To Continue or to Withhold Opioid Analgesics? An Ethical Dilemma Involving a 63-year-old Cancer Patient Who ‘Broke the Pain Contract’

摘要

We present a 63-year-old woman with a history of polysubstanceabuse, end-stage pancreatic adenocarcinoma andten recent admissions for pain control. She re-presented withsevere epigastric pain and anorexia. Prior to presentation,the patient’s pain was controlled with opiates prescribedby a palliative care physician. This physician was no longerprescribing opiates because of a breach in the patient’s paincontract: the patient was believed to be selling her opiatesto support her methamphetamine addiction. At the timeof previous discharges, she would be given a short courseof opiates to last until the follow-up appointment. Despitethis, the patient would return days after discharge complainingof severe pain and asking for or even demanding morepain medication. Upon each re-admission, even though thepatient’s toxicology screen was positive for methamphetamines,opiates were restarted. Per the chart, the patient hadadmitted that she was selling her pills to obtain illicit drugs.Consequently, during the patient’s final admission, thepatient’s treatment team encountered an ethical dilemma.