I still recall the look on my patient’s face and her words 2 years later.
“I am done with this life,” she told me. “Don’t let me die in pain,” she added as she folded her hands to physically plead with me.
I simply cannot convey in words how painful it was to witness the agony of this patient.
Here is what happened: My hospital requested a consultation for cancer pain management involving a relatively young patient with metastatic pancreatic cancer. Making matters worse, she was admitted with a severe apparent infection and displayed signs of failure to thrive with anorexia/cachexia. And then there was the pain, which doctors called intractable.
Typically, such pain cannot be cured and is merely managed at best.
My partner physician on the case treated the young patient for several days. There was a documented recommendation of “NO IV OPIOIDS,” citing past medical history of use of injected heroin.
One day, as I entered the patient’s room, I saw that she was fragile, moaning loudly in pain. She was visibly distressed, holding her belly. “I need some pain medicine,” she said immediately.
As I introduced myself and inquired about her pain, she held my hand and said, “Listen, Doc, I have lived in pain my entire life. I beg you, do not let me die in pain.”
Pain is the most prevalent and debilitating symptom in advanced cancer and at the end of life. Opioids are the mainstay treatment for cancer pain treatment. It is challenging when patients with a history of substance use disorder with opioid-type medication get diagnosed with cancer.
Since the start of the opioid epidemic, there has been a more significant push by federal agencies like FDA and CDC to decrease opioid prescriptions with no backup options in treating patients’ pain and mental health illnesses like substance use disorder. Abrupt brakes were applied to prescription opioids, forcing patients to resort even more to illegal means of obtaining pain medications on the street.
As expected, physicians and other clinic providers often fear prescribing opioids. This is even more of a reality when patients with a history of substance use are in their last days of life and dying from another disease like terminal cancer, and healthcare workers cite that they are not comfortable prescribing opioids in the current setting.
Substance use disorder is a mental health illness. As of 2015, approximately 10% of U.S. adults had drug use disorder at some point in their lives, and about 4% had met the criteria for drug use disorder in the past year. Additionally, 3.4% of Americans ages 12 and older misuse opioids at least once over a 12-month period. The COVID pandemic added oil on the burning flame of poor mental health.
Given the high prevalence of various types of cancer, many of these patients with a history of substance use disorder may get diagnosed with cancer at some point in their lives. But their mental illness will leave them unqualified to receive pain medications like morphine or buprenorphine to treat severe pain.
Do they deserve to die in pain because they suffered from addiction to illegal substances? People with drug use and mental health issues need the same empathy, compassion, and treatment as any other person.
What Can Be Done?
A multi-disciplinary team approach ensuring close collaboration among palliative and addiction specialists, psychologists, and supportive oncology is the need of the hour. The teams can thoroughly support and evaluate the patient and determine whether prescribing opioids is the most appropriate option. This approach will also help ensure patients aren’t handed-off between various specialties without continuity, leaving them with a sense of abandonment and increasing mistrust between the patient and the medical field.
The palliative subspecialty group is ethically bound to take care of their patients in the last phase of life, relieve their suffering to the best of their ability, and assist with a peaceful transition to the end of life. In my opinion, the presence of inherent empathy and additional training would produce real gems of palliative physicians who can provide comprehensive care to all patients with life-limiting diseases.
We must work with patients on a treatment plan that the provider and patient are comfortable with and maximize the quality of life for the short time the patient has left. The fear of opioid addiction should not cause needless suffering or lead patients to die in pain.
The stigmatization of medically complex patients with mental illness at the hands of the providers is not only unacceptable but morally unethical and reflects discrimination in the medical field. The situation is indescribable when such a patient also suffers from a terminal illness.
Ramandeep Kaur, MD, is a palliative medicine physician at Rush University Medical Center and a fellow with The OpEd Project.