Purpose: To present a case of concurrent cancer-pain and substance use disorder and propose the need for clear guidelines from professional organizations regarding the proper assessment and management of cancer-related pain in patients with a current or past history of addiction, particularly opioid use disorder.

Summary: A 36-year-old male with active polysubstance abuse (heroin, alcohol, marijuana) and recently diagnosed metastatic non-seminomatous germ cell tumor (liver, multiple lymph nodes) was deemed not a candidate for a potentially curative auto-stem cell transplant due to his substance abuse. Palliative Care clinic was able to stabilize him on buprenorphine. Initially, he required as-needed hydromorphone for breakthrough pain, but eventually, he was weaned off all prescription opioids. With aggressive behavioral therapy, in addition to the buprenorphine, he remained clean off illicit drugs. He is now in the process of being reevaluated for auto-stem cell transplant candidacy for a potential cure. Buprenorphine has promising results for both treating pain and substance abuse, with low risk of developing dependance. It is a better safety profile compared to other opioids, is safer in patients with renal disease, displays anxiolytic and anti-depressive properties, and can be used for treating hyperalgesia. Despite these benefits, buprenorphine remains on underutilized treatment modality. 

Methods: Case study and literature review

Conclusion: Currently, there are no formal guidelines for how to manage cancer pain in patients with substance abuse histories, especially for opioids or for other active illicit substances. This case illustrated that we were able to treat this patient’s cancer pain with buprenorphine while simultaneously managing his substance abuse, enabling him to receive a potentially curative stem cell transplant. We need formal guidelines when chronic pain/substance abuse and cancer combine so that more patients can be offered the best treatment available.