Collaborative Management of Opioid Use Disorder and Cancer Care in a Patient With Medical Complexity and Housing Instability

A 41-year-old female with a past medical history of depression, anxiety, intravenous drug use, and opioid use disorder (OUD) presented to the emergency department in December with frostbite of her bilateral hands and feet after living outside. She was found to have a left brachial artery occlusion and underwent embolectomy the next day. Her 51-day hospital course was subsequently complicated by an ST-elevation myocardial infarction, heart failure with reduced ejection fraction, stroke, right brachial vein deep vein thrombosis, pyelonephritis, acute hypoxic respiratory failure, and a new diagnosis of stage IV vulvar and anorectal squamous cell carcinoma, necessitating ostomy placement. Her frostbite also led to significant debility of her legs. The patient had a 20-year history of using opioids, and at the time of index admission, smoked 1 gm of fentanyl daily. Throughout her hospital course, the Addiction Medicine, Palliative Care, Psychiatry, Gynecologic Oncology, Cardiology, and General Medicine teams collaborated to manage her pain, cravings, and withdrawal, and to coordinate care in the setting of multiple comorbidities. For OUD and pain, she was initially started on methadone, then switched to buprenorphine due to prolonged QTc, and discharged when stable. However, she relapsed on fentanyl during her time out of the hospital, and upon readmission was ultimately switched back to methadone through close coordination with all teams, including Cardiology. The patient was stabilized on a regimen of methadone, gabapentin, and duloxetine, with several other medications tried and provided as needed for pain management throughout her admissions. Her medical teams also advocated to the hospital leadership to allow her to remain inpatient for her radiation therapy, given her insecure housing situation; she ultimately completed all radiation and chemotherapy treatments. Particularly given that guidance for the management of OUD in patients with advanced cancer is relatively nascent, this case demonstrates innovative, multidisciplinary management of a patient with significant medical and psychiatric complexity, multiple pain syndromes, and successful completion of inpatient cancer treatment in a patient with OUD and housing insecurity.