Pain Management in a Patient with Pancreatic Cancer and Substance UseDisorder

Objective: People with a history of substance misuse may develop cancer and associated pain syndromes requiring opioid therapy. These patients are at increased risk of receiving inadequate pain management due to fear of exacerbating the addiction by using opioid medications and the lack of knowledge about treating patients with addiction. We present our pain treatment strategy in a pancreatic cancer patient with a history of substance abuse. Case report: A 38 years male patient was admitted to emergency service with severe epigastric pain. He had a diagnosis of pancreatic cancer and underwent surgery 3 years ago. He had recurrence while receiving chemotherapy. He was using transdermal fentanyl 100 mcg/h and morphine subcutaneously given by his primary doctor. He was unable to obtain morphine because of prescription problems and experiencing severe pain and abstinence symptoms. On pain consultation, it was learned that he had a history of substance abuse and received treatment. A bilateral neurolytic splanchnic block was performed for pain relief and the patient was integrated to a supportive program with psychiatry clinic. After 3 months, pain control was adequate with transdermal fentanyl 50 mcg/h and adjuvant drugs. Conclusion: Splanchnic plexus neurolysis is a technique that can potentially improve pain control and quality of life in pancreatic cancer. For the effective management of pain in patients with a co-occurring addictive disorder, invasive treatment techniques might be preferable early in the course of pain treatment instead of opioid dose escalation. Good communication between teams is essential.