My 14 Year Old Cancer Patient May Be Addicted to Opioids. What Do I Do?

I’m a pediatric oncologist, but cancer is not always the most serious problem my young patients face. Currently one of them, a 14-year-old boy, his mother, or both may be opioid addicts. I may be enabling their addiction.

Tragically, their situation is not unique. Adolescent patients are at risk for addiction from opioid pain medications just as adult patients are. But pediatric patients are overlooked in this war against opioid addiction. No policies protect them or those caring for them.

Usually pain is short-term, and only limited opioids are needed. Most providers, including those caring for children, are trained in acute pain management. Patients and providers are also protected by policies limiting the prescribed amount of opioids for acute pain.

Occasionally, complications such as bone, muscle, nerve damage, or scar tissue development result in longer-term, chronic pain. These complications happened to my 14-year-old patient, and happens with enough frequently that cancer patients are often exempt from prescription limits.

A person’s ability to cope with pain varies greatly. Some patients with identical complications manage with minimal narcotics and instead use lidocaine patches, ibuprofen, physical therapy, and mind-body awareness to continue their lives with resilience. Others, like my patient’s mother, insist nothing but opioids work.

Most doctors avoid chronic pain management and worry about the liability of authorizing repeated narcotic refills. I worry, too. In this case of this patient, I worried particularly after an online opioid prescription registry showed that in one month, my patient had filled my oxycodone prescription, as well as other prescriptions, four times what I had prescribed.

I cannot tell who is taking the pills — my patient or his mother. He does not know what medications he takes when they are handed to him. However, he frequently comments that his mother cannot wake up early or drive sometimes because of her pills. Indeed, our office knows she may be incoherent and forgetful if we call in the morning.

Prescribers who suspect an addiction usually refer their patients to a specialist trained to manage chronic pain. By referring the patient to a pain specialist, providers remove themselves from the opioid liability while preserving the relationship to treat other health issues. Unfortunately, my state, New Hampshire, which has the nation’s second highest opioid overdose death rate, has no pediatric pain clinic. None.

Adult chronic pain specialists are not trained to manage pediatric patients even if they are adult-sized. Children cannot sign opioid contracts or be held directly responsible for their care. Chronic pain is as much psychological as physical, and adult pain specialists are not prepared to manage the interdependent psychosocial complexities between children with cancer and their traumatized and anxious parents.

My patient and his mother went for a single visit to the closest pediatric pain clinic three hours away. Physical therapy, non-addictive neuromodulators, counseling, and opioid weaning were recommended. His mother was offended by the counseling suggestion, unhappy opioids were not prescribed, and refuses to return to the pain clinic. I cannot force them. It is too far and the cost is not covered by insurance.

I suggested medical marijuana, which can improve coping with pain. Professionally, marijuana is easy. Physicians do not prescribe marijuana. We only certify a diagnosis. The state is responsible for determining eligibility, investigating abuse risk, and dispensing it. I have no responsibility or liability in my pediatric patient’s marijuana use. But as a pediatric opioid prescriber, I am fully exposed.

Although his stuffed animals talk to him when he uses marijuana, he still has pain and his mother still demands oxycodone. I expect him to have pain, but I have no idea how bad it is, how many opioids he needs, or who really takes the pills.

Some suggested treating only his cancer and not his pain. I would follow that suggestion, if pain management were available elsewhere. But it is not, and I know he has painful complications from the chemotherapy I gave him.

Others suggested entirely refusing to treat him because of his non-compliance. But he is not solely responsible for his non-compliance. And, it is unethical to deny him cancer care when the next closest pediatric oncologist is three hours away and outside his insurance network.

So I do what I can. I cannot provide ideal chronic pain care. Instead I focus on minimizing the damage that could be done to him, his mother, and myself.

I am scared for my patient and his mother and their addiction risk. I am scared for myself and other providers who lack guidance and protection in pediatric chronic pain management and the inadvertent role we may play in addiction. I am scared because writing prescription after prescription feels wrong, but I see no alternative.

So I am curing this boy’s cancer at the cost of his life? How many other pediatric patients are like him, successfully battling a disease and yet falling through cracks of our healthcare system into a deadly pit of addiction?

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7 replies »

  1. Thank you for sharing this interesting case Dr. Kim. One particular concern you did not raise here is diversion outside of the family. That is rather than the drugs being used by the patient or a family member, it could be sold on the street or in the patients school. Drug testing, as mentioned by another commentator, is useful as are random pill counts and strict drug contracts. The drug testing should be regular and checking for drug levels can help monitor if more or less drug is being used over a period of time. As far as medical marijuana, which you mentioned, it is true that medical marijuana can help patients wean off of opioid painkillers. I have written on the subject here https://goo.gl/Y2m69W. However, contrary to popular belief, physicians are generally responsible to monitor their patients and for adverse effects of medical marijuana even if they don’t “prescribe” it. That is definately the case in New York, where I am from, and in most other states. To complicate things further, there is some evidence that the rate of dependence for medical marijuana in adolescents is 4 – 7 times greater than in adults and recommending medical marijuana in someone with a history of addiction is a relative contraindication.

  2. There is a great deal you can do Dr Kim. First of all urine drug test the child to see if the opioid is in his system. Second call the pharmacy and find out what HIS narcotic looks like A 14 yr old can know perfectly well what he is given Next clarify for us why there could have been a PMP notation(prescription monitoring program) notation that said there was four times as much med filled as your prescribed? That is impossible One can only fiill what you prescribed. Are you suggesting the prescription was altered? Narcotic prescriptions must have the numerals in words as well Talk to the pharmacist If a prescription was altered you alert the police immediately!. If the parents have a PCP call them .No matter if there is no peds pain program nearby Pick up the phone and talk to one on the phone It seems pretty obvious that there is narcotic abuse here Did you look up the parent on the PMP also? You can also call a patient in without warning for a pill count There is a lot you can do and it soundslike you have better step on it.

  3. “I cannot tell who is taking the pills — my patient or his mother. He does not know what medications he takes when they are handed to him. However, he frequently comments that his mother cannot wake up early or drive sometimes because of her pills. Indeed, our office knows she may be incoherent and forgetful if we call in the morning.”

    Looks to be that child protective services should be called. Why is that not an option?

  4. Well written interesting and poignant problem. Thank you.
    The pain fibers, nociceptors, all enter the CNS at the dorsal root ganglia or in the trigeminal nerve. One or the other. These are so accessible and close to the skin’s surface, it is hard to believe we haven’t figured out how to interfere with ascending pain. But pain may be something screwing up the negative feedback downward flowing neural inhibitors from the brain or within the brain too. Maybe this is where the THC whatever is working. They used to rave about small doses of tricyclics plus compazines. Allodynia is scary too, because this is where non-noxious stimuli are perceived as pain. As we get older I think we all get some of this. Lots more work to do.

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  6. A mother with a son with fragile health may be one of the trickiest ethical and moral problems that a Primary Physician, as you have become, will face. During the last 4 years of my practice, a similar pair actually involved a Munchausen by Proxy process.
    In the absence of worsening metastatic disease, there is a certain level of daily narcotic use that further dose increases will actually worsen the pain control. For an adult, it is probably around 30-40 mg per day. I suspect that it would be similar for an adolescent, adjusted by weight or surface area. To survive the next 4 years, you may need to seek consultation with someone you trust about how to handle the family dynamics to prepare for his 19th birthday. Then, you are in a position of requiring a narcotic contract for any further involvement. You should be sure that it requires all narcotic prescriptions be filled at one pharmacy, and he has one year to become fully compliant to avoid termination of your involvement (ask your attorney about the wordage). In the meantime, the basics of a caring relationship apply.

    Parenthetically, there are people who have certification to evaluate whether or not a person has a true addiction. Locally in my community of Omaha, they are called a “Drug Eval.” There reports are usually very comprehensive and may give you insights into the contributing factors. It is too time consuming to try mitigating the pain with non-narcotic meds, especially if there are underlying non-compliance. With those meds, it usually takes about two years to make good progress. In the long run, they work better when started during the initial severe pain episode.

  7. We have been working on this. What we found is that most networks throughout the country have zero, as in none, addiction specialists. (Our own unpublished survey.) So, it is not surprising that your state has no pediatric specialists. This also ties in with the general lack of mental health services. Given the home situation, I don’t see how you resolve this w/o addressing the mother. My heart goes out to you as I don’t know how you can successfully address this w/o a lot of trained support.

    Treatment is hard. We are hoping prevention may help. Part of what is missing here is good acute pain treatment, I think. We need to have acute pain care specialists who can intervene and help so that there is less risk of developing a chronic pain problem. I feel very let down as the medical profession as a whole really doesn’t train many people to do this. We train chronic pain docs, but few with acute pain expertise. I keep hoping that some clever residency or fellowship will create “total pain” specialists who are trained to manage the complete spectrum of pain issues. (The insurers will pay for chronic pain care, for the most part. Not so much for acute pain. So I think that is part of the problem here.)