People who use drugs (PWUD) deserve same access to primary care as everyone else
One of my biggest frustrations as a doctor are the “care-silos” patients get stuck in. A colleague who’d taken a gig at a methadone clinic told me she was reprimanded for prescribing antibiotics for cellulitis on a patient’s hand. “The patient should go elsewhere for that.” As a Family doctor and social worker, part of my motivation is reducing those structural barriers to care.
People who use drugs deserve primary care, just like everyone else. As I said recently to a new patient in her 50s, “Just because you use drugs doesn’t mean you don’t get primary care like everyone else. Which means you get a screening for cholesterol, diabetes, hypertension, as well as breast, cervical and colorectal cancer.” When we don’t offer PWUD equitable access to primary care, we imply their lives are less valued. This demonstrates another example of systemic stigma.
Stigma is the biggest barrier when treating cancer pain in PWUD
The systemic and societal stigma of PWUD along with conflicting guidelines for treating cancer pain while providing opioid agonist therapy (OAT) makes treatment complex for patients with opioid use disorder (OUD).
Care teams lack clear guidance from the literature on interventions and patients often suffer with poor pain control as a result. This impacts the potential care needs of over 80,000 British Columbians with OUD–almost half of them will develop cancer in their lifetime and about 25% will die from cancer, according to the Canadian Cancer Society and the Canadian Medical Association Journal.
Improving pain control and quality of life for PWUD with cancer
Our project aims to improve pain control and quality of life for patients with concurrent cancer pain and OUD using illicit opioids and/or OAT–such as methadone, buprenorphine/naloxone (Suboxone), and slow-release oral morphine (Kadian)–as described in the BC Centre on Substance Use guidelines.
This patient population is marginalized and vulnerable. They already encounter significant and persistent barriers to receiving quality healthcare. Poorly controlled pain places a large demand on primary care teams and emergency departments.
This project builds on previous Quality Improvement projects done in BC including: initiation of OAT in emergency room settings, fast follow up and rapid access clinics and the use of injectable hydromorphone and pharmaceutical heroin (iOAT) to increase retention in care. At this point, none have focused on concurrent treatment of cancer pain–nor does any report we have found reflect the dual pandemics of COVID-19 or the poisoning of illicit street drug supply with synthetic opioids like fentanyl.
We conducted a scoping review exploring the depth, range and nature of existing literature on cancer pain and OUD.The research team consisted of a family physician with a speciality in addictions medicine, a family medicine resident at St. Paul’s Hospital and two medical students. We retrieved 28 original research papers, case reports and clinical trials commenting on strategies and approaches for managing cancer pain in patients with active OUD or with OUD in remission using OAT. Key expert consultations were completed in the form of a roundtable discussion at a Seminar offered via Zoom in November, 2020. Physician experts included Addictions and Palliative care specialists, including affiliates of the British Columbia Cancer Agency, who work with this patient population.
Initial recommendations for treating cancer pain in patients with concurrent Opioid Use Disorder
Results from the narrative analysis of the literature and qualitative thematic analysis of the key expert consultations led to the identification of the following key themes:
- A multidisciplinary, anti-stigma approach to care for patients with concurrent cancer pain and OUD.
- There is evidence for methadone and buprenorphine as recommended opioids for treating cancer pain in patients with OUD.
- Pharmacologic and non-pharma options, plus continuing OAT and treating acute mental illness are non-opioid considerations for pain management.
- Co-create a management plan with patients: setting parameters and prescribing naloxone for safety are approaches for risk mitigation.
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Photo by: Anthony Metcalfe on Unsplash.