Abstract and Introduction
Abstract
Pain is a common, feared, and often undertreated symptom faced by people with life-limiting illnesses. Those with substance use disorder are at an even greater risk of inadequate pain management. Much of the literature addresses those with chronic nonmalignant pain, with limited literature focusing on those with advanced illness, pain, and comorbid addictive disease. The purpose of this article was to provide assessment and treatment strategies for safe pain management in this population. This article highlights a case study of a patient with advanced illness, pain, and comorbid substance use disorder who was seen by the palliative care consultation team in the home care setting.
Introduction
People with life-limiting diseases often have pain. In those with cancer, prevalence may range from 14% to 100%. Despite advances in the treatment of pain, many people do not have their pain adequately managed. Certain subgroups of patients such as the elderly, minorities, children, and people with a history of substance use disorder (SUD) face a greater risk of being undertreated. People with histories of SUD are often undertreated because of clinician treatment biases. Some may argue that if someone has advanced cancer or another life-limiting disease, there is no reason to be concerned about substance abuse. However, with the advent of advanced therapies, people with life-limiting diseases and pain may live longer and require analgesic treatment for months to years. It is imperative to treat the pain yet provide safeguards to prevent misuse during this time.
Substance Use Disorder and Advanced Disease
Substance use disorder is a term that encompasses both dependence on and abuse of alcohol and/or drugs including nonmedical use of prescriptions drugs taken voluntarily for the purpose of their effect on the central nervous system or to prevent withdrawal. Substance use disorder should not be confused with physical dependence or tolerance that occurs in people who take opioids but do not have an addiction disorder (Table 1). The prevalence of SUD in the United States has been reported to be more than 22 million, and there is a higher incidence in those with mental illness. People with SUD may be subcategorized as those with remote histories of substance abuse, those actively abusing, those in methadone maintenance programs, and those with chronic noncancer pain and SUD. Most of the literature on SUD and pain management reflects those having chronic noncancer pain, with little literature focusing on those with life-limiting diseases. Substance use disorder exists in people with advanced disease, but its prevalence has not been studied extensively.
The clinician must explore differential diagnoses of aberrant drug-related behavior such as pseudoaddiction and chemical coping in people with advanced disease and SUD. Pseudoaddiction can result from inadequately treated pain where a patient exhibits behaviors that may be seen as aberrant. The behavior is a result of inadequate pain management, not the patient's desire for a central nervous system effect. Chemical coping results in the use of analgesics to treat symptoms such as anxiety and depression and must be differentiated from SUD. The clinician should also assess for underlying psychiatric disorders or delirium, which may be mistaken for SUD. This case study will focus on the assessment and treatment of a person with advanced illness, pain, and comorbid SUD who was seen in the home-care setting by the palliative care nurse practitioner.