It seems innocuous, but the term ‘dual diagnosis’ describes a very complicated subset of patients — those who have a substance use disorder as well as a primary psychiatric disorder (anything from depression to schizophrenia). Throw a serious medical illness into the mix, and you have a recipe for one very overwhelmed palliative care physician.

Moving along, I’ve paraphrased key info from the case that was presented –

  • Presenters describing patient: “Opiate dependence, stopped methadone maintenance therapy, mood disorder, trauma history, cocaine, family estrangement, new cancer diagnosis.
  • Most of room: “This doesn’t sound good…”
Never fear, this patient is manageable! The most important thing is to recognize that a team approach is essential — involve psychiatry, social work, the patient’s outside providers, clinic staff, etc. Try proactive measures like a pain contract (though not infallible), and encourage the patient to bring her sources of support with her to appointments, whether they be friends or family.

  • Presenters: “Now she’s your patient and you’ve been noticing she’s missed a lot of appointments with you and her oncologist, she’s had a number of early pain med refills due to lost scripts and stolen meds, and she’s still having a lot of pain despite very high opioid doses. She refuses to switch over to methadone because she doesn’t like the side effects. Now what?”
  • Most of room: “Refer patient to someone else!”
    Wait! Let’s think about it first and consult with the interdisciplinary team. This is a patient who has had a long history of opioid addiction who is now back on opiates. Of course she’s going to fall back into addictive habits, so let’s figure ways to help the patient change some of those habits. But also don’t forget the phenomenon of pseudoaddiction, which is an iatrogenic syndrome of abnormal behavior that’s a direct consequence of inadequate pain relief.
    There are some strategies we can implement – prescribe only small amounts of opioids at a time, do pill counts, and get random urine drug screens (remember that standard UDS dont’t test for oxycodone, so you have to add that separately). Can we combine her psych/substance abuse counseling appointments with her already-scheduled palliative care appointments? And of course, ask the patient about her perception of the obstacles preventing her from full compliance (if you went to the Motivational Interviewing session, this is a perfect time to practice those skills).
    Now, say the patient is in remission, but still on high dose opiates due to continuing pain. Keep her on these? Since our ultimate goal is to manage pain while also optimizing function, we should probably wean her off the opioids. She’s wary of methadone, but lets explore those fears and discuss it with her substance abuse counselor. The addiction psychiatrist probably has some other ideas as well.
    This is the sort of patient who can be very trying yet ultimately very rewarding to work with. Though keep in mind that It’s especially important to have an outlet to vent the jumble of emotions that these patients stir up, which is another crucial function of the interdisciplinary team.
Erin Zahradnik, MD, Yale University Dept of Psychiatry