Opioid Use Disorder in Palliative Care

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Opioid Use Disorder (OUD) in palliative care patients presents a unique challenge that requires a delicate balance between managing pain and minimizing the risk of substance misuse.  Opioid use disorder can be a chronic, life-limiting illness, and people with OUD are less likely to receive palliative care in communities during the 90 days before death1.

Health care providers should receive training in palliative care and addiction medicine to support people with OUD1. National statistics show that between 62% and 89% of individuals in Canada who pass away could benefit from palliative care1. However, the extent to which people with opioid use disorder (OUD) receive palliative care at the end of life remains unclear1. Given the ongoing drug toxicity crisis, it is important to better understand and provide support for this group1.

Behaviours that may suggest opioid use disorder (OUD) include seeking opioid prescriptions from multiple providers, showing up late to appointments, and avoiding pain management specialists or offers of treatment2.

Screening Tools for Assessing OUD

  • CAGE Questionnaire (Cut down, Annoyed, Guilty, Eye-opener)
  • Opioid Risk Tool (ORT), and various versions of the Screener
  • Opioid Assessment for Patients with Pain (SOAPP)
    • SOAPP-SF (Short form)
    • SOAPP-R (Revised)
    • SOAPP-14 (14-item)2.

Education is a crucial aspect of managing OUD in palliative care. Both healthcare providers and patients must be informed about the complexities of opioid use and addiction, the potential risks of opioid use and misuse, as well as the options available for managing pain2.

Treatment Considerations

  • Under-estimation and under-treatment of pain in patients who are tolerant to, or dependent on, opioids is common3.
  • Opioid therapy should not be withheld in these patients if they require opioid therapy to treat pain resulting from progressive disease4
  • Requests for increases in opioid dose or reports of pain by these individuals should be taken seriously and all attempts be made to identify the source of pain(s) through thorough examinations and investigations as deemed appropriate.4
  • Treatment should proceed with close monitoring and a contract between the patient and the attending physician.4
  • These patients may use higher doses than patients with similar disease processes but without abuse histories4.
  • Providers should discuss openly with patients their history with opioid use and preferences for pain management (both pharmacological and non-pharmacological), and a shared understanding of the risks and benefits of different approaches2.

 

Offering support through counseling, addiction treatment services, and even peer support groups can improve outcomes for patients with OUD receiving palliative care1.

Resources

  1. Lau, J., Scott, M., Everett, K., Gomes, T., Tanuseputro, P., Jennings, S., Bagnarol, R., Zimmermann, C., Isenberg, S. (2024). Association between opioid use disorder and palliative care: a cohort study using linked health administrative data in Ontario, Canada. CMAJ Apr 2024, 196(16), E547-E557. Retrieved from https://www.cmaj.ca/content/196/16/E547
  2. Lewis, C., Schutzer-Weissmann, J., & Farquhar-Smith, P. (2023). Opioid use disorder in cancer patients. Supportive and palliative care, 17(2), 98-103. Retrieved from https://www.binasss.sa.cr/jun23/36.pdf
  3. Hargett, J., & Criswell, A. (2019). Non-pharmacological interventions for acute pain management in patients with opioid abuse or opioid tolerance: a scoping review protocol. JBI database of systemic reviews and implementation reports, 17(7), 1283-1289, July 2019. Retrieved from https://journals.lww.com/jbisrir/fulltext/2019/07000/Non_pharmacological_interventions_for_acute_pain.4.aspx
  4. Pallium Canada. (2018). The Pallium Palliative Pocketbook Pain (Second edition, pp.5-57) https://www.pallium.ca/pocketbook-and-app/

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