When evaluating potential opioid management approaches among patients who are experiencing advanced cancer-related pain and using nonmedical stimulants such as methamphetamine and cocaine, members of a panel of palliative care and addiction experts “expressed indifference about stimulant use when the (patient’s) prognosis is short,” according to the authors of a recent study.
In assessing hypothetical situations where a patient with cancer who has a prognosis of weeks to months to live and is using stimulants as well as prescribed opioids, one addiction expert was reported to have noted that “they may have a stimulant use disorder, but they still have terminal cancer,” while another stated that “if prognosis is just weeks to months and pain is well-controlled, (I’m) not sure I really care about other illicit substance use,” according to a study published in the journal Cancer.
“I think (the indifference) has to do with intersectional stigma related to cancer and substance use,” co-author Kate Fitzgerald Jones, Clinical Center and a palliative and addiction nurse practitioner in the section palliative care for the VA Boston Healthcare System, told CURE®.
“Some experts seem to assume that all substance use is pleasurable but in many instances the reasons for substance use may be a source of suffering (such as fatigue or the need to stay awake while unhoused) or even a substance use disorder which is characterized by impairment in function and quality of life,” Jones said. “Likewise, I think sometimes with cancer, people can have an attitude like, ‘Why bother, they may be dying anyway.’ However, I think this misses an opportunity to improving quality of life in the moment and (could be) diminishing the value of someone’s life just because they have a serious illness.”
Among the 120 experts consulted for the study, most were women (74, 62%), White (94, 78%) and physicians (115, 96%), with 57 experts evaluating cases of patients with short prognoses and 63 weighing in on scenarios where patients’ prognoses were longer.
Members of a separate panel evaluating cases where the patient’s prognosis was moths to years “said it was appropriate to continue opioids so long as stimulant use was not an ongoing issue,” and members of both panels agreed that tapering patients’ opioids was inappropriate, with experts referring to such actions as “punitive,” “disruptive,” “not indicated” and could “create more problems” such as “undue suffering” and “opioid withdrawal,” according to the authors.
“Moreover, experts highlighted that opioid tapering would not address the underlying issues of stimulant use and rapid tapering was almost ‘never the right thing,’” the authors wrote.
“I was surprised that more experts did not recommend opioid tapering because I see this in practice and was common several years ago,” Jones said. “I think this is because we have learned that opioid tapering and worsening pain can drive substance use rather than improve safety.”
Jones noted that, consistent with findings published in JAMA Network Open in 2021 and in JAMA Oncology in 2022 (the latter of which she co-wrote), “we found that in the context of cancer, experts weighted heavily the importance of pain control — favoring continuing opioids with close follow up and avoiding opioid tapers. Experts in our study also embodied the spirit of harm reduction and considered rotation to buprenorphine to decrease the risk of opioid related harms with concurrent stimulant use. Although, if patients with cancer had a stimulant use disorder the management strategies were less clear and underscore a need for future research.”
Citing a study published in 2010 in The American Journal of Drug and Alcohol Abuse which found that among 106 adults with chronic myelogenous leukemia or primary myelodysplastic syndrome, 9% reported having used cocaine — a rate, Jones and her co-authors noted, is three times the reported rate in the general American population. The 2010 study also found that lifetime cocaine use was associated with a six-fold risk of death.
“Co‐occurring nonmedical stimulant use in individuals with cancer pain‐prescribed opioids is a significant clinical challenge,” Jones and her co-authors wrote. “Despite this, there are no guidelines or empiric studies (e.g., trial testing or observational studies comparing various management strategies) for how to approach opioid decision‐making in this complex situation.”
“Although we might not be there yet, it is my hope that the healthcare system can be a safe place for people to disclose substance use and for clinicians to develop a non-stigmatizing approach to assessing and treating at risk substance use that incorporated harm reduction,” Jones said. “I think sometimes in cancer care, we demand complete cessation of substance use such as abstinence but for many people that may not be possible or the goal.
“Ideally, a patient and family would be able to voice their goals and values around their medical care and substance use benefits and harms and develop a plan with their healthcare team that best positions the person to achieve their goals while attending to their safety.”
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