We read with interest the article by Boyd etal., Living and dying well with end-stage liver disease: time for palliative care?1 We work closely with the liver unit at the Royal Free Hospital and are well aware of the lack of information available on the pharmacokinetics of opioids in liver disease and the challenges this presents. However, we read with some concern the statement that “Opioids can be problematic in a population with a high prevalence of substance abuse.” Clearly there are anxieties (not least for the patient concerned) associated with prescribing opioids in this population but, regardless of a patient's previous history or the etiology of their underlying disease, it would be ethically wrong for this to result in poorly managed pain.
Patients with end stage liver disease (ESLD) are a population where, historically, their pain was not acknowledged. With the added complication of a prevalent history of substance misuse resulting in a reluctance to prescribe opioids, this can mean that pain in this population is frequently poorly managed.2 These patients report an incidence of pain that is similar to that experienced in advanced colon and lung cancer,3,4 and we have a duty to provide good symptom control despite a previous history of opioid use.
It can be very difficult to predict how patients with ESLD will respond to some medications, particularly opioids. Fear of causing an encephalopathy, particularly where a previous history exists, can result in a reluctance to prescribe opioids when they are needed. Regular and careful monitoring together with the use of short-acting opioids given at increased intervals means that a safe opioid regime can be prescribed. Although fentanyl is the opioid that appears to be the best tolerated in ESLD,5 there are practical difficulties in using it where pain is unstable and rapidly changing. Ideally, the use of a short-acting opioid is preferable but each patient should be monitored individually considering the many factors that affect the pharmacokinetics of these medications.
This is a population where some have led lives where addictive behavior may have been prevalent, alienating family and friends, resulting in social isolation with very little support.
It is imperative that these patients are supported along their disease trajectory with the emphasis being on each individual's needs and appropriate symptom management, regardless of their previous history, which is where palliative care can play a pivotal role.