Palliative care providers caring for patients suffering a heavy pain burden are torn between their calling to relieve suffering and the risk of opioid addiction.
• Most use urine drug-testing, treatment agreements, and practitioner database monitoring programs.
• Many palliative care providers lack training in caring for patients with addiction.
• There is a shortage of addiction specialists to treat patients.
Palliative care specialists once became involved only at the very end of a patient’s life, but many referrals now occur much earlier. The American Society of Clinical Oncology’s recently updated guidelines recommend that patients suffering from advanced cancer receive dedicated palliative care services with eight weeks of diagnosis.1
This change has resulted in many benefits for patients. It also means that opioids are being given for longer time frames, raising some ethical concerns. “This is a very complex zone that has gotten more complex in the context of the opioid epidemic,” says Timothy E. Quill, MD, a professor of medicine, psychiatry, and medical humanities at University of Rochester (NY)’s Palliative Care Program and co-author of a recent paper on this topic.2
For years, palliative care providers believed, based on claims of pharmaceutical companies and medical societies, that the risk of addiction was very low. “The thinking was that opioids could safely be given at high doses as long as they were given under medical supervision,” explains Jessica S. Merlin, MD, PhD, MBA, another co-author of the paper. Merlin is a visiting associate professor of medicine at the University of Pittsburgh.
Opioids were initially used only to keep hospitalized patients comfortable in advanced stages of cancer. “The field of palliative care fought so hard to get opioids seen as something that were not given only at the patient’s dying breath,” says Merlin.
Unrelieved suffering was the ethical concern then — and now, Quill explains. “The pendulum has swung so far in the direction of fear of prescribing opioids, such that many patients who have very serious, potentially terminal illness that is very painful now have a hard time finding a clinician willing to treat their pain.”
Culture Shift Needed
There are not enough palliative care providers to evaluate and see all such patients. Yet, many providers in other specialties refuse to prescribe opioids under any circumstance. “Clinically, this is a problem that occurs a lot. And it is a topic of much concern and consternation among palliative care providers,” says Merlin. Palliative care providers treating patients with a heavy burden of pain symptoms are torn between their calling to relieve suffering and the risk of opioid addiction.
“We wanted to start a national dialogue about it, and hopefully encourage people to do educational research and policy work around this topic,” says Merlin.
Another recent study looked at 157 palliative care providers’ experiences with managing chronic pain in cancer survivors prescribed long-term opioid therapy.3 Key findings include the following:
• most reported using tools such as urine drug-testing (71%), treatment agreements (85%), and practitioner database monitoring programs (94%);
• only 27% of providers reported having training or systems in place to address addiction.
“This verified what we had hypothesized about addiction treatment resources,” says Merlin, the study’s lead author.
What should palliative care providers do if the patient develops an opioid use disorder? “Ideally, their role should be to treat that opioid use disorder, just as the palliative care provider would treat any other complication of the opioids they’re prescribing,” says Merlin. There are multiple barriers to ethical care if patients develop an opioid use disorder, including:
• some institutions do not have a culture of identifying and treating addiction;
• many palliative care providers lack training in how to care for patients with addiction;
• treating addiction takes time and resources, and providers may lack both;
• there is a shortage of addiction specialists to treat patients.
“Integrating addiction treatment into the palliative care setting is one solution,” says Merlin. In this model, palliative care providers give basic addiction care and call a specialist only if necessary, similar to a primary care physician providing basic diabetes care and involving an endocrinologist as needed.
“Embedding addiction specialists within clinics encountering significant numbers of patients with opioid use disorder is another possibility,” says Merlin. This mirrors the integration of addiction specialists in some primary care clinics.
There is no reason why palliative care providers can’t treat an opioid use disorder, argues Merlin: “Treatment may depend on the patient’s prognosis, but it doesn’t require a whole lot of specialized knowledge. We don’t need to reinvent the wheel.”
There is always the risk that someone will misuse and divert opioids to the general population. “This must be balanced against the risk of undertreating seriously ill patients who may die in pain because we are afraid of overtreating,” says Quill.
Known best practices include prescribing contracts and clear policies of how best to prescribe and monitor. More research is needed, says Quill, “to learn the specifics about what works and what does not since, there is so little data.”
At the institutional level, Merlin wants to see frontline palliative care providers become more vocal: “A culture shift is needed around this issue.”
1. Ferrell BR, Temel JS, Temin S, et al. Integration of palliative care into standard oncology care: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol 2017; 35:96-112.
2. Schenker Y, Merlin JS, Quill TE. Use of palliative care earlier in the disease course in the context of the opioid epidemic. JAMA 2018; 320(9):871-872.
3. Merlin JS, Patel K, Thompson N, et al. Managing chronic pain in cancer survivors prescribed long-term opioid therapy: a national survey of ambulatory palliative care providers. J Pain Symptom Manage 2018 Oct 17. pii: S0885-3924(18)31000-5. doi: 10.1016/j.jpainsymman.2018.10.493. [Epub ahead of print]
• Jessica S. Merlin, MD, PhD, MBA, Visiting Associate Professor of Medicine, University of Pittsburgh. Email: firstname.lastname@example.org.
• Timothy E. Quill, MD, Professor of Medicine, Psychiatry and Medical Humanities, Center for Ethics, Humanities and Palliative Care, University of Rochester (NY) School of Medicine. Phone: (585) 273-1154. Email: email@example.com.