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Presentation Description
Institution: Southern Adelaide Palliative Services, Southern Adelaide Local Health Network - South Australia, Australia
The management of pain for patients with a prior history of Substance Use Disorder Use (SUD) is challenging. This becomes more complex when the patient is actively using illicit substances, and an acute crisis and risk management concern when the patient is discovered injecting in the Hospice.
We describe a complex case of this situation and the strategies put in place to manage this.
A 46-year-old patient with metastatic melanoma with choroidal metastases, extensive leptomeningeal deposits, and spinal cord involvement with lower limb paralysis was admitted to our Hospice for control of severe pain. Large doses of opioids, methadone and adjuvants were being prescribed, with minimal benefit. The patient was heavily sedated at times, however would wake and request further breakthrough doses of opioids. We discovered that the patient was self-injecting extra opioids and methamphetamines consistent with long-term behaviours.
Urgent planning was undertaken by treating medical and nursing clinicians and risk management. Open and frank conversations with the patient and family ensued, with an attempt to set strict limits around illicit use and appropriate behaviour. Management strategies were put in place for patient and visitors, and staff safety.
Tension was evident between the abuse of the system, balancing safety for staff and other patients, mitigating risk for the health service, whilst aiming to provide the best care for a person who was suffering from the duality of an advanced malignancy with a short prognosis and intractable drug addiction.
Staff were engaged in consultation, formal debriefing undertaken and a checklist developed for future patients with a life limiting illness and a SUD, which will guide proactive management of similar situations.
We hope our learnings from this clinically and ethically complex case can improve the care for this small but complex group of patients with a terminal illness and substance use disorder.
Presenters
Authors
Authors
Dr Emma Foreman - Southern Adelaide Palliative Services Southern Adelaide Local Health Network , Dr Georgia Salamon - Southern Adelaide Palliative Services, Southern Adelaide Local Health Network , Ms Angela Robinson - Southern Adelaide Palliative Services, Southern Adelaide Local Health Network , Assoc Professor Tim To - Southern Adelaide Palliative Services, Southern Adelaide Local Health Network. Flinders University RePaDD , Dr Peter Allcroft - Southern Adelaide Palliative Services, Southern Adelaide Local Health Network. Flinders University RePaDD
