The case

B was initially admitted to hospital with an infective exacerbation of chronic obstructive pulmonary disease (COPD). He still smoked and had previously misused opioids. At the time of admission, he was on methadone maintenance therapy.

B's chest radiograph had shown a “suspicious mass” on admission. Further investigations eventually lead to a diagnosis of extensive non-small cell lung cancer. His prognosis was deemed poor. Our only option was to palliate.

B was homeless. Now that he was known to have a terminal condition and would require long-term oxygen therapy, alternate living arrangements were needed. All these took time. B therefore stayed in hospital longer.

Two weeks after his admission, B was observed talking to another patient on the ward about buying benzodiazepines from another inpatient. He was given a verbal warning. No further concerns were noted after that.

Over the next few weeks, B began to complain of breathlessness and chest pain. Dexamethasone had been started soon after cancer was diagnosed. Nebulised bronchodilator and oxygen therapy had continued. Oral morphine sulphate was thus prescribed. His dose requirements however escalated rapidly. Prescribing increasingly larger “prn” and regular slow release doses of morphine that should have supported his calculated daily requirements did not affect this.

This was a difficult situation. On one hand, we could see that B was clearly distressed each time he asked for more morphine. We knew that his disease was “a real one” and that his condition was terminal. On the other, we were aware that drug dependency had continued to be a problem for him. B never exhibited any signs of overdosing and did appear to be more comfortable each time after he received morphine. He never truly “settled” however.

It was difficult to differentiate between the two possibilities. It was also felt that it would be unkind to try to do so now during his last days – “he is a dying man…” was the general feeling among staff. So, the situation continued.

The social worker eventually found B an apartment. After a package of care was implemented, he was discharged from hospital. Follow up arrangements were also made with the community MacMillan team and methadone clinic.

B was found near collapse the following day due to severe breathlessness at home. He was therefore readmitted. His breathlessness and pain continued to be difficult to control despite a trial of different opioids and other anxiolytics. He was eventually sent to the local hospice.

Could we have done things “better”?

What was B's problem?

As Table 1 demonstrates, physical dependence, tolerance and addiction are separate phenomena but may also co-exist (₁). Difficulties arose in this case because B's comorbidities contributed to his symptoms. Pain, breathlessness and anxiety are common complaints of patients with advanced cancer (Table 2) (₂). His COPD and smoking would not have helped either.

Figure 1

Table 1: Clarification of terms (,, )

Figure 2

Table 2: Prevalence of symptoms in cancer patient populations ()

Could his pain and breathlessness really have been that severe?

What could we have done better?

What about his breathlessness?

What (else) could we have done for B?

• We could have been more open about our concerns and discussed them directly with B sooner

• Other adjuncts could have been added

• We could have asked for help sooner from other “experts”

Figure 3

Table 3: Methadone (, , )

Figure 4

Table 4: Treatment of intractable breathlessness in palliative care (, , )

Why is this case important?

This case serves as a reminder that our current training and resources remain inadequate in this area. Thus far this year, 177052 opioid “misusers” have entered treatment in England (₁₅). This figure is expected to rise in the future.

Patients on methadone maintenance therapy often have other health conditions that bring them to seek medical attention. This population may present in any area of healthcare. Some of their complaints then might be related to misuse of substances while others might not.

Quite often however, pain is a related complaint. Acute pain might be due to traumatic injury, infection or cancer. Chronic pain is also a major problem here. Zero to 40% of chronic pain sufferers may have substance use disorders (₄). The reverse also applies. Rosenbaum et al in 2003 (₁₆) found that 24% - 37% of patients on methadone maintenance have chronic pain.

Drug rehabilitation is not routinely included in our medical curriculum. Thus we still struggle in complicated cases, especially since methadone clinics are not directly connected to hospital services. Similar concerns could arise for patients on newer medications such as buprenorphine and lofexidine (₁₇).

Finally, we also need to be more familiar with methadone because palliative care doctors may be using it in the future. Methadone is, after all, fairly cheap and easily manufactured (₁₈). This is already happening across the Atlantic although physicians in the UK remain slower on the uptake (₁₉).

In Summary

• Patients on methadone maintenance therapy may present in any area of medicine

• When they do, they are at risk of poor symptom relief because of misconceptions on either side

• We need to learn more about methadone and patients on drug rehabilitation therapy