Finding the Balance: Treating Cancer Related Pain in Patients with Opioid Use Disorder

Outcomes 1. Identify strategies for treating cancer related pain in patients with opioid use disorder when buprenorphine and methadone are not viable options.2. Identify harm reduction strategies to keep patients with OUD safe. Key Message Patients with opioid use disorder (OUD) and cancer related pain (CRP) can face many barriers to care. While patients with OUD and CRP should ideally be treated with buprenorphine-naloxone or methadone this is not always feasible. Harm reduction strategies and a trauma-informed approach to care are important considerations when caring for these patients. Background Opioids serve as a fundamental component of cancer pain management. However, managing cancer related pain (CRP)in patients with opioid use disorder (OUD) requires a nuanced approach. Harm reduction, a philosophy and public health construct, employs strategies to enhance safety in the context of ongoing substance use. This case illustrates the application of harm reduction in a supportive oncology setting. Case A 63yo male with Stage IV hepatocellular carcinoma (HCC) and daily heroin use was referred to palliative care clinic for abdominal pain. He reported that heroin use helped manage his cancer related chronic pain (CRP). Guidelines suggest using buprenorphine or methadone for such cases, but the patient struggled with buprenorphine's dosing frequency and resisted having to take “standing” medication. Prior to his cancer diagnosis, he was in a methadone program, but did not have the bandwidth to re-engage. The methadone program also had concerns about managing his OUD, given his medical complexity. Our clinic, unable to utilize buprenorphine or methadone, opted for harm reduction strategies and a trauma-informed approach to managing his CRP. His pain is controlled with as needed hydromorphone. He is educated on naloxone and reminded not to use heroin when alone. Short-term prescriptions and close follow-up involving both physicians and social workers facilitated a trauma-informed care approach. The team communicates regularly with his case manager. This patient trusts his providers, is honest about his substance use, and consistently attends appointments. His hydromorphone use has remained stable for months. Conclusion Striking a balance between harm reduction, safety, and adequate pain relief in cancer patients with OUD is a complex clinical challenge that necessitates further research. A trauma-informed approach to care for these patients should integrate harm reduction options, recognizing the myriad challenges faced by these patients both within and beyond the healthcare system. Keywords Interdisciplinary Teamwork / Professionalism / Communication