Disorders of substance use in palliative care

Ewing, 1984Galvani, 2020Galvani, 2019Haley, 2020MacCormac, 2017Passik, 2000

Disorders of substance use (eg excessive alcohol use, nonmedical use of medications¹, use of illicit substances) can affect clinical management of patients with palliative care needs; for example, substance use can:

• increase patient, carer and family distress
• complicate pain management (see Managing pain in patients with disorders of substance use in palliative care)—disorders of opioid use can be particularly complex
• obscure symptom detection
• increase the risk of delirium
• worsen psychological symptoms (eg anxiety, depression, agitation, psychosis)
• complicate management of psychiatric disorders
• cause drug interactions.

Disorders of substance use can be longstanding or may be triggered by distress associated with the diagnosis and impact of living with a life-limiting illness.

Substance use may not become apparent until a patient moves into a supervised setting (eg hospital, residential facility) and can no longer use the substance, precipitating withdrawal. For management of withdrawal, see advice in substance-specific topics in the Addiction guidelines.

Assess substance use with a thorough clinical evaluation; pay particular attention to current and previous substance use (including prescription, over-the-counter and illicit drugs). For general information on screening for and assessment of substance use, see the Addiction guidelines. Some tools can guide assessment of specific substances (eg the AUDIT tool for excessive alcohol useSaunders, 1993). For advice on screening for (and assessment of) use of individual substances, see the substance-specific topics in the Addiction guidelines.

Seek advice from and work in collaboration with a drug and alcohol service, particularly for patients who require opioids and who receive medication-assisted treatment of opioid dependence (MATOD), or who have severe withdrawal symptoms or complex care needs. See clinician resources in the Addiction guidelines for contact details of substance use clinical advisory services.

Identify and treat co-existing psychiatric disorders (eg mood and anxiety disorders, psychotic disorders) because these are highly prevalent in patients with disorders of substance.

Address disorders of substance use in the palliative care plan, and agree on realistic management goals.

For patients with palliative care needs and disorders of substance use, consider potential benefits and burdens of treatment, and the patient’s prognosis, preferences and goals of care—see Principles of symptom management in palliative care. Take a nonjudgmental, flexible and compassionate approach when working with patients with disorders of substance use, based on trauma-informed care and awareness of stigma as a barrier to accessing treatment. For an outline of management options, see an overview of interventions. Aspects of management may involve:

• psychosocial support
• harm reduction strategies to reduce the impact of continued substance use (eg strategies to reduce risk of falls or overdose)
• replacement—for example, nicotine replacement therapy to aid smoking management
• gradual dose reduction
• monitoring for and managing withdrawal symptoms that may occur with reducing or stopping use (eg alcohol withdrawal, benzodiazepine withdrawal).