Special Populations
Children, the frail elderly, and patients with addiction issues present special challenges that often result in gross undertreatment.
Children
The side effects of high-dose chemotherapy agents used to treat cancer in children may cause more pain than the disease itself, particularly in the case of leukemia. These include neuropathies, mouth ulcers, and joint pain.
Frail Elderly
Many clinicians are hesitant to prescribe opioids for this population because they fear precipitating side effects such as delirium, sedation, constipation, and falls. Older patients are generally more susceptible to adverse drug reactions. Physicians should reassure patients and family members that these side effects are not universal and can be avoided or treated if necessary.
Start with half the standard adult dosage (such as 2.5mg of hydrocodone or oxycodone) and observe. Monitor the patient frequently on the basis of expected absorption and pharmacokinetics of the drug. Anticipate and treat side effects proactively.
Patients with Addictions, Past or Current
Physicians are frequently reluctant to prescribe opioids to patients with a history of addiction or with ongoing addiction issues, and these patients may be equally reluctant and fearful. Such concerns can result in gross under-treatment of patients who are experiencing very severe pain.
Guidelines exist for treating terminally ill patients with addiction issues:
Use a multidisciplinary approach, including a mental health provider who has experience with drug addiction.
Perform a detailed assessment of the patient's substance-use history, including duration, frequency, specific drug preferences, and desired effect of drug use.
Set realistic goals for therapy. Although complete abstinence from drug abuse would be ideal, the stresses of dealing with a terminal illness may make this an unrealistic goal.
Evaluate and treat co-morbid psychiatric disorders in this population.
Provide written statements that explain the roles of team members, expectations, and policies for lost prescriptions.
Patients should be seen more frequently.
Consider referral to a 12-step program.
Suggest family sessions and meetings. The team should become familiar with family and friends and identify those who may be abusing as well.