviors that characterize active abusers of illicit drugs) and phenomena related to tolerance or physical dependence. Clinicians and patients may use the word addicted to describe compulsive drug-taking in one patient and to describe nothing more than the possibility for withdrawal symptoms in another. It is not surprising that patients, families, and staff become very concerned about the outcome of opioid treatment when this term is applied.
The labels addict and addiction should never be used to describe patients who are only perceived to have the capacity for abstinence syndrome. These patients must be labeled physically dependent. Use of the word dependent alone also should be discouraged because it fosters confusion between physical dependence and psychological dependence, a component of addiction. For the same reason, the term habituation should not be used.
The psychiatric terminology applied to drug abuse and addiction, which has been codified in the DSM-IV, is also problematic. The DSM-IV eschews the term addiction altogether and offers definitions of two types of substance use disorders: substance abuse and the more serious substance dependence. The criteria for substance abuse are focused on the negative psychosocial sequelae of drug use rather than the pattern of use. In contrast, a pattern of use outside of sociocultural convention is considered to be the most important criterion for abuse in other definitions (see list on Proposed Terminology for Substance Abuse). The disparity in these definitions of abuse is confusing and underscores the challenge in labeling drug-taking behaviors in patients who are receiving potentially abusable drugs for legitimate medical purposes.
The DSM-IV criteria for substance dependence highlight psychosocial dysfunction and add the dimensions of physical dependence and tolerance. This is perhaps the most striking example of the nomenclatural problems that occur when criteria developed in substance abusers without medical illnesses are applied in a different context. Most of the criteria for substance dependence disorder indicate that the term is meant to be used in a manner synonymous with addiction. The criteria of tolerance and physical dependence, therefore, are inappropriate and preclude the use of this terminology in the medically ill who may develop tolerance and physical dependence as expected consequences of therapeutic drug use.1Colliver JD, Kopstein AN: Trends in cocaine abuse reflected in emergency room episodes reported to DAWN. Drug Abuse Warning Network. Public Health Rep 106 (1): 59-68, 1991 Jan-Feb.2Gfroerer J, Brodsky M: The incidence of illicit drug use in the United States, 1962-1989. Br J Addict 87 (9): 1345-51, 1992.3Regier DA, Myers JK, Kramer M, et al.: The NIMH Epidemiologic Catchment Area program. Historical context, major objectives, and study population characteristics. Arch Gen Psychiatry 41 (10): 934-41, 1984.4Burton RW, Lyons JS, Devens M, et al.: Psychiatric consultations for psychoactive substance disorders in the general hospital. Gen Hosp Psychiatry 13 (2): 83-7, 1991.5Derogatis LR, Morrow GR, Fetting J, et al.: The prevalence of psychiatric disorders among cancer patients. JAMA 249 (6): 751-7, 1983.6American Psychiatric Association.: Diagnostic and Statistical Manual of Mental Disorders: DSM-III-R. 3rd rev. ed. Washington, DC: American Psychiatric Association, 1987.7Bruera E, Moyano J, Seifert L, et al.: The frequency of alcoholism among patients with pain due to terminal cancer. J Pain Symptom Manage 10 (8): 599-603, 1995.8Dole VP: Narcotic addiction, physical dependence and relapse. N Engl J Med 286 (18): 988-92, 1972.9Martin WR, Jasinski DR: Physiological parameters of morphine dependence in man--tolerance, early abstinence, protracted abstinence. J Psychiatr Res 7 (1): 9-17, 1969.10Wikler A: Opioid Dependence: Mechanisms and Treatment. New York, NY, Plenum Press, 1980.11Portenoy RK: Opioid tolerance and responsiveness: research findings and clinical observations. In: Proceedings of the 7th World Congress on Pain, 1994. pp 595-619.12Foley 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 181-203.13Redmond DE Jr, Krystal JH: Multiple mechanisms of withdrawal from opioid drugs. Annu Rev Neurosci 7: 443-78, 1984.14World Health Organization.: Youth and Drugs. Geneva, Switzerland: World Health Organization, 1973.15American Psychiatric Association.: Diagnostic and Statistical Manual of Mental Disorders: DSM-IV. 4th ed. Washington, DC: American Psychiatric Association, 1994.16Halpern LM, Robinson J: Prescribing practices for pain in drug dependence: a lesson in ignorance. Adv Alcohol Subst Abuse 5 (1-2): 135-62, 1985 Fall-1986 Winter.17Dai S, Corrigall WA, Coen KM, et al.: Heroin self-administration by rats: influence of dose and physical dependence. Pharmacol Biochem Behav 32 (4): 1009-15, 1989.18Jaffe JH: Current concepts of addiction. In: O'Brien CP, Jaffe JH, eds.: Addictive States: Research Publications-Association for Research in Nervous and Mental Disease. Vol. 70. New York, NY: Raven Press, 1992, pp 1-21.19Rinaldi RC, Steindler EM, Wilford BB, et al.: Clarification and standardization of substance abuse terminology. JAMA 259 (4): 555-7, 1988 Jan 22-29.20Sees KL, Clark HW: Opioid use in the treatment of chronic pain: assessment of addiction. J Pain Symptom Manage 8 (5): 257-64, 1993.
Conceptual Issues in Defining Terms for the Medically Ill
Undertreatment, sociocultural influence on the definition of aberrancy, and disease-related variables are concerns that increase the difficulty of assessing drug-taking behavior.
Clinical observation suggests that inadequate management of symptoms may be an impetus for aberrant drug-related behaviors. This concept has been extensively explored in the area of cancer pain. There is compelling evidence that pain is undertreated in populations of medically ill patients, including those with cancer and AIDS. The term pseudoaddiction was coined to depict the distress and drug-seeking that can occur in the context of unrelieved cancer pain. The cardinal feature of this syndrome is that the aberrant behaviors disappear when an effective analgesic intervention is administered. In the cancer population, first-line intervention is often a higher dose of an opioid.
Assessment for pseudoaddiction in the population of known substance abusers who develop painful medical disease is a challenge for clinicians. Clinical experience suggests that aberrant behaviors driven by unrelieved pain can become dramatic or particularly worrisome in substance abusers. Some patients appear to return to illicit drug use as a means of self-medication, at least in part. Others adopt patterns of behavior with health care providers that also generate intense concern about the possibility of true addiction. Although it may be clear that the drug-related behaviors are aberrant, the meaning of these behaviors may be difficult to discern in the context of unrelieved symptoms. Management strategies must reflect the diagnostic complexity.
When a drug is prescribed for a legitimate medical purpose, there is decreasing certainty about the behaviors that could be characterized as aberrant, abusive, or addictive. Although the aberrancy of some behaviors would not be argued (e.g., prescription forgery or the intravenous injection of an oral formulation), many other behaviors are less clear-cut. For example, is it aberrant for the patient with unrelieved pain to consume extra doses of a prescribed opioid, particularly if this behavior was not specifically prescribed by the clinician? Is it aberrant to use an opioid drug prescribed for pain as a nighttime hypnotic?
The importance of social and cultural norms raises the possibility of bias in determinations of aberrancy. Bias against a social group, even if subtle, could influence the willingness of clinicians to label a questionable drug-related behavior as aberrant when performed by a member of that group. Clinical observation suggests that this type of bias is common in the assessment of drug-related behaviors of patients with substance abuse histories. Questionable behaviors by such patients may be promptly labeled as abuse or addiction, even if the drug abuse history was in the remote past. In a similar way, the possibility of bias in the assessment of drug-related behaviors exists for patients who are members of racial or ethnic groups different from that of the clinician.
The core concepts used to define addiction may also be complicated by changes resulting from progressive disease. Deterioration in physical or psychosocial functioning that is caused by the disease and its treatment may be difficult to separate from the morbidity caused by substance abuse. This may particularly complicate efforts to evaluate the concept of “use despite harm,” which is critical to the diagnosis of addiction. For example, the nature of questionable drug-related behaviors can be difficult to discern in the patient who develops social withdrawal or cognitive changes following brain irradiation for metastases. Even if impaired cognition is clearly related to the drugs used to treat symptoms, this outcome might reflect a low therapeutic index rather than the patient's desire for these psychic effects.
The accurate assessment of drug-related behaviors in patients with advanced medical disease usually requires detailed information about the role of the drug in the patient’s life. Time spent out of bed or the existence of mild mental clouding may be less meaningful than other outcomes, such as noncompliance with primary therapy because of drug use or behaviors that jeopardize relationships with physicians, other health care providers, or family members.
Operationalizing the Definitions of Abuse and Addiction
The foregoing discussion emphasizes the difficulties inherent in formulating and applying a nomenclature that would allow appropriate diagnosis of drug-related phenomena in the medically ill. Previous definitions that include phenomena related to physical dependence or tolerance cannot be the model terminology for medically ill populations who receive potentially abusable drugs for legitimate medical purposes. A more appropriate model definition of addiction notes that it is a chronic disorder characterized by “the compulsive use of a substance resulting in physical, psychological or social harm to the user and continued use despite that harm.” Although this definition was developed from experience in populations of addicts who do not have medical illness, it appropriately emphasizes that addiction is, fundamentally, a psychological and behavioral syndrome. Any appropriate definition of addiction must include several important characteristics, including loss of control over drug use, compulsive drug use, and continued use despite harm.
Even appropriate definitions will have limited utility unless operationalized for a clinical setting. The concept of aberrant drug-related behavior is a useful first step in operationalizing the definitions of abuse and addiction. The concept also recognizes the broad range of behaviors that may be considered problematic by prescribers. Although the assessment and interpretation of these behaviors can be challenging, the occurrence of aberrant behavior signals the need to re-evaluate and manage drug-taking, even in the context of an appropriate medical indication for a drug.
In assessing the differential diagnosis for drug-related behavior, it is useful to consider the degree of aberrancy. Less aberrant behaviors (such as aggressively complaining about the need for medications) are more likely to reflect untreated distress of some type, rather than addiction-related concerns. Conversely, more aberrant behaviors (such as injection of an oral formulation) are more likely to reflect true addiction. Although empirical studies are needed to validate this conceptualization, it may be a useful model when evaluating aberrant behaviors.1Breitbart W, Rosenfeld BD, Passik SD, et al.: The undertreatment of pain in ambulatory AIDS patients. Pain 65 (2-3): 243-9, 1996 May-Jun.2Cleeland CS, Gonin R, Hatfield AK, et al.: Pain and its treatment in outpatients with metastatic cancer. N Engl J Med 330 (9): 592-6, 1994.3Weissman DE, Haddox JD: Opioid pseudoaddiction--an iatrogenic syndrome. Pain 36 (3): 363-6, 1989.4Rinaldi RC, Steindler EM, Wilford BB, et al.: Clarification and standardization of substance abuse terminology. JAMA 259 (4): 555-7, 1988 Jan 22-29.
Risk of Abuse and Addiction in Populations Without Drug Abuse Histories
Extensive worldwide experience in the long-term management of cancer pain with opioid drugs has demonstrated that opioid administration in cancer patients with no histories of substance abuse is only rarely associated with the development of significant abuse or addiction. Indeed, concerns about addiction in this population are now characterized by an interesting paradox. Although the lay public and inexperienced clinicians still fear the development of addiction when opioids are used to treat cancer pain, specialists in cancer pain and palliative care widely believe that the major problem related to addiction is the persistent undertreatment of pain driven by inappropriate fear of addiction.
The experience in the cancer population has contributed to a desire for a reappraisal of the risks and benefits associated with the long-term opioid treatment of chronic nonmalignant pain. The traditional view of this therapy is negative. Early surveys, which noted that a relatively large proportion of addicts began their addiction as medical patients who received opioid drugs for pain, provided some indirect support for this perspective. The most influential of these surveys recorded a history of medical opioid use for pain in 27% of white male addicts and 1.2% of black male addicts.
Surveys of addict populations, however, do not provide a valid measure of the addiction susceptibility associated with chronic opioid therapy in populations without known abuse histories. Prospective patient surveys are needed to define this risk accurately. The Boston Collaborative Drug Surveillance Project evaluated 11,882 inpatients who had no histories of addiction and were administered an opioid while hospitalized; only four cases of addiction could be identified subsequently. A national survey of burn centers could find no cases of addiction in a sample of more than 10,000 patients without histories of drug abuse who were administered opioids for pain, and a survey of a large headache clinic identified opioid abuse in only 3 of 2,369 patients admitted for treatment, most of whom had access to opioids.
Other data suggest that the typical patient with chronic pain differs significantly enough from the addict without painful disease that the risk of addiction during therapy for pain is low. For example, surveys of cancer patients and postoperative patients indicate that euphoria (a phenomenon believed to be common during the abuse of opioids) is extremely uncommon following administration of an opioid for pain; dysphoria is observed more typically in those who receive meperidine. Although the psychiatric comorbidity identified in addict populations could be an effect, rather than a cause, of the aberrant drug taking, the association suggests the existence of psychologic risk factors for addiction. The likelihood of genetically determined risk factors for addiction has also been suggested by a twin study that demonstrated a significant concordance rate for aberrant drug-related behaviors.
Overall, the evidence generally supports the idea that opioid therapy in patients with chronic pain and no histories of abuse or addiction can be undertaken with a very low risk of these adverse outcomes. This is particularly so in the older patient, who has had ample time to reveal a propensity for abuse. There is no substantive support that large numbers of individuals with no personal or family histories of abuse or addiction, no affiliations with substance-abusing subcultures, and no significant premorbid psychopathologies will develop abuse or addiction when administered potentially abusable drugs for medical indications.
The inaccurate perception that opioid therapy always has a high likelihood of addiction has encouraged assumptions that are not supportable in populations with no histories of substance abuse. For example, agonist-antagonist opioid analgesics are less likely to be abused by addicts than pure mu agonist opioids. Consequently, some clinicians view the agonist-antagonist drugs as safer in terms of addiction liability. There is no evidence for this conclusion in populations without drug abuse histories. Extensive experience with long-term opioid therapy for cancer pain and chronic nonmalignant pain  has relied on pure mu agonists. Similarly, there is a common perception that short-acting oral opioids and opioids delivered by the parenteral route carry a greater risk of addiction because of the rapid delivery of the drug. Again, these perceptions are derived from observations in the healthy addict population and are not relevant to the treatment of pain in medical patients with no histories of substance abuse.1Jorgensen L, Mortensen MJ, Jensen NH, et al.: Treatment of cancer pain patients in a multidisciplinary pain clinic. The Pain Clinic 3 (2): 83-9, 1990.2Moulin DE, Foley KM: A review of a hospital-based pain service. In: Foley KM, Bonica JJ, Ventafridda V, eds.: Advances in Pain Research and Therapy. Volume 16: Proceeding of the Second International Congress on Cancer Pain. New York: Raven Press, 1990, pp 413-27.3Schug SA, Zech D, Dörr U: Cancer pain management according to WHO analgesic guidelines. J Pain Symptom Manage 5 (1): 27-32, 1990.4Schug SA, Zech D, Grond S, et al.: A long-term survey of morphine in cancer pain patients. J Pain Symptom Manage 7 (5): 259-66, 1992.5Ventafridda V, Tamburini M, Caraceni A, et al.: A validation study of the WHO method for cancer pain relief. Cancer 59 (4): 850-6, 1987.6Walker VA, Hoskin PJ, Hanks GW, et al.: Evaluation of WHO analgesic guidelines for cancer pain in a hospital-based palliative care unit. J Pain Symptom Manage 3 (3): 145-9, 1988 Summer.7WHO Expert Committee on Cancer Pain Relief and Active Supportive Care.: Cancer Pain Relief and Palliative Care: Report of a WHO Expert Committee. Geneva, Switzerland: World Health Organization, 1990.8Drug therapy for severe, chronic pain in terminal illness. Ann Intern Med 99 (6): 870-3, 1983.9Cancer Pain Assessment and Treatment Curriculum Guidelines. The Ad Hoc Committee on Cancer Pain of the American Society of Clinical Oncology. J Clin Oncol 10 (12): 1976-82, 1992.10American Pain Society.: Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain. Skokie, Ill.: American Pain Society, 1992.11Zech DF, Grond S, Lynch J, et al.: Validation of World Health Organization Guidelines for cancer pain relief: a 10-year prospective study. Pain 63 (1): 65-76, 1995.12Portenoy RK: Opioid therapy for chronic nonmalignant pain: current status. In: Fields HL, Liebeskind JC, eds.: Progress in Pain Research and Management, Volume 1. Seattle, Wa.: IASP Press, 1994, pp 247-87.13Zenz M, Strumpf M, Tryba M: Long-term oral opioid therapy in patients with chronic nonmalignant pain. J Pain Symptom Manage 7 (2): 69-77, 1992.14Kolb L: Types and characteristics of drug addicts. Ment Hyg 9: 300-13, 1925.15Pescor MJ: The Kolb Classification of Drug Addicts. Washington, DC: Public Health Reports Suppl 155, 1939.16Rayport M: Experience in the management of patients medically addicted to narcotics. JAMA 156 (7): 684-91, 1954.17Porter J, Jick H: Addiction rare in patients treated with narcotics. N Engl J Med 302 (2): 123, 1980.18Perry S, Heidrich G: Management of pain during debridement: a survey of U.S. burn units. Pain 13 (3): 267-80, 1982.19Medina JL, Diamond S: Drug dependency in patients with chronic headaches. Headache 17 (1): 12-4, 1977.20Kaiko RF, Foley KM, Grabinski PY, et al.: Central nervous system excitatory effects of meperidine in cancer patients. Ann Neurol 13 (2): 180-5, 1983.21Grove WM, Eckert ED, Heston L, et al.: Heritability of substance abuse and antisocial behavior: a study of monozygotic twins reared apart. Biol Psychiatry 27 (12): 1293-304, 1990.22Gardner-Nix JS: Oral methadone for managing chronic nonmalignant pain. J Pain Symptom Manage 11 (5): 321-8, 1996.23Tennant FS J, Uelmen GF: Narcotic maintenance for chronic pain. Medical and legal guidelines. Postgrad Med 73 (1): 81-3, 86-8, 91-4, 1983.24Taub A: Opioid analgesics in the treatment of chronic intractable pain of non-neoplastic origin. In: Collins JG, Kitahata LM: Narcotic Analgesics in Anesthesiology. Baltimore, Md. : Williams and Wilkins, 1982, pp 199-208.25France RD, Urban BJ, Keefe FJ: Long-term use of narcotic analgesics in chronic pain. Soc Sci Med 19 (12): 1379-82, 1984.26Portenoy RK, Foley KM: Chronic use of opioid analgesics in non-malignant pain: report of 38 cases. Pain 25 (2): 171-86, 1986.27Urban BJ, France RD, Steinberger EK, et al.: Long-term use of narcotic/antidepressant medication in the management of phantom limb pain. Pain 24 (2): 191-6, 1986.
Risk of Abuse and Addiction in Populations With Drug Abuse Histories
There is little information about the risk of abuse or addiction during or after the therapeutic administration of a potentially abusable drug to patients with current or remote histories of abuse or addiction. Anecdotal reports have suggested that successful long-term opioid therapy in patients with cancer pain or chronic nonmalignant pain is possible, particularly if the history of abuse or addiction is remote. Although there is a lack of empirical information on this subject, it is generally accepted that the risk of aberrant drug-related behaviors during treatment for a medical disorder is higher among populations with current histories of substance abuse and, to a lesser extent, remote histories.
The most prudent actions cannot obviate risk, and clinicians must recognize that virtually any drug that acts on the central nervous system can be abused through any route of drug administration. Effective risk management of patients with substance abuse histories necessitates a comprehensive approach that recognizes the biologic, chemical, social, and psychiatric aspects of substance abuse and addiction, as well as a practical means to manage risk.1Gonzales GR, Coyle N: Treatment of cancer pain in a former opioid abuser: fears of the patient and staff and their influence on care. J Pain Symptom Manage 7 (4): 246-9, 1992.2Dunbar SA, Katz NP: Chronic opioid therapy for nonmalignant pain in patients with a history of substance abuse: report of 20 cases. J Pain Symptom Manage 11 (3): 163-71, 1996.
Clinical Management of Patients With Substance Abuse Histories
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.[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.
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.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. 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. 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.[Level of evidence: II] 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.1Passik 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, 2000.2Crowther J, Fainsinger R: Incorrect diagnosis and subsequent management of a patient labeled with cholangiocarcinoma. J Palliat Care 11 (4): 48-50, 1995 Winter.3Lawlor 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, 1997.4McCorquodale S, De Faye B, Bruera E: Pain control in an alcoholic cancer patient. J Pain Symptom Manage 8 (3): 177-80, 1993.5Khantzian EJ, Treece C: DSM-III psychiatric diagnosis of narcotic addicts. Recent findings. Arch Gen Psychiatry 42 (11): 1067-71, 1985.6Foley 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 181-203.7Ling 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, 1989.8Kaplan 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, 2000.9Breitbart W, Rosenfeld BD, Passik SD, et al.: The undertreatment of pain in ambulatory AIDS patients. Pain 65 (2-3): 243-9, 1996 May-Jun.10Cleeland 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.
Inpatient Management Plan
Planned approaches can help to ensure the safety of hospital staff and patients with current substance abuse histories. These approaches can help control manipulative behaviors by patients, maintain surveillance of illicit drug use, avoid conflicts surrounding the use of medications appropriately used for pain and symptom control, and communicate knowledge of pain and substance abuse management.
If possible, patients with current substance abuse issues who are scheduled for surgical procedures should be admitted to the hospital several days early to permit stabilization of the drug regimen. This period can be used to prevent withdrawal and provide an opportunity to judge the need for alteration of the plan established on admission.
A variety of actions can be considered in developing appropriate guidelines for the specific concerns posed by a patient. Some patients may be given a private room close to the nursing station to allow for monitoring. Patients may be restricted to their rooms or floors until the danger of withdrawal or illicit drug use is judged to be diminished. It can be appropriate to require a patient to wear hospital pajamas to reduce the risk of departure from the hospital to buy drugs. A patient’s visitors can be limited to family and friends known to be drug-free. Visitors can be told that check-in with the staff is required before contact with a patient is made.
Some patients should undergo one or more searches of their hospital rooms. If illicit drugs, previously prescribed medications, or alcohol are discovered, the items should be removed and discarded in accordance with hospital protocol. Packages brought to the hospital by family members and friends can be searched by responsible staff to ensure that they do not contain illicit drugs or alcohol.
In some cases, it is useful to require periodic urine drug screening. To simplify this process, the patient can be instructed to provide a daily specimen. Some of these specimens are sent for analysis, and others are discarded. The frequency of screening depends on the behaviors observed in the hospital. This approach establishes the concept of regular surveillance for the patient, without excessive use of the laboratory.
Again, this plan must be tailored to reflect the degree of risk perceived by the staff. In some cases, no special requirements are needed, and in others, the severity of recent abuse indicates the need for maximal caution. In discussions with patients, staff can emphasize that the implementation of these guidelines is in the best interests of the patient and institution. Aggressive medical management unencumbered by doubts about the history and concerns about ongoing drug use is possible only if the staff can be reassured that drug abuse is not occurring.
Once a structure is established to control drug use, the medical management of the active abuser must proceed attentively. Frequent visits are usually needed to assess and manage symptoms. Drug withdrawal should be prevented, and prescribed drugs for symptom control should be administered regularly, to the greatest extent possible. This avoids frequent encounters with staff that focus on the patient’s desire to obtain a drug.1Passik SD, Portenoy RK, Ricketts PL: Substance abuse issues in cancer patients. Part 1: Prevalence and diagnosis. Oncology (Huntingt) 12 (4): 517-21, 524, 1998.2Passik 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.
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.1Passik SD, Portenoy RK, Ricketts PL: Substance abuse issues in cancer patients. Part 1: Prevalence and diagnosis. Oncology (Huntingt) 12 (4): 517-21, 524, 1998.2Passik 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.
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