To whom should a patient with opioid use disorder due to active heroin use and requiring chemotherapy for cancer treatment be referred for comprehensive management?

Referral for Patients with Opioid Use Disorder and Cancer Requiring Chemotherapy

Patients with active heroin use (opioid use disorder) who require chemotherapy should be referred to a multidisciplinary team including palliative care specialists, pain management specialists, and substance use disorder specialists to collaboratively manage both their cancer pain and addiction treatment. 1

Primary Referral Targets

Substance Use Disorder Specialist

• Immediate referral to an addiction medicine specialist or certified opioid treatment program is essential for initiating or continuing medication-assisted therapy (MAT) with methadone or buprenorphine 1
• These specialists can provide buprenorphine treatment (requires DEA waiver) or arrange for supervised methadone treatment through SAMHSA-certified opioid treatment programs 1
• The patient's maintenance therapy must be verified and continued uninterrupted, as undertreating addiction worsens pain perception and treatment outcomes 2

Palliative Care Specialist

• Palliative care consultation is strongly recommended for managing the complex intersection of cancer pain and opioid use disorder 1
• These specialists have expertise in aggressive pain management while navigating the challenges of opioid tolerance and cross-tolerance that develop with MAT 2
• They can implement multimodal analgesic strategies and coordinate care between oncology and addiction services 1, 2

Pain Management Specialist

• Referral to a pain specialist is indicated when cancer pain becomes difficult to control or when higher-dose opioid therapy is needed in the context of existing opioid tolerance 1
• Pain specialists can provide advanced interventional techniques and optimize complex medication regimens 1

Critical Coordination Strategy

Collaborative Care Model

• The oncology team should NOT dismiss or abandon the patient due to substance use disorder, as this represents a life-threatening safety issue 1
• All three specialist teams (addiction, palliative care, pain management) should collaborate to determine the optimal approach, as patients with comorbid substance use disorder and mental health conditions face greatly exacerbated obstacles in obtaining pain relief 1
• Primary care clinicians often defer opioid prescribing to oncology teams in these complex cases, making specialist coordination even more critical 1

Medication-Assisted Therapy Continuation

• Continue the patient's methadone or buprenorphine maintenance therapy while adding short-acting opioids for cancer pain control 2
• Methadone dose escalation can serve dual purposes: controlling both OUD symptoms and cancer-related pain, and may be considered as a first-line approach in this specific population 3
• Never use mixed agonist-antagonist opioids (pentazocine, nalbuphine, butorphanol) as they precipitate acute withdrawal 2

Resource Utilization

Finding Qualified Providers

• SAMHSA's buprenorphine physician locator (http://buprenorphine.samhsa.gov/bwns_locator) 1
• SAMHSA's Opioid Treatment Program Directory for methadone programs 1
• SAMHSA's Provider Clinical Support System for expert consultation on opioid therapies and the pain-addiction interface 1

Common Pitfalls to Avoid

• Do not wait to refer until pain becomes uncontrolled—early specialist involvement improves outcomes 1
• Do not attempt to manage this patient without addiction medicine support—the complexity requires specialized expertise 1
• Do not abruptly discontinue the patient's maintenance therapy—this increases illicit substance use, emergency visits, overdose, and suicide risk 1
• Reassure the patient explicitly that addiction treatment will continue uninterrupted and pain will be aggressively treated, as this decreases anxiety and improves cooperation 2