Background     The spectrum of substance use disorders (SUDs) is characterized by increasing degrees of craving, compulsive use, loss of control, and continued use despite harm (see Fast Fact #68). Addiction is understood to be a disease with complex genetic, neurobiological, psychosocial, and behavioral determinants. If not properly managed an SUD can: 1) complicate the diagnosis and treatment of psychological (e.g. depression) and physical (e.g. pain) symptoms; 2) compromise compliance with the palliative treatment plan; 3) impair a stressed social support network; 4) weaken trust in patientphysician/nurse relationships; and 5) promote the use of opioids to cope with emotional distress and decision-making – “chemical coping.” 

Prevalence of SUDs in Palliative Care Patients:  Unknown, but it likely reflects that of the general population in which alcoholism and abuse of prescription and non-prescription drugs is common.  Bruera reported a prevalence of alcoholism of 27% in patients admitted to a tertiary care palliative medicine unit.  Kwon identified an 18% prevalence of chemical coping in a Palliative Medicine clinic. Far from being a source of pleasure, SUDs are more commonly a source of suffering for affected individuals and their loved ones. Addressing addiction may allow for: 1) preservation/restoration of damaged social supports; 2) restoration of self-respect and dignity; 3) accomplishment of end-of-life work through recovery; and 4) improvement in quality of life for patients and families. 

Substance Use Disorders and Pain Management     Patients with a current or past history of an SUD are particularly challenging. Patients who are in recovery are often fearful of using opioids, even in the setting of severe pain near the end-of-life. Conversely, the ability to complete a pain assessment and use opioids effectively is challenging in patients with an active SUD. 

Listed below are suggested management techniques in patients with a past or current SUD. 

1. Complete a thorough substance use history. Distinguish between those who have active SUDs from those who are at-risk or in recovery. Validated tools such as the Opioid Risk Tool are available for risk stratification. Explain to patients why your knowledge of this information is important for their care. Be empathic and nonjudgmental. 
2. Encourage participation in recovery programs (e.g. 12-step) 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.  The need for this agreement to be signed by both the patient and provider is controversial but having an agreement that both patient and provider can refer to can foster clearer expectations for safe opioid use and may foster a sense of control over SUD. Components of an opioid agreement include: establishing a single opioid prescriber and pharmacy, employing regular pill counts and urine drug testing (see Fast Fact #110), and utilizing an electronic drug monitoring database. 
5. Use non-opioid analgesics and non-pharmacological measures to their full potential; poorly controlled pain can increase substance abuse behaviors (see Fast Fact #69).
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 counseling and antidepressants; this has been shown to reduce illicit drug use in a hospice population (8). Caution with the co-prescription of opioids with benzodiazepines especially in patients with an estimated prognosis longer than a few months. Retrospective analyses have associated their concurrent use with an increased risk of one-year mortality, opioid overdose, respiratory depression, and emergency room visits (11,12).
8. Monitor closely; frequent contact allows for close patient observation and prescription of limited quantities of opioids. Careful monitoring will usually distinguish whether deteriorating function is due to substance abuse or disease progression. 
9. Recognize that addiction is a chronic, relapsing illness – and respond with increasing structure and compassion. 
10. Develop system policies for identifying and appropriately treating patients with substance abuse.

References

1. Kwon JH. Hui D, Bruera A. A pilot study to define chemical coping in cancer patients using the Delphi method. J Palliat Med. 2015;18. Epub ahead of print.
   1. Kwon JH, Tanco K, Park JC, et al. Frequency, predictors, and medical record documentation of chemical coping among advanced cancer patients. Oncologist. 2015; 20(6):692-697.
   1. Bruera E, Moyano J, Seifert L, et al. The frequency of alcoholism among patients with pain due to terminal cancer. J Pain Symptom Manage. 1995; 10(8):599-603. 
   1. Barclay JS, Owens JE, Blackhall LJ. Screening for substance abuse risk in cancer patients using the Opioid Risk Tool and urine drug screen. Support Care Cancer, 2014;22:1883-1888.
   1. Passik SD, Theobald DE. Managing addiction in advanced cancer patients: why bother? J Pain Symptom Manage. 2000; 19(3):229-234. 
   1. Passik SD, Portenoy RK, Ricketts PL. Substance abuse issues in cancer patients. Part 1: prevalence and diagnosis. Oncology. 1998; 12(4):517-521. 
   1. Passik SD, Portenoy RK, Ricketts PL. Substance abuse issues in cancer patients. Part 2: evaluation and treatment. Oncology 1998; 12(5):729-734.
   1. Podymow T, Turnbull J, Coyle D. Shelter-based palliative care for the homeless terminally ill. Palliat Med. 2006; 20(2):81-86.
   1. Childers JW, King LA, Arnold RM. Chronic pain and risk factors for opioid misuse in a palliative care clinic. Am J Hospice & Palliative Med, 2014  
   1. Blackhall LJ, Alfson ED, Barclay JS. Screening for substance abuse and diversion in Virginia hospices. J Palliat Med, 2013;16(3):237-242.
   1. Sun EC, Darnall BD.  Association between concurrent use of prescription opioids and benzodiazepines and overdose: retrospective analysis. BMJ 2017; 356:j760.
   1. Jann M, Kennedy MK, Lopez G.  Benzodiazepines: a major component in unintentional prescription drug overdoses with opioid analgesics. J Pharm Pract 2014; 27(1):5-16.

Version History:  This Fast Fact was originally edited by David E Weissman MD and published in December 2004. 2^nd edition published April 2009. It was re-edited by Mary Rhodes MD in July 2015 for the 3^rd Edition. 4^th edition edited by Sean Marks MD in April 2019.