Substance Abuse Issues In Cancer (PDQ®)
This patient summary on substance abuse issues in cancer is adapted from the summary written for health professionals by cancer experts. This and other credible information about cancer treatment, screening, prevention, supportive care, and ongoing clinical trials, is available from the National Cancer Institute. Substance abuse rarely develops in people who have cancer who do not have a history of drug or alcohol abuse. This brief summary describes substance abuse issues in patients with cancer who have a history of substance abuse, and addresses the use of opioid drugs to control cancer pain.
People with cancer very rarely develop substance abuse problems unless they abused drugs and alcohol before cancer was diagnosed. Generally, people without a history of substance abuse can take opioids and other drugs to control cancer pain without developing substance abuse problems. People with a history of substance abuse, however, are at risk for developing problems when drugs are prescribed to control cancer symptoms.
Patients who have a history of substance abuse may find that illegal drug and alcohol use interfere with their ability to receive cancer therapy. The use of drugs may interfere with the effectiveness of anticancer therapy and may cause patients to become even sicker.
Patients with cancer who are current substance abusers, or who have been substance abusers in the past, may find it difficult to develop a trusting relationship with a network of friends and family members and with the cancer treatment team. The lack of trust may compromise cancer treatment and follow-up care and may worsen the patient's quality of life.
Prevalance Among the Physically Ill
Substance abuse is very uncommon among patients with cancer. The number of known patients with cancer who are substance abusers may be small because these patients do not seek medical help in hospitals, or they may not acknowledge to health care providers that they have a substance abuse problem.
Physical dependence is defined as the occurrence of withdrawal symptoms when a drug is abruptly stopped, the dose is significantly reduced, or when a second drug is given that counteracts the actions of the drug to which the patient has developed a dependence. The dependence is not apparent until one of these actions occurs. When a patient with cancer is receiving an opioid drug for cancer pain, care is taken to avoid stopping the drug abruptly or prescribing other drugs that decrease or negate the effect of the opioid. Physical dependence on opioid pain medications does not seem to occur in patients with cancer. In these patients, once the pain disappears (usually through the effective treatment of the cancer), the pain medicine can be stopped without difficulty.
Tolerance to opioid pain medications may develop. Tolerance is the need to take increasingly larger doses of medication to relieve pain symptoms. Among patients taking opioid drugs for medical reasons, tolerance has not been shown to lead to drug addiction or drug abuse problems.
Substance abuse is the use of a drug in any manner that does not conform to the physician's orders or the use of any illegal drug.
Addiction is the use of a substance in a manner that is out of control, compulsive, used in increasing amounts, and is continued despite the risk of harm. A patient who uses opioids to relieve cancer pain may become physically dependent on the drugs, but is not described as being addicted to them.
These terms are generally used in association with people who do not have a medical illness. The terms are not entirely appropriate to use to describe medically ill people who are using drugs therapeutically.
Defining Terms for the Medically Ill
The following issues make assessing substance abuse among patients who are receiving treatment for medical illness more difficult.
If cancer pain is not adequately treated, a patient may use drugs recklessly in an attempt to seek relief. Many patients may not receive effective treatment for their pain. When the prescribed treatment is adjusted and pain is controlled, the patient's need to use drugs in a manner in which they were not prescribed disappears.
Because the terminology used to describe drug abuse is not intended to include people without a history of drug abuse who are using medications therapeutically, many questions have yet to be answered. For example, while it is clear that a patient who forges a prescription, or injects a drug that was meant to be taken by mouth, is displaying deviant behavior, it is not clear if the same may be said about a patient who increases the dosage to control unrelieved pain, or takes a pain medication to fall asleep at night.
Health care professionals may make assumptions about the risk of drug abuse based on a patient's social group. If the patient belongs to a social group in which there is a high incidence of drug abuse, or if the patient has a history of drug abuse, it may be incorrectly assumed that the patient is at risk for abusing drugs prescribed for therapeutic purposes.
Substance abuse may be difficult to identify if the disease is progressing and causing the patient to have physical and mental changes. Treatment for disease may also cause these changes; radiation therapy to stop brain metastases, for example, can cause the patient to become withdrawn and experience mental changes.
To determine the cause of drug-related behaviors in patients who have advanced medical disease, the patients may be asked if the drug in question has been used at other times in the patient's life, whether drug use interfered with the patient's ability to complete treatment for the disease, and whether drug use prevented the patient from establishing a relationship with the health care team or family members.
Redefining abuse and addiction for the medically ill
The behavioral characteristics that are present in substance abusers, such as loss of control over drug use, compulsive drug use, and continued drug use despite harm, should be monitored in patients who are using drugs for medical conditions. Should a patient develop these behaviors, the health care provider should re-evaluate the patient's drug regimen.
Risk in Patients Without Substance Abuse Histories
In patients who do not have a history of drug abuse, the use of opioids to control cancer pain very rarely develops into a significant abuse or addiction problem. Patients and some health care professionals continue to have unfounded fears that opioid use for controlling cancer pain may become addictive when a more significant problem is the undertreatment of pain.
At one time it was assumed that many addictions originated from the use of drugs prescribed for pain. Because cancer patients are able to use opioids for cancer pain without experiencing significant problems, the risks and benefits of long-term opioid treatment for chronic pain that is not related to cancer needs to be reassessed. Three studies of over 24,000 patients without drug addiction histories who were being treated for burn, headache, or other pain, found opioid abuse in only 7 patients.
It is also suggested that the feeling of euphoria that a drug addict experiences does not happen in patients taking drugs to control pain. A patient taking opioids therapeutically more typically experiences a sense of depression rather than euphoria, thereby reducing the risk that the patient will become addicted to the drug.
The overall evidence indicates that in patients who do not have drug abuse or addiction histories, relationships with substance abusers, or psychological problems, the use of opioid therapy for control of chronic pain has a very low risk of developing into drug abuse or addiction. This is especially true for older patients who have never abused drugs.
Risk in Patients With Substance Abuse Histories
Patients who have a history of substance abuse can be treated successfully for chronic pain. Although studies have not yet been done, it is assumed that these patients may be more likely than patients without a drug history to abuse a pain medication or become addicted to it.
Treatment of Patients With Substance Abuse Histories
Involve a multidisciplinary team
Patients with histories of substance abuse are best treated for progressive medical illness by a team of health care providers. A team of one or more physicians, nurses, social workers and, if possible, an expert in addiction medicine, will address the many medical, psychosocial, and administrative problems that patients with drug histories and progressive illness may have.
Set realistic goals for therapy
Patients who have drug abuse and addiction problems experience periods of recovery and relapse. The risk of relapse is increased when patients have a life-threatening disease and have access to pain medication. In this situation, the goal of treatment may not be the complete prevention of relapse, but may be to provide a structure that will limit any harm done by abuse of the drugs. Some patients who have severe substance abuse and related psychological problems may never be able to use therapeutic drugs as prescribed. The health care team should monitor and revise treatment goals for these patients as often as necessary to avoid treatment that is not successful.
Treat related psychiatric disorders
Alcoholics and patients with substance abuse histories are very likely to also suffer from depression, anxiety, and personality disorders. The risk of relapse may be decreased if the patient also receives treatment for anxiety and depression.
Prevent or minimize withdrawal symptoms
Many patients with a history of drug abuse consume multiple drugs. The health care provider must be made aware of all drug use so the patient may be effectively monitored to prevent withdrawal symptoms.
The impact of tolerance
Patients who are actively abusing drugs may have developed a tolerance that limits the effectiveness of drugs prescribed for a medical condition.
Treat chronic pain
Opioid regimens used for long-term control of medical symptoms are individualized for each patient so that the dosage is large enough to control symptoms. In patients with substance abuse histories, prescribing dosages that are not large enough may result in undertreatment of the symptoms. The undertreatment does not relieve the patient's pain, and may encourage drug abuse in an effort to control the symptoms. This behavior may cause the physician to become more cautious in prescribing opioids. The physician and patient must work together closely to determine the necessary dosage and to agree on guidelines for responsible use of therapeutic drugs.
Recognize drug abuse behaviors
While all patients who are prescribed drugs that may be abused must be monitored closely, monitoring is especially important for people who have a history of substance abuse. The patient may be reassessed frequently, and the patient's significant others may be asked to provide observations about the patient's drug use. The physician may find it appropriate to test the patient's urine for illegal or unprescribed drugs. If a patient is agreeable to drug testing and monitoring and uses prescribed drugs responsibly, a trusting relationship may be established with the physician. A physician who is confident that the patient will not abuse drugs is more likely to adjust therapies to control symptoms.
Use nondrug approaches
Taking a substance abuse history
To avoid offending a patient, a health care provider may choose not to ask about drug abuse. The health care provider may assume that the patient may become offended, angry, threatened, or may not tell the truth. Such attitudes are not helpful in establishing truthful communication between health care provider and patient and may cause problems in monitoring therapy.
A patient may withhold information about his or her drug use because of negative attitudes the health care provider may have about drug users. The patient may not trust the health care provider, or the patient may fear that if his/her drug abuse history is known, inadequate medication may be prescribed to control symptoms. The physician must know the patient's drug use history in order to control symptoms and to keep the patient comfortable by prescribing adequate medication to prevent withdrawal symptoms and reduce pain. The physician needs to know which drugs the patient has taken, the length of time drugs have been used, the frequency of drug use, and the situations that cause the patient to use drugs.
Patients with current substance abuse problems who are scheduled to undergo surgery should, if possible, be admitted to the hospital several days early in order to stabilize drug use to prevent withdrawal and to plan treatment. To prevent the patient from obtaining illegal drugs, he or she may be given a room in a location that can be easily monitored, and he or she may be restricted to the room or the floor. Restrictions may also be placed on the patient's visitors. The patient's room as well as packages brought by visitors may be searched periodically for drugs or alcohol. The patient's urine may also undergo regular testing. The restrictions placed on the patient are necessary to ensure that medical treatment will not be jeopardized by ongoing drug use. Treatment should include frequent monitoring to prevent withdrawal and to control symptoms.
Ideally, outpatients who currently abuse drugs should be enrolled in a drug rehabilitation program; however, patients with advanced medical illnesses may not be able to be enrolled. The health care provider may outline for the patient the role of the treatment team, what is expected of the patient, and the consequences to the patient should he or she continue to abuse drugs while receiving treatment for medical illness. Patients must receive detailed instructions for taking prescribed drugs responsibly. They must be seen frequently so symptom control may be maintained and drug abuse may be monitored. Frequent visits also avoid the need to prescribe large amounts of drug at one time, and may help the patient stay on the treatment schedule and attend appointments with the physician. Some patients may find that a "twelve-step" program is helpful in stopping illegal drug use while they are receiving treatment.
Outpatients may be required to undergo periodic drug testing. The patient should be informed in advance of the consequences of a positive test. A urine test that indicates the patient is using illegal drugs may result in the need to visit the outpatient department more frequently, smaller quantities of prescribed drugs, referral to a drug rehabilitation program, or other restrictions.
If the patient lives with family members who are substance abusers, the family members can be encouraged to enroll in a drug treatment program to help the patient avoid illegal drugs and alcohol. The patient should also be aware that friends and family members may attempt to buy or steal the prescribed drugs. It is very helpful to identify people who will be supportive of the patient.
A treatment team that includes a specialist in addiction medicine may be able to provide more effective treatment for the outpatient with a progressive medical disease and a history of substance abuse than can a single physician.
Patients who have successfully stopped abusing drugs or alcohol may be reluctant to begin using prescribed drugs for their medical illness for fear of developing an addiction. They may fear rejection from friends and family members who will object to their use of prescribed drugs, and they may fear that others will attempt to buy or steal the drugs. The health care provider should help the patient resolve these concerns and assure the patient that use of opioids to control symptoms of progressive disease does not result in the euphoria experienced by opioid abusers who do not have a medical illness.
If the patient is very reluctant to begin opioid therapy, the physician may develop strict guidelines for use of the prescribed drug to provide the patient with a sense of control. The patient may also be provided with counseling to help identify situations in which he or she is likely to abuse drugs or alcohol, and to develop strategies for avoiding future abuse of illegal or prescribed drugs.