Substance Use, Pain, and Palliative/End-of-Life Care
Withdrawal
Alcohol withdrawal is the lethal one: tremor, diaphoresis, tachycardia, hallucinations, seizures and delirium tremens. Use symptom-triggered benzodiazepines (CIWA-Ar), give thiamine before glucose, and expect kindling in repeat episodes. Benzodiazepine withdrawal is dangerous and needs a slow taper. Opioid withdrawal is miserable but not fatal: clonidine, symptomatic care, and buprenorphine or methadone to transition to treatment. Never make benzodiazepines first-line for opioid withdrawal.
Pain and addiction
Assess pain and substance use simultaneously. Undertreating pain in a patient with opioid use disorder drives pseudoaddiction, illicit use and discharge against advice; the answer is structure, not abstinence: a full agonist with a written plan, short supplies, urine testing, prescription monitoring and a treatment referral. Know equianalgesic principles, incomplete cross-tolerance (reduce 25-50% when rotating), and avoid meperidine and mixed agonist-antagonists in patients already on full agonists.
Palliative and end-of-life care
Depression and anxiety are treatable at the end of life; psychostimulants and low-dose antidepressants have a role. Distinguish depression from demoralization and normal grief. Evaluate capacity to refuse treatment or to request hastened death, and screen for untreated depression, pain and delirium. Ethics concepts include double effect, withholding versus withdrawing, palliative sedation, advance directives and surrogate decision-making.
Trap
Missing thiamine, or withholding adequate analgesia from a patient with a substance use history.
Rule of thumb
Treat the pain and the addiction together; structure and monitoring replace under-dosing.