We are delighted to receive a response to our article, “Living and dying well with end-stage liver disease: time for palliative care,” highlighting the importance of pain control in people with end-stage liver disease (ESLD) and drug dependency. We agree entirely that trying to achieve optimal pain and symptom control for all our patients, whatever their medical or social history, should be our aim. When we stated that opioids can be problematic in patients with a history of substance abuse (alcohol or drug dependency or both), we sought to highlight that opioid analgesics should be used with additional care, as we outlined in the paragraph that followed. We had insufficient space to address the wider medical and supportive care challenges of providing good care for a complex patient group who often benefit from multidisciplinary management by clinicians with expertise in palliative care, pain management, and drug and alcohol liaison services. We need to avoid fear of opioid use from depriving patients of effective analgesia while also monitoring drug supply and carefully titrating any opioids used. Longer acting opioids are recommended in patients with continuing drug dependency, if at all possible.1,2 Incomplete cross-tolerance between opioids and opioids given by different routes of administration is compounded by the abnormal pharmacokinetics of advanced liver disease. For example, we have observed a relatively small dose of subcutaneous morphine added to regular methadone to cause significant sedation in our patients with ESLD. It is clear that there is a huge need to develop and research supportive and palliative care in this relatively neglected patient group. Hopefully, improving the care of all patients with ESLD will have a higher profile in the future.


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  • 1
    Haber PS, Neasham K. Alcohol and drug abuse. In: Walsh D, Caraceni AT, Fainsinger R, Foley KM, Glare P, Goh C, et al. Palliative Medicine. Philadelphia, PA: Saunders; 2009: 451458.
  • 2
    Farrell M, Wodak A, Gowing L. Maintenance drugs to treat opioid dependence. BMJ 2012; 344: e2823.