Substance Use Disorder in Hospice Patients: To Treat or Not to Treat?
By Jaimy Abraham
The use of opioids amid the current opioid crisis is a problem many health-care providers are facing when managing pain in patients. A sharp rise in overdose deaths involving opioids was seen in 2013 and is still trending upward. Since then, several restrictions have been placed on opioids in efforts to prevent misuse and substance use disorders (SUDs); however, hospices have been largely exempted from falling under those restrictions. Opioids continue to be the mainstay of treatment for pain in hospice patients, yet a common challenge seen with many of those patients is the diagnosis of a SUD. Up to 25% of hospice patients have SUDs and unfortunately, most hospice programs do not have policies or guidelines in place to combat it. Gabbard et al. recognized this dilemma and found that it begs the question: since the goal of hospice is to alleviate pain and suffering in patients, what should providers do if their patient has a SUD?1
Providers opposed to treating SUDs in hospice patients argue their patients should be allowed to continue taking their opioid analgesics, even with a SUD. One of many concerns is that refusing opioid analgesics could be considered maltreatment in these patients with uncontrolled pain and that opioid induced analgesia is a comfort measure for a dying patient. Since the management of a SUD can be very time consuming and labor intensive, some providers feel it is not a good use of their time, especially since these patients are close to end of life. Additionally, it may be difficult to assess if a patient’s pain is “true pain” or if it may be due to an addiction, so clinicians find that withholding opioids become harmful in that setting.2
On the other hand, there are clinicians who feel that hospice providers need to recognize SUDs as a disease that can result in uncontrolled pain. These untreated addictions can lead to worsening quality of life and difficulties for both patients and their loved ones. Unmanaged SUDs can also open the door to many complications such as increased suffering and stress, poor physician-patient communication, significant drug interactions seen with polypharmacy, tolerance issues, and very importantly—potential for diversion. Providers argue that addiction can mask other symptoms complicating palliative care efforts and it is crucial for hospice providers to screen for SUDs and properly manage uncontrolled pain.
Many providers have a recognition of the importance of SUDs management yet find themselves lacking the proper understanding of how to do so. The CDC published guidelines for prescribing opioids for chronic pain in 2016 but it was not intended for use in end of life care. Some states have introduced additional practices adopted from the CDC guidelines such as the use of a Risk Evaluation and Mitigation Toolkit aimed to reduce substance misuse and diversion by the Virginia Association for Hospices and Palliative Care.3
Management of hospice patients with SUDs calls for an increase in staff education, use of screening tools, and techniques to ensure patient safety while managing pain. Hospice staff should receive proper training on how to recognize risk factors for SUDs, red flags for misuse, and how to communicate with patients and families when opioid misuse occurs. All hospice patients should be screened for SUDs using a validated screening tool such as the Opioid Risk Tool (ORT). Techniques to ensure patient safety should be implemented such as a pain management agreement between the provider and patient, use of buprenorphine or methadone, and naloxone co-prescription training for family members. Several providers voice the importance of approaching patients with SUDs by openly communicating their pain management with firmness alongside empathy. Overall, routine screening for SUDs in the hospice setting is warranted in order to provide appropriate pain management and prevent potential diversion.
1. Gabbard, J., Jordan, A., Mitchell, J., Corbett, M., White, P., & Childers, J. (2019). Dying on Hospice in the Midst of an Opioid Crisis: What Should We Do Now? American Journal of Hospice and Palliative Medicine®, 36(4), 273–281. https://doi.org/10.1177/1049909118806664
2. Spitz, Aerin, et al. “Primary Care Providers’ Perspective on Prescribing Opioids to Older Adults with Chronic Non-Cancer Pain: A Qualitative Study.” BMC Geriatrics, vol. 11, no. 1, 2011, doi:10.1186/1471-2318-11-35.
3. Virginia Association for Hospices and Palliative Care: http://c.ymcdn.com/sites/www.virginiahospices.org/resource/resmgr/REM_Folder/Final_REM_Tool_Kit_for_elect.pdf