Special considerations in managing pain and psychosocial distress in patients with opioid use disorder and cancer: the role of the supportive care and psycho-oncology interdisciplinary team

Introduction

People with a substance use disorder (SUD) have shortened lifespans due to complications from their substance use and challenges engaging with traditional health care settings and institutions (1,2). This impact on life expectancy is especially prominent in patients with co-occurring SUDs and cancer, and often has a much worse prognosis from the cancer than a similar patient without a SUD. Palliative care teams are experts in serious illness communication and symptom management and have become increasingly embedded in the routine care of patients with cancer. We argue that the skill set of palliative care teams is uniquely suited for addressing the needs of this oft marginalized group. Meeting the medical, psychological, social and spiritual needs of these patients can be particularly challenging, but also uniquely rewarding. In this article, we provide a comprehensive review of tools for addressing these needs, including medications that can both treat pain and opioid use disorder (OUD), and highlight psychosocial approaches to treating patients with OUD and cancer in a way that is respectful and effective. Using a trauma informed framework, we focus on the application of harm reduction principles from addiction medicine and the principles of clear communication, accompaniment, and emotional presence from palliative care to maximize support. We also focus on ways to reduce stigma in the delivery of care, by providing language that reduces barriers and increases patient engagement. Finally, we describe a clinic embedded within our institution’s cancer center which aims to serve patients with cancer and SUDs, built on the framework of harm reduction, accompaniment and trauma informed care (TIC).

While data estimating the co-occurrence of OUD and cancer is sparse (3), the increases in OUD seen in the general population similarly affect the cancer population. Given the stress associated with a diagnosis of cancer, people who use drugs (PWUD) or a history of OUD can be particularly vulnerable. As such, the unique challenges that people with co-occurring cancer and OUD experience present an important opportunity for patient-centered care during this taxing period in an individual’s life. Clinical and psychosocial interventions across multiple disciplines, including palliative care, spiritual care, social work, and addiction medicine, as collaborators with the oncology team, should be thoughtfully employed to enhance peoples’ abilities to engage in care. As the opioid epidemic continues to cause significant morbidity and mortality in this country (4), there has been greater focus on evidence-based whole-person treatment for people living with OUD, including medications for OUD (MOUD), interpersonal treatment, and psychosocial support (5). Many of these interventions are easily translated to the oncology setting and overlap with approaches of the interdisciplinary palliative care team. In fact, cancer clinics can be among the most well-resourced parts of a medical institution, and this allows patients access to providers that they may not otherwise encounter.

Harm reduction

Harm reduction is an approach to care that focuses on lessening the individual harms associated with risky behaviors rather than trying to stop patients from using/engaging entirely. Harm reduction is an important overarching framework that captures both the psychosocial approaches and use of MOUD for pain and OUD that allows for nonjudgmental, person-centered care for people living with OUD and cancer. A diverse array of psychosocial and medical interventions is used in harm reduction. Examples of harm reduction strategies include the use of methadone and buprenorphine to treat withdrawal and cravings in OUD, condom use to prevent sexually transmitted infections, providing bridge prescriptions for buprenorphine therapy when a patient misses an appointment, access to sterile supplies to use drugs (needles, cotton balls, water, alcohol wipes), syringe exchange programs, and safe injection sites for observed substance use. Harm reduction approaches in medicine have been shown to reduce drug related morbidity and mortality, as well as infections [bacterial, fungal, human immunodeficiency virus/hepatitis C virus (HIV/HCV) and other sexually transmitted infections] and suicidality (6-9). The principles of harm reduction acknowledge that individuals have autonomy in their decision-making. While abstinence from substance use is not a realistic goal for many, reducing the risks related to the engaging in substance use is achievable for many.

Harm reduction and stigma

Harm reduction has significant overlap with palliative care: to meet a patient where they are cognitively and emotionally, to determine their individual values and goals, to structure a care plan to support those values, and to overcome barriers to achieving the best possible quality of life given the current circumstances. Like palliative care, harm reduction at its core is about improving quality of life by reducing stigma to increase engagement in care. Evidence shows that the clinical effects of stigma include decreased patient involvement in and commitment to care and taking medications as prescribed across multiple disease processes, including cancer and other serious illness, as well as SUDs (10). Stigma is associated with poor health outcomes, including health seeking behaviors, and has been shown to be a significant source of stress in the lives of marginalized patients (11-15). As such, approaches to reduce stigma around substance use become important vehicles to engagement in care, taking medications as prescribed, and stress reduction, all of which are valuable outcomes in people living with cancer and SUD. A harm reduction framework encourages non-judgmental clinical environments where people can talk about the reality of their lived experience as it relates to their substance use without the weight of shame.

The benefits of a non-stigmatizing clinical environment go beyond objective health outcomes. It fosters a more dynamic relationship between patient and provider and creates space for challenging conversations. Non-stigmatizing care takes a strength-based approach and avoids a punitive tone when addressing barriers and focusing on solutions. When providers create this type of safe environment, it opens avenues for therapeutic approaches that are targeted to the individual. It allows the care plan to employ the person’s unique strengths and create a system of support around identified barriers and weaknesses. Importantly, the knowledge gained about the patient and their life through these destigmatized conversations using a harm reduction framework also allows for a more clinically accurate assessment. Ms. L, for example, was reluctant to discuss the crippling anxiety that led to her self-medicating in the clinic waiting room until she had developed a therapeutic trust with the medical team. The team then was then able to understand that her anti-anxiety regimen had been discontinued, which ultimately led to her return to drug use.

Open and honest conversations about a patient’s drug use are a fundamental part of a harm reduction model. Conversations about whether the patient is interested in continuing to use drugs, reducing the amount, or would like to consider ways of using that reduce risk are fundamental to developing a care plan. Nonjudgmental engagement around both the positives and negatives of substance use provides useful information for clinicians. Questions such as what the patient enjoys about drug use, what purpose it serves in their life, and what they do not like about it are key pieces of data and essential for oncologic care planning. The patient’s answers often implicitly or explicitly shape important clinical decisions, including the type of cancer-directed therapy, delivery method, frequency of visits, monitoring parameters and additional support provided. Knowledge of the benefits that a harm reduction model can create allows the medical team to decrease stigma in practice, and thus promote open conversations and avoid punitive care plans. Table 1 has examples of types of questions and language to use to reduce stigma when discussing substance use in patients with cancer.

Destigmatizing language is particularly important when caring for patients with cancer, as the discussions about care plans can be quite complex, and moral judgement about substance use can confound the delivery of bad news or treatment plan changes. Table 1 shows three commonly occurring scenarios for patients with OUD and cancer that can be challenging and offers language to use to approach patients non-judgmentally. Table 2 includes an expanded set of communication tools. With the employment of a harm reduction framework and nonjudgmental language, these challenges can become opportunities for patient centered care and shared decision making.

Accompaniment

The subtle theme woven throughout harm reduction principles and destigmatization of substance use in clinical settings is that of accompaniment. Accompaniment means being present during both the easy and successful times, as well as the challenging times. Used across multiple disciplines, including social medicine, pastoral support, social psychology and regularly in palliative care, accompaniment references the transformative potential of being present for another. Paul Farmer describes the elements and opportunities of this approach: to accompany someone is to go somewhere with him or her, to break bread together, to be present on a journey with a beginning and an end. There’s an element of mystery, of openness, of trust, in accompaniment. The companion, the accompagnateur, says: “I’ll go with you and support you on your journey wherever it leads. I’ll share your fate for a while—and by “a while”, I don’t mean a little while. Accompaniment is about sticking with a task until it’s deemed completed—not by the accompagnateur, but by the person being accompanied.” (16). In our circumstances, that task may be cancer treatment with curative intent, or decrease in substance use, or the end of life. But all of these tasks have great opportunity to witness and support, whatever path the patient takes. While performing a buprenorphine induction, we must create space to sit with the possibility that the patient has continued to use. While we are asking open ended, person-first questions and employing shared decision making, we must remain present for the difficult answers we will hear. When someone returns to use after a period of nonuse, when they have an accidental overdose, when they show up late or intoxicated to an appointment—across all these traditionally challenging scenarios an important opportunity remains, which is to be present for the patient. If we are able to accompany them throughout their journey, we begin to build a truly therapeutic relationship. The benefits of accompaniment in caring for people with OUD parallel the same benefits of accompaniment and witnessing the journey of people with cancer. This approach takes on significance in the setting of cancer diagnosis and treatment, which can be a pivotal and life-altering phase in peoples’ lives. This work requires the skillset of a transdisciplinary care team, including social work, psychology, psychiatry and spiritual care.

Trauma-informed care

Up to 35% of patients with cancer meet criteria for posttraumatic stress disorder (PTSD) (17). Patients with comorbid cancer and posttraumatic stress are more likely to experience a high symptom burden, including pain, fatigue, and anxiety (18). Additionally, people with a history of PTSD have an increased risk of developing misuse of opioids prescribed during the course of treatment (19). The management of trauma, OUD, and comorbid cancer symptoms require a skilled and intentional framework for reducing psychological and physical symptoms that arise from the confluence of these diagnoses. TIC describes a framework which includes the assessment and modification of clinical care to address the ways in which trauma can affect a person’s ability to interact with the healthcare system (20). Importantly, TIC does not require a diagnosis of PTSD. This is because the symptoms that trauma can cause during the course of a cancer diagnosis and treatment can be tended to without requiring the patient to disclose a history of trauma or diagnosis of PTSD. Recounting this history without the support of a trauma specialist, and at the vulnerable time of cancer treatment could be retraumatizing for some patients. As a result, palliative care clinicians have recommended taking a “universal precaution approach” when caring for patients who are exhibiting possible trauma symptoms such as anxiety, avoidance of triggering or painful environments, or difficulty engaging with providers (21). In this setting, universal precaution means using tools to reduce barriers to engaging in care that do not require screening for trauma. For example, if a patient appears agitated in the waiting room of the clinic, they can be offered early rooming, or alternative more private space to wait. TIC is closely aligned with harm reduction and accompaniment in their shared focus on promoting patient-centered care. TIC is not a single intervention, nor is it structured trauma treatment. Rather, the model is comprised of key assumptions (i.e., the “4 R’s”) and six key principles that can shape how we communicate with patients and develop a mindful care plan (see Table 3) (22).

Although evidence-based trauma therapies are often appropriate for patients with cancer looking to engage in trauma recovery, they require physical and emotional stability, as well as a prognosis that permits several weeks or months of trauma therapy. For example, many trauma therapy modalities require several weeks of intensive psychotherapy that requires revisiting traumatic memory (17,23). While many patients with cancer may benefit from this model of recovery, it is not always feasible for patients with advanced illness. TIC is a framework of care that can be provided by clinicians without disclosure of a trauma history or revisiting a traumatic event. Application of this framework aims to decrease symptoms of trauma, overcome barriers to engaging in health care, and create spaces of safety in oncologic care settings.

Case

Ms. L is a 44-year-old woman with a history of anxiety, depression, post-traumatic stress disorder, stimulant use disorder-cocaine, alcohol use disorder, benzodiazepine use disorder, and OUD on methadone, who was diagnosed with appendiceal adenocarcinoma after presenting to the emergency department with abdominal pain and constipation. In the Emergency Department (ED), her pain was treated with two doses of intravenous hydromorphone yielding adequate reduction in her symptoms. An outpatient consultation with gastrointestinal oncology was arranged for 3 days later, and she was given a prescription for 5 days of oxycodone for pain management. She presented to that visit with her boyfriend and learned the details of her cancer and a positron emission tomography (PET) scan was ordered to guide treatment planning. She reported moderate pain and significant anxiety about the diagnosis of cancer; no medications were prescribed by her oncologist at that visit given her engagement with the methadone clinic. However, she was referred to psychiatry and supportive/palliative care and scheduled with both specialties within the week. The patient missed her PET scan but did arrive for her psychiatry intake appointment in the cancer center. At that visit, when the medical assistant called her name in the waiting room, no one responded. After several attempts, the Medical Assistant (MA) realized that there was a woman slumped over one of the tables in the outer hallway of the clinic waiting room. She rustled the patient awake and walked her back to the exam room, but within a few minutes the patient became increasingly somnolent. Her psychiatrist examined her and then brought her to the adjoining infusion suite, and she received intravenous (IV) hydration and Narcan with rapid improvement in her mental status. She described having such significant anxiety prior to the visit that she took a “Xanibar” that her boyfriend had purchased off the street. She was monitored in the clinic for four hours and advised to go to the ED for continued observation but elected to go home instead due to fears of presenting to the ED. Her urine toxicology screen was positive for opioids, methadone, fentanyl, and benzodiazepines. With the support of oncology navigation, her PET scan was rescheduled, and she arrived for the test, but had not followed the protocol for the dietary restrictions and was forced to reschedule for a second time to avoid inaccurate results. She ultimately had the PET scan done 3 weeks after her initial appointment, and it revealed metastatic disease in the liver. Her oncologist met with her to discuss the PET scan results, but her overwhelming anxiety limited effective communication of details around her serious illness. She was scheduled to return the next day and presented to clinic with a friend for support. She was again found unresponsive in the exam room and received Narcan with effect. After acute management, she reported that her primary care physician had stopped prescribing her long-term benzodiazepine prescription a few months prior to her diagnosis because of not taking medications as prescribed and difficulty following up. Psychiatry was able to meet with the patient the same day, and she was prescribed a 1-week supply of twice daily clonazepam. She met with the oncologist again, this time in a combined visit with the palliative care physician, and recommendations were made for chemotherapy. Given that she endorsed actively using street fentanyl, her medical team feared the risks of a port and open intravenous access and elected to start her treatment with oral capecitabine. She had significant difficulty in communicating with the chemotherapy teaching nurse and the oncology navigators to coordinate her oral chemotherapy. Her cell phone was lost twice, and she struggled to remember appointments.

When caring for Ms. L, we can see the role of TIC in promoting safety, trust, and choice. Utilizing a harm reduction approach for Ms. L’s substance use promotes physical safety by reducing negative health impacts of substance use. Employing destigmatizing language fosters psychological and emotional safety and the approach of accompaniment and non-abandonment can begin to build rapport and trust. Finally, we utilize shared decision-making in care planning around her substance use and cancer, creating opportunity for Ms. L to feel connected to the care team as well as empowered to have some autonomy in her illness narrative. These approaches are all aspects of TIC that can reduce the risk of exacerbation of trauma symptoms by the healthcare setting.

Symptom management and MOUD

More than 50% of patients with advanced cancer have significant pain (5,24,25). Using traditional opioids, such as oxycodone and morphine, which are the mainstay of treatment for cancer-related pain, can create challenges for patients with OUD and can contribute to return to use of street drugs, increase of cravings and emotional turmoil. Therefore, we find that using the same medications used to treat OUD, methadone and buprenorphine, are beneficial for the diverse purposes of treating withdrawal, reducing cravings and treating pain in patients with cancer and OUD (5).

Methadone

Methadone is a synthetic opioid that is a full agonist at the mu receptor and antagonizes the N-methyl-D-aspartate (NMDA) receptor. Its duration of action for analgesia is about 6–8 hours, but half-life ranges widely from 8 to 120 hours. Half-life is on the longer end of this range for opioid naive people and closer to 24 hours for those who are opioid tolerant, but there remains significant interindividual variability across all populations. Methadone is dosed twice to four times daily for pain and once daily for OUD (26). Methadone is available as a pill or liquid, and can be administered orally, through a feeding tube, via intramuscular injection or by vein. Methadone was developed in the 1930s in Germany as researchers sought a synthetic drug to relieve Germany’s opium and morphine shortage (27). It was found to bind the mu opioid receptor effectively and with high affinity, thus playing the dual role of analgesia and blocking the effects of other opioids’ activity at the mu receptor (26). Because the Harrison Narcotic Act of 1914, which regulated the distribution of opiates and cocaine products, was interpreted in court as not allowing physicians to prescribe opioids to treat addiction, methadone would require a federal waiver to be used in the treatment of OUD when it became approved for this indication in the US in 1971. Methadone was Food and Drug Administration (FDA)-approved for use in the US for analgesia in 1947 (27). These regulations continue to shape prescribing today; methadone can be prescribed in split dosing for pain and filled at any pharmacy, but for OUD, methadone must be prescribed by a physician with a federal waiver at a highly regulated outpatient treatment center (OTP) as outlined in the Controlled Substances Act. In general, OTPs require patients to present and receive their methadone dose daily at the clinic itself, though the COVID-19 pandemic has prompted increased flexibility in these regulations (28-30). For the purpose of treating pain, however, even with concomitant OUD, methadone can be prescribed in split dosing by any physician or advance practice provider and distributed through a community pharmacy. For people who are newly not using street opioids, additional layers of support may be necessary in this case to ensure dosing is adequate for analgesia, suppression of cravings and treatment of withdrawal symptoms.

Methadone has been shown to reduce OUD related mortality due to lower infectious disease transmission, acute bacterial complications, and overdose (31). Because there is a wide range of doses available, when dosed appropriately, methadone can adequately provide analgesia as well as withdrawal management and minimize cravings even in patients with significant opioid debt due to OUD. Additionally, because of its diverse activity at both mu and NMDA receptors, it is a good pharmacologic form of pain control for neuropathic, visceral, and somatic pain, which have made methadone an important tool in managing cancer related pain (32,33).

For patients starting methadone for pain with split dosing, regardless of whether they have OUD, providers can start at any dose. A typical starting dose would be 5 mg BID or TID and we rarely start higher than 10–15 mg TID even in opioid tolerant people. However, if starting methadone for treatment of OUD in the hospital or OTP, federal law requires the first dose not to exceed 30 mg and the first day’s dose not to exceed 40 mg, unless there is physician documentation that the 40 mg dose did not adequately control withdrawal. Methadone should be avoided in patients with severe liver disease, or known prolonged corrected QT interval (QTc), and monitoring includes checking liver enzymes and QTc at dose increases (34).

Buprenorphine

Buprenorphine is a partial agonist at the mu opioid receptor and an antagonist at the kappa opioid receptor. Buprenorphine has extremely high affinity and slow dissociation at the mu opioid receptor, thus resulting in analgesia, withdrawal treatment, craving suppression and receptor blockade to other opioids (35). As a result of this activity, buprenorphine has been approved by the FDA for the treatment of acute pain, chronic pain and OUD, and has been shown to reduce the risk of overdose when used in combination with other opioids. The medication is lipophilic and has poor oral availability, so is available in buccal films and tabs, intravenous injections, long-acting subcutaneous depo injections, and weekly patches (36,37). It was approved by the FDA for OUD in 2002, again requiring a waiver to allow physicians to prescribe an opioid for addiction due to the Harrison’s Narcotic Act, known as the Drug Addiction Treatment Act of 2000 (DATA 2000). The DATA 2000 waiver initially required all providers who prescribed buprenorphine for pain to have a specific waiver, which was obtained after an 8-hour course. In the first year after certification, providers could prescribe to no more than 30 patients, with the ability to apply to increase in subsequent years to 100, and then 275 patients. In 2002, SAMSHA allowed all providers to prescribe up to 30 patients buprenorphine for OUD by simply registering online. Importantly, a Drug Addiction Treatment Act (DATA) waiver has never been required to prescribe buprenorphine for pain, and now is no longer required for the treatment of OUD (38,39).

The safety profile has made buprenorphine a good choice for many patients with varying types of pain (add number). At analgesic doses, it is approximately 30 times stronger than morphine. Studies range from 1 mg sublingual (SL) buprenorphine being equivalent to 10–90 oral morphine equivalents with significant interindividual variability (40). Due to its partial agonism, it has clinically significant reduction in sedation and respiratory depression and a lower overdose potential (41,42). There is also increasing data to suggest that buprenorphine has less immunosuppression, and cognitive effects compared to some full agonist opioids (41). There remains debate on whether there is a ceiling effect on analgesia, though evidence suggests that increasing doses continue to provide further pain control (42,43). At a dose of 2 mg, approximately 41% of mu opioid receptors are bound, at 16 mg, approximately 80% are saturated, and at 32 mg approximately 84% are saturated (44). Studies done on people who use heroin found that 16 mg was required to treat symptoms of withdrawal and adequately suppress cravings. Recent data suggests that higher doses are needed to treat withdrawal and cravings in people who use fentanyl (45,46). More recent studies and expert opinion have also demonstrated the utility of buprenorphine in cancer-related pain (32,47).

Withdrawal cocktail

Other medications can be used to treat physical and psychologic symptoms of withdrawal. For these symptoms, we generally utilize a withdrawal cocktail for further symptom management: quetiapine [25–100 mg twice a day as needed (BID PRN)] for agitation/insomnia, lorazepam [0.5–1 mg TID (three times a day) PRN] for anxiety, clonidine (0.1 mg TID PRN) for agitation/anxiety, ibuprofen (800 mg TID PRN) and acetaminophen (1,000 mg TID PRN) for bone/other pain associated with withdrawal (48).

Case scenarios

We will describe some common case scenarios and recommendations on approaches to take utilizing the above medications.

Patient who is actively using fentanyl or street opioid and does not have cancer-related pain: in this patient, we generally recommend induction on buprenorphine, or if they have a strong preference, methadone at an OTP. To transition from a street opioid or prescribed full agonist, we recommend one of two approaches:

• Buprenorphine:
  • If the patient is already in withdrawal.
    • Day 1: begin dosing buprenorphine/naloxone at 4 mg every 2–6 hours up to 16 mg;
    • Day 2: give the total dose from day 1 in the morning. Up to an additional 8 mg can be given, if needed, in the afternoon;
    • Day 3: the total daily dose established on day 2 (up to 24 mg) can be given once daily, or in split dosing, if patient prefers.
  • If the patient is not in withdrawal.
    • We utilize a microdosing approach, or Bernese method, either with low doses of buccal/sublingual buprenorphine, or with a butrans patch. See Tables 4,5 for example of microdosing.
  • Prescribe appropriate elements of the withdrawal cocktail described previously to manage withdrawal symptoms.
• Methadone:
  • Refer to a methadone clinic (OTP).

Patient who is actively using fentanyl or street opioid and has non-cancer-related pain: for patients in this category, we generally recommend buprenorphine in split dosing, as described below, but methadone remains an option in some patients.

• Buprenorphine:
  • Buprenorphine induction as above, but instead of daily dosing, use either TID or QID dosing, evenly splitting the 24-hour dose, which would be expected to range from 16–24 mg or even 32 mg (if regular fentanyl use).
• Methadone:
  • Under close support and monitoring, we recommend starting at 10 mg TID while they are in the hospital. A more typical starting dose for methadone is 5 mg TID, but patients with high opioid tolerance generally have a more effective initiation at 10 mg TID. After 3 days, if the person has not started to experience pain relief and decrease withdrawal symptoms and cravings, we increase by 5 mg per dose every 3 to 5 days (15 mg TID, then 20 mg TID, etc.) until a total of 90 mg daily. If the patient remains poorly controlled at that time, we increase by 10 mg per dose every 3 to 5 days. In the outpatient setting, we use the same pattern but titrate every 7 days for ease of prescriptions. For increased support, we will usually provide 1 week supply of methadone with split dosing, initially.

Patient currently on methadone through an OTP and requires additional analgesia either due to end of dose failure with daily dosing, or worsening cancer related pain: we generally take one of three approaches, always done in discussion between palliative care/oncology team with patient and their methadone team:

• Split dosing with prescribing continuing from OTP. This usually requires provider to provider discussion with case discussion. Good candidates for this approach are generally people more recently started on methadone, less stable in their ability to avoid street medications, or who are continuing to actively use opioids; or
• Split dosing with palliative care/oncology team prescribing. Good candidates for this are generally patients who are more stable in their desire and ability not to return to use or those with shorter prognoses, for whom going to daily OTP has a significant quality of life burden. We generally begin with one to two week supply of methadone with close support for patient; or
• Continue daily dosing through the OTP with additional opioid agonist in addition (hydromorphone, oxycodone, or morphine) most often prescribed by the palliative care/oncology team, and with close communication with OTP team.

Patient currently on buprenorphine for OUD through another provider or you, and has worsening cancer related pain:

• Increase buprenorphine split dosing to a total daily dose of up to 32 mg.

Patient who is actively using fentanyl and does not want to stop, or is not confident in their ability to stop:

• Buprenorphine is still recommended for people with ongoing opioid use, for the purpose of overdose reduction. If the patient is amenable, after initiating buprenorphine, a switch/augmentation with sublocade (extended-release buprenorphine injection) is appropriate.

Patient for whom MOUD does not adequately control pain:

• If the patient is on buprenorphine, increase the total daily dose to 32 mg in split three or four times daily, and if not adequate consider rotation to either methadone or another full agonist medication.
• If methadone is not adequate, consider opioid rotation or addition of a different full agonist as needed.

Return to the case

In collaboration with her oncology team, psychiatry and palliative care established a routine weekly visit at a regular time. During those appointments, she met jointly with the psychiatrist, the palliative care physician, the social worker and the chaplain, each of whom was intricately involved in her care. Her oncologist met with her monthly following the integrated team meeting. As a result of the initiation of the weekly visit, her ability to engage in care changed drastically and she did make it to all of her appointments. When she was running late because of transportation barriers, she called the clinic from the methadone clinic and social work was able to troubleshoot a solution with her. Over the next 4 months, the patient continued to attend her weekly clinic visits and remained stable on her oral chemotherapy regimen. Her next monitoring CT scan revealed evidence of small progression of her primary tumor, necessitating treatment change. Given her consistency with visits and avoidance of intravenous drug use, her oncologist, in collaboration with the patient, decided to have a port placed and to initiate IV chemotherapy. While she experienced anticipatory anxiety about the initiation of IV chemotherapy, she was able to discuss the concerns with her interdisciplinary treatment team for support. She arrived on-time to her appointment for port placement and the procedure was performed uneventfully. IV chemotherapy was started and she successfully completed 6 months of FOLFOX, which necessitates a 48-hour take-home infusion. She remained involved with the interdisciplinary treatment team with weekly visits.

After the success seen with the patient described above, our supportive care and psycho-oncology teams recognized the opportunity to coordinate supports for patients with SUDs actively receiving treatment for cancer. Our team identified both the major barriers faced by patients with SUD and best practice approaches to help patients navigate these challenges throughout cancer treatment. With these challenges in mind, we proposed a novel multidisciplinary clinic that provided a team-based approach with a diverse group of clinicians with unique perspectives to provide holistic patient-centered care. We met with the cancer center administration to review the goals, the financial requirements, and workflow of the clinic and how it aligned with the needs of the cancer center and the patients. Our administration was enthusiastic and supportive. The model included weekly combined visits with the palliative care physician, psychiatrist, social worker and chaplain. Many of our patients have peer support in the form of sponsors, community health workers and peer recovery specialists from the community or other departments of our organization, so are always included in care coordination and support when available. Other team members—including the palliative care nurse navigator, the healing arts therapist, and learners—join the team and patients at these visits when schedule permits. Of note, the oncologist and oncology advanced practice providers continue to meet with patients at the appropriate intervals based on an individual’s treatment plan and diagnosis and are not seeing patients in the combined recovery clinic. Our visits are billed as regular outpatient palliative care and psychiatry visits and our social workers and chaplains are not billing providers at this time. Funding for their support comes from the cancer center funding for spiritual care and social work.

We created eligibility criteria for the patient referral process, which consisted of patients with known active SUD or evidence of active SUD, receiving or planning for active cancer treatment, a referral from the primary oncology team, and the ability to be seen at our primary clinic location. In addition, patients could not be in treatment with another addiction recovery team, with the exception of care at a methadone clinic, unless an agreement with that team had been specifically made to transition care during cancer treatment to our team. After several months of planning, our clinic began weekly operation. We recognize the importance of consistency for our patients, so each patient is given a specific time slot held for them. The time slot does not change week to week and the appointment structure, place and time is always the same. For example, we advise patients that it does not matter if they lose their phone, are in transition with housing, or have other stressors, we will see them at 10:00 every Wednesday morning on the first floor of the cancer center. Initial visits are one hour, and all subsequent visits are thirty minutes. The visits are combined, so in their 30-minute time slot, the patient sits together at a small conference table with all four clinicians. If a comprehensive physical exam is warranted, one of the physicians can accompany the patient to the exam room next door.

At a typical visit, topics of discussion include news from the patient’s week, symptoms that arose during the week and evaluation of symptoms that are currently being monitored, pain levels, anxiety symptoms, discussions about key relationships, drug use during the preceding week, urges and cravings, new and ongoing social stressors, upcoming medical tests, the most recent visit with medical oncology, coping strategies and fun or enjoyable things that happened that week. We utilize a collaborative approach with the discussion flowing easily among providers and the patients. In certain situations, the social worker may take the lead in the discussion or reference something that she and the patient had been working on the week prior. Other situations are more medication-focused and thus one of the physicians will take the lead.

Medications are consistently prescribed for recovery, as well as pain, anxiety, insomnia and other symptoms common during cancer treatment. All patients are encouraged to have their prescriptions for controlled substances (opioids and benzodiazepines) filled at the hospital pharmacy, so that our team can have enhanced communication with the pharmacists and to access pharmacy benefits to provide no cost medications, if needed, through our social work department. For any controlled substance, we provide weekly prescriptions to best support consistency, follow-up and lower the possibility of return to substance use. When appropriate, we refer patients to additional behavioral health services within our hospital or in the community, including various forms of trauma-based therapy, cognitive behavioral therapy, dialectical behavioral therapy, group therapy, intensive outpatient program, partial hospitalization program, and if needed inpatient hospitalization. While we provide referrals, as well as social work, chaplain and psychiatric support within our clinic, we do not require patients to engage in mental health care if they do not feel ready. Following an evidence-based approach to substance use recovery, we generally recommend MOUD as first line therapy, providing education around the increased risk of return to use and fatal and non-fatal overdose in the first year of recovery for people with OUD not on an opioid agonist or antagonist, when compared to detoxification, behavioral treatment and no treatment at all (49). For many patients, psychosocial and behavioral treatment are important adjuvants to MOUD, however, it is important to take a patient centered approach, utilizing shared decision-making to develop a care plan that delineates which modalities are appropriate for the individual at various points in their recovery process.

Providing this high touch and intensive connection with the cancer center team allows patients to feel supported, feel accountable to themselves and to the team, and have their needs assessed on a regular basis. Importantly, the team uses a trauma-informed approach in interactions with patients, most of whom have a significant trauma history. Much of the language provided in Table 2 is aimed at understanding the unique strengths and triggers for people who have experienced trauma. We aim to use patient-first terms and language that would be utilized in front of the patient when discussing privately with the team. Using person-first language is an evidence-based approach to reduce stigma around substance use and mental health in the medical setting (50). This practice also often leads to more nuanced language that both more accurately captures the clinical picture and positively shapes how we conceptualize what is happening for patients. The practice allows room for discussing providers’ own frustrations and challenges while acknowledging and honoring the lived experience of the patient.

Conclusions

In this manuscript, we hope to have provided a context for addressing the common challenges that have emerged from our work with patients with cancer and OUD, including the direct impact of psychosocial stress on their substance use and cancer treatment, delays in disease directed treatment that can potentially impact further treatment options, as well as outcomes, challenging pain management due to greater opioid debt, and potential loss of primary coping mechanism through substance use in the face of potential terminal diagnosis. We have seen that a thoughtful interdisciplinary palliative care team as a partner to the primary oncology team is a powerful way to reduce stigma, accompany patients, provide symptom management and ultimately support disease directed therapy in people with OUD and cancer.

Acknowledgments

We would like to thank our patients, who allow us to accompany them on their journey with serious illness.

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Annals of Palliative Medicine, for the series “Palliative Care in GI Malignancies”. The article has undergone external peer review.

Peer Review File: Available at https://apm.amegroups.com/article/view/10.21037/apm-22-1409/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://apm.amegroups.com/article/view/10.21037/apm-22-1409/coif). The series “Palliative Care in GI Malignancies” was commissioned by the editorial office without any funding or sponsorship. K.A. served as the unpaid Guest Editor of the series. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent for publication of this case not obtained from the patient or the relatives after all possible attempts were made.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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