Cancer Pain Control in the Setting of Substance Use: Establishing Goals of Care

Abstract

Mr. I.M. was a 62-year-old man with a presumptive diagnosis of non-small-cell lung cancer. He also had a long history of alcohol and street drug use, including cocaine and morphine. His other comorbidities included: COPD, liver disease secondary to alcohol use, hepatitis C, peptic ulcer disease, degenerative disc disease, and chronic pain after a remote traumatic episode. A left upper lobe lesion was first noted on chest x-ray in October 2002. Over the following year, he was investigated on two different admissions for weight loss and hemoptysis, but each time he refused biopsy of the lung mass. During the second admission, appointments were made for the patient to follow up with oncology, but he did not attend these appointments. Three years after the initial abnormal chest x-ray, he was assessed for hospice placement. At this time, Mr. I.M. was staying at a single men's shelter in the inner city area. Each day he had been dispensed eight tablets of MS Contin 60 mg and eight tablets of Percocet by the nurse at the single men's shelter. He was assessed by the regional palliative care team (5). It was felt that he would benefit from admission to the tertiary palliative care unit for further workup and symptom control prior to transfer to a hospice. The patient agreed to this and was admitted the following day. On arrival, when asked what his expectations were of this stay, he stated only that he just needed a place to stay. When assessed on admission, he complained of pain, his description of which was vague in location and nature. He also had shortness of breath on exertion, cough, and hemoptysis. Drowsiness and myoclonus suggestive of opioid-induced neurotoxicity were observed. It was suggested that he be rotated to methadone. He agreed and a three-day methadone rotation was begun.

Goals of care: a concept clarification

“…Communication must happen if patients are to understand their diagnosis, prognosis and treatment options and for providers to understand patient's values, desires and preferences for treatment. It is essential that there be communication with the patient to establish GOC (Burton‐Macleod & Fainsinger ).…”

“…Ongoing discussions to reassess goals appeared commonly as a consequence for all disciplines. Ongoing discussions are needed to reassess goals as people, circumstances, diagnoses and technology change (Burton‐Macleod & Fainsinger , Kaldjian et al . , Hui et al .…”

“…Ongoing discussions to reassess goals appeared commonly as a consequence for all disciplines. Ongoing discussions are needed to reassess goals as people, circumstances, diagnoses and technology change (Burton-Macleod & Fainsinger 2008, Kaldjian et al 2008, Hui et al 2009, Irvin et al 2011. While there can be conflicts between goals, the literature supports following the patient's wishes over the family's or healthcare team's wishes (National Cancer Institute n.d., Smith & O'Neill 2008, American Nurses Association 2009, Grooms et al 2010, Kaldjian 2010.…”

Prevalence of Substance Use in Patients With Cancer Receiving Radiation Therapy

“…A lack of knowledge regarding tolerance and analgesic principles represents a barrier to effectively prescribing opiates, which can lead to inappropriate pain management (Kim, Park, Park, & Park, 2011). Finally, patients with cancer have reported that they are not asked by their providers about their substance use histories (Burton-MacLeod & Fainsinger, 2008).…”

“…Interventions include harm reduction strategies called "universal precautions," a set of practices such as pain contracts and routine assessment of aberrant behaviors. Also recommended is the use of substance use treatment concurrent with cancer therapy (Burton-Macleod & Fainsinger, 2008;Kirsh & Passik, 2006;Passik & Theobald, 2000;Whitcomb et al, 2002).…”