The Clinical Guide to Supportive and Palliative Care for HIV/AIDS

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A Clinical Guide to Supportive and Palliative Care for HIV/AIDS • Chapter 11: Substance Use ProblemsThe substance-using patient may contribute to the difficulty of treating pain by his or her ownbehavior. Trust between clinician and provider is fundamental to mobilizing an effective treatmentregimen. If the patient has lied, manipulated, sold prescription drugs or otherwise createdcause26forpicasmistrust, such a negative atmosphere is not easily overcome. In these instances, theprovider should discuss the situation directly and frankly with the patient, articulate reasonablelimits, develop a written contract and move on. Such a contract should stipulate the following:• The total amount of medication is specified that will be prescribed over a shortperiod of time (with the provider dispensing only small amounts, as necessary,to limit the possibility of abuse)• Only one person will write and one pharmacy will fill prescriptions forcontrolled substances• Refills will not be given for “lost” or “stolen” prescriptions• Random toxicology screenings will be part of the treatment plan• Forgery of prescriptions or other serious violations of the law will result incriminal prosecution of the patientWhile these efforts can be very effective in helping to prevent manipulation and abuse of prescribednarcotics, abuse can sometimes still occur. It is important for providers to recognize thetypes of behaviors suggestive of abuse, in order to be able to prevent and address these problems(Table 11-3). 5Table 11-3:Spectrum of Aberrant Drug-Related Behaviors Occurringduring Treatment with Narcotic AnalgesicsMore Suggestive of Drug Abuse• Reports of ‘lost’ or ‘stolen’ prescriptions• Selling prescription drugs• Prescription forgery• Stealing drugs from others• Injecting oral formulations• Obtaining prescription drugsfrom nonmedical sources• Concurrent abuse of alcohol orillicit drugs• Repeated dose escalations or similarnoncompliance despite multiplewarnings• Repeated visits to other clinicians oremergency rooms without informingthe prescriber• Drug-related deterioration in functionat work, in the family, or socially• Repeated resistance to changes intherapy despite evidence of adversedrug effectsLess Suggestive of Drug Abuse• Aggressive complaining about theneed for more drugs• Drug-hoarding during periods ofreduced symptoms• Requesting specific drugs• Openly acquiring similar drugs fromother medical sources• Occasional unsanctioned dose escalationor other noncompliance• Unapproved use of the drug to treatanother symptom• Reporting psychic effects not intendedby the clinician• Resistance to a change in therapyassociated with tolerable adverse effects• Intense expressions of anxiety aboutrecurrent symptomsSource: Passik SD, Portenoy RK. Substance abuse issues in palliative care. In Berger A, ed. Principles and Practices of SupportiveOncology. Philadelphia: Lippincott-Raven Publishers, 1998.256U.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau
A Clinical Guide to Supportive and Palliative Care for HIV/AIDS • Chapter 11: Substance Use ProblemsWhile patients’ own behaviors can damage trust, a provider can also unintentionally damagetrust in his or her relationship with the patient. A provider who does not take a complaint of painseriously simply because of a patient’s socioeconomic status, race or history of substance use isviolating26thepicasimplicit trust that the patient places in his or her hands. Several studies havedemonstrated that nonwhite patients are more likely to have pain underdiagnosed andundertreated than white patients. 7 It has also been shown that pharmacies in poor minorityneighborhoods may not stock narcotic medications and thus make access to pain treatmentmore difficult. 8 As will be discussed below, substance-using patients often have long histories ofnegative interactions with the health care system. Provider prejudices, when brought to thepalliative care of an HIV-infected patient, can inflict further damage precisely at a time whentrust and healing are most needed.Pharmacologic Properties and Physiologic Impact of SubstancesProviders must know what substance(s) the patient is using, the pharmacologic properties,and the physiologic impact. A patient with a chronic addiction to alcohol will have differentphysiologic response to a given dose of an opiate than someone who has become tolerant toheroin. Similarly, someone with alcohol-related peripheral nerve damage might experience HIVrelatedneuropathy more severely than a cocaine user.Care must be taken to precisely describe the patient’s use of the substance. Tables 11-4 and 11-5 provide definitions of commonly used terms in this regard. 5, 9, 10, 11 Proper use of these termsallows clear communication among all members of the palliative care team (including addictionspecialists) and forms the basis of an explicit clinical rationale for both pain and addictiontreatment decisions.XITable 11-4: Definitions of Substance Dependence and AbuseSubstance Dependence:A maladaptive pattern of substance abuse, leading to clinically significant impairment or distress,as manifested by three or more of the following, occurring at any time in the same twelvemonthperiod:Tolerance, as defined by either of the following:• A need for markedly increased amounts of substance to achieve intoxication ordesired effects, or• Markedly diminished effect with continued use of the sameamount of the substance.Withdrawal, as manifested by either of the following:• The characteristic withdrawal syndrome for the substance, or• The same (or closely related) substance is taken to relieve or avoid withdrawalsymptoms.The substance is often taken in larger amounts or over a longer period than was intended.There is a persistent desire or unsuccessful effort to cut down or control substance use.A great deal of time is spent in activities necessary to obtain the substance, use thesubstance, or recover from its effects• (e.g., visiting multiple doctors or driving long distances, chain smoking).U.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau 257
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DedicationA Clinical Guide to Suppo
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Lynn A Jansen, RN, PhDAssistant Res
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TABLE OF CONTENTSPart IChapter 1Cha
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Chapter 6.26 picasPulmonary Symptom
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Chapter 8.26 picasOral ProblemsDavi
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Chapter 15.26 picasSpecial Populati
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Chapter 17.26 picasEthical IssuesLy
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DRUGS AND THERAPIES INDEXNOTES: Ent
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