Palliative Care and Harm Reduction: Improving Outcomes for Patients With Cancer, SUD

Pain management and substance use disorder (SUD) present unique challenges for patients with cancer. At the 2024 Society of Pain and Palliative Care (SPPCP) Virtual Conference, presenters Sachin Kale, MD, MBOE, and Kyle Quirk, PharmD, discussed challenges related to limited training of health care professionals (HCPs) in the management of patients with cancer-related pain and SUD. They highlight a need for a more comprehensive medical model that incorporates harm reduction strategies in palliative care and fosters a patient-centric approach to treatment.

Harm reduction strategies are an integral step to effectively incorporating palliative and substance use care for patients receiving cancer-related pain treatment.

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HCPs often face uncertainty and have limited training in managing concurrent pain and SUD, leading to improper application of treatment models for patients with multiple conflicting conditions. Historically, palliative care is an inpatient setting reserved for patients with serious, complex, and/or terminal illnesses. However, Kale explained that palliative care, due to its focus on pain management and pain reduction therapy, is a successful treatment method for patients with cancer-related pain and SUD.

Cancer-related pain and SUD are traditionally treated separately in palliative care without additional investigation into the impacts of substance use on cancer treatment and the interactions between non-prescribed substances and prescribed medications. Palliative care practices often refer patients to addiction medicine and rely on addiction specialists, who typically lack training in pain reduction therapy and complex symptom management. This separation of care has significant consequences for patients who may struggle with being moved between clinics, may experience inconsistent symptom management, or may be prescribed opioids without prior consideration of existing SUDs.

“The challenges of referring [patients] out to addiction medicine include the fact that addiction specialists typically lack training in pain and complex symptom management. That's what palliative care does,” Kale said.

Kale discussed the development of a palliative-led approach focused on harm reduction as a beneficial clinical approach for patients with cancer and SUD. According to Kale, integration of harm reduction strategies in palliative care require 3 steps: adopting the principles of harm reduction, adopting the strategies of harm reduction, and adding those strategies for safer opioid prescribing.

Harm reduction principles are centered around relationships between HCPs and their patients, paying close attention to creating and nurturing a patient-centric environment. The 6 principles discussed—humanism, pragmatism, individualism, autonomy, incrementalism, and accountability without termination—help HCPs best approach cases of substance use. This equips them with tools to foster a patient-centric approach that recognizes their patients as individuals who have the autonomy to participate in establishing treatment regimens, have their own morals and goals related to substance use, and are deserving of care regardless of relapse.

Harm reduction strategies are an integral step to effectively incorporating palliative and substance use care for patients receiving cancer-related pain treatment. Not all strategies may apply for every practice, however the mechanisms by which harm is reduced are. Mechanisms of harm reduction aim to reduce acute harms of substances, such as an overdose; reduce the complications of use, such as infection or trauma; reduce harm by decreasing use of substances; and reduce harm by continuing to engage in care.

“I think what's most important is the mechanisms by which these reduce harm,” Kale said, “And how you can incorporate these mechanisms into your practice.”

In addiction medicine, traditional harm reduction strategies provide patients with overdose education, take home naloxone rescue kits, and fentanyl test strips to reduce risk of overdose during substance use. When reducing risk of infection or trauma, patients receive access to resources like pre- and post-exposure HIV prophylaxis syringe needle exchange programs, opioid agonist or antagonist mediations, and supervised substance consumption venues. These strategies are standard in addiction medicine but can be incorporated into palliative care models to offer patients a more comprehensive set of treatment options.

When treating patients with SUD or opioid use disorder (OUD) for cancer related pain, HCPs need strategies for safer opioid prescribing to help decrease substance use and the integration of using buprenorphine as a first-line opioid during drug testing. The speakers discuss the success of buprenorphine, an opioid partial agonist, in their practice, noting benefits such as less misuse potential, decreased tolerance, fewer gastrointestinal adverse effects, and cognitive impairment.

“It's safer in organ dysfunction, especially in renal dysfunction. And, importantly, if these patients have OUD we might want to treat their OUD as well,” Quirk said. “The gold standard for that is buprenorphine.”

Expert guidance recommends starting or continuing use of buprenorphine for patients with OUD and cancer-related pain as a first line of treatment. Patients starting treatment may benefit from dividing the dosage more frequently throughout the day to take advantage of the peak analgesia potential of each dose. In cases of continued uncontrolled pain despite buprenorphine use, HCPs may consider incorporating full opioid agonists, like methadone, and increase monitoring of patients, a crucial step for optimal patient outcomes.

In the speakers’ practice, patients with SUD or OUD who relapse or present potential signs of prescribed opioid misuse benefitted from increased engagement in care. Through a collaborative care model, their patients have access to a network of HCPs, including pharmacists, addiction psychiatrists, harm reduction counselors, and oncology specialists. Physicians may also increase frequency of visits and communication opportunities, utilizing physical appointments, phone calls, or telemedicine options and contacting patients prior to their appointment to monitor treatment progress or identify a potential need for intervention.

The insights shared by Kale and Quirk underscore the critical importance of integrating harm reduction strategies into palliative care models for patients with cancer-related pain and SUDs. By adopting harm reduction principles and strategies, alongside safer opioid prescribing practices such as utilizing buprenorphine as a first-line treatment, HCPs can provide more effective, compassionate care. Through collaborative care models and increased engagement, HCPs can optimize outcomes and enhance the quality of life for individuals navigating the complex intersection of cancer, pain, and SUDs.

REFERENCES

Kale S, Quirk K. Balancing compassion and concern: a palliative Harm reduction clinic for patients with cancer pain and concurrent substance use disorders. Presented at: 2024 SPPCP Virtual Conference. May 21, 2024. Virtual.