Substance Use
Introduction
There is not a medical condition under the sun that undiagnosed and unaddressed problematic substance use does not make more difficult, and in some cases, even impossible, to treat. Cancer is no different, and in many ways the negative consequences of unchecked substance use in oncology patients are more dire and serious. Substance use can undermine adherence to desperately needed oncology treatments; it can render the diagnosis and treatment of physical and psychiatric symptoms in people with cancer ineffective or worse, harmful. And yet, despite this importance, and incredible and unfortunate prevalence in our society, many oncology professionals lack training and expertise in general principles involved in the diagnosis and treatment of substance use problems. In the sections that follow, we will outline general principles with particular focus on the interface of substance use disorder and pain management – the single most difficult and obvious way in which many oncology professionals encounter and struggle with these issues.
The Substance Abuse and Mental Health Services Administration (SAMHSA) estimated that in 2020 approximately 13.5% of individuals 12 years of age or older reported using an illicit substance in the past month and 6.6% met criteria for a substance use disorder (SUD) in the past year. Cancer is primarily a disease of people in the fifth decade of life and later and with 85% of addictions being manifest by the age of 35, many have thought that especially older cancer patients are in some ways protected from addiction when exposed to potentially abusable drugs for symptom management and/or that addiction issues will not be encountered in the oncology setting. This view is particularly naïve when one considers that some cancers are strongly associated with substance use (e.g., bladder and lung cancer with nicotine/tobacco use, intravenous drug use with liver cancer via hepatitis C infection, alcohol with head and neck cancer). Although the prevalence of SUD among patients with cancer is poorly understood, just over 8% of individuals 50 years of age or older in the general population reported past month illicit substance use (skewed toward cannabis and misuse of prescription drugs) and slightly less than 3% met criteria for a SUD for illicit substances in the past year. These estimates are even higher for alcohol use disorders (7.1%) and co-occurring alcohol and substance use disorders (9.3%). Tertiary care centers may not see these issues as frequently because of the lack of health insurance and ties to medical care that often characterize people with addictions, but outside of tertiary care centers these issues are exceptionally common in patients of all ages. The belief, widely held until recently, that problematic substance use would diminish and vanish with age is no longer the case. As the “baby boom” cohort ages, the extent of alcohol and medication misuse is predicted to significantly increase because of the combined effect of the growing population of older adults and cohort-related differences in lifestyles and attitudes, potentially doubling since the year 2000. The treatment of alcohol represents the greatest proportion of the substance-use treatment in these older patient groups. The use of illicit drugs and nonmedical prescription opioids have increased significantly in the general population over the last two decades, with the highest prevalence among younger adult men. However, alarming trends are emerging among older adults. Recently, among adults in the U.S. aged 50 or older, nearly 5 million, or a little more than 5 percent of that age group, report using illicit drugs in the past year. Marijuana is the most common, but among adults aged 60 or older, the misuse of prescription drugs is equally common (e.g., benzodiazepines, pain relievers, stimulants).
Guidelines
NCCN Guidelines Adult Cancer Pain Guidelines V.2.20241
Substance Abuse and Mental Health Services Administration
TIP 54: Managing Chronic Pain in Adults with or in Recovery from Substance Use Disorders
AAPM/APS Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain
https://www.jpain.org/article/S1526-5900(08)00831-6/fulltext
National Institute on Alcohol Abuse and Alcoholism: Helping Patients Who Drink Too Much A CLINICIAN’S GUIDE
https://pubs.niaaa.nih.gov/publications/practitioner/cliniciansguide2005/guide.pdf
Evaluation and Diagnosis
Pain management efforts must occur in a context of risk stratification and ongoing management. As part of this approach, prescribers can utilize brief screening tools when determining risk and safety planning and then engage in good charting techniques for ongoing assessment and management. This can be helpful for identifying patients that they can treat alone, those whom they can treat with help, and those whom they must refer to other specialists. In general, older patients who do not have a history of substance use disorders, do not manifest major psychiatric problems increasing risk for self-medication and overuse/misuse of prescribed analgesics and are not living in a home environment at high risk for drug diversion are easily managed by oncology professionals without consultation. Patients who may be inclined to overuse/misuse medications at times of stress based on their history or those who have recent or active addictions should be managed with assistance from psychiatric and addiction medicine specialists. The clinician might inquire as to whether the patient has a history of problematic drug use in the aftermath of a painful loss or trauma to assess their needs (see Kirsh and Passik, 2008 for further discussion).
Several standardized and validated screening tools are available to assess for the presence of substance use disorders (SUD). These include:
- Screening Tool for Addiction Risk (STAR)
- Screening Brief Intervention and Referral to Treatment (SBIRT)
- Drug Abuse Screening Test (DAST)
- Screener and Opioid Assessment for Patients with Pain (SOAPP)
- Opioid Risk Tool (ORT)
Although these screening tools have been validated and used extensively in clinical and research settings, they may not be ideally suited for all groups. For example, fewer instruments have been designed or validated in older adults and assessment tools validated in younger populations may be less sensitive to certain features of addiction in older individuals. More specifically, some of these instruments include items about criminal activity and justice involvement related to substance use which are less commonly endorsed by older individuals. It is also important to note the dynamic nature of a patient’s risk over time. As patients’ medical conditions, pain states, and stressful life events change with time, so too does their risk of developing a substance use disorder. An objective assessment tool widely utilized in settings where controlled substances are prescribed, and an important component of universal precautions is urine or oral-fluid testing (henceforth referred to as urine drug testing; UDT). UDT is initially an assessment tool that provides information about current use of prescribed and non-medical drug use but can become part of ongoing monitoring during the management phase. However, UDT results should be interpreted carefully and an appreciation for the capabilities and limitations of the UDT method(s) used is essential to support the best clinical decision-making and avoid unintentional harm. Consultation with other experts (e.g., pharmacists and toxicologists) who have in-depth knowledge of drug metabolism and UDT technologies is strongly recommended when unexpected UDT results are obtained that may have broader implications for ongoing treatment.
Along with screening efforts, the interview process is essential. The interview process should include risk factors such as age at first use of all substances including tobacco, and not just opioids. Thus, obtaining a detailed history of duration, frequency, and desired effect of drug use in a nonjudgmental, compassionate and direct manner is vital. The use of a careful, graduated-style interview can be beneficial in slowly introducing the assessment of drug abuse. This approach begins with broad and general inquiries regarding the role of drugs in the patient’s life, such as caffeine and nicotine, and gradually proceeds to more specific questions regarding illicit drugs. In anticipating defensiveness on the part of the patient, it can be helpful for clinicians to mention that patients often misrepresent their drug use for logical reasons, such as stigmatization, mistrust of the interviewer, or concerns regarding fears of under-treatment. It is also wise for clinicians to explain that in an effort to keep the patient as comfortable as possible, by preventing withdrawal states and prescribing sufficient medication for pain and symptom control, an accurate account of drug use is necessary 50,51.
With pain medications, it may be helpful to consider four domains for assessing pain outcomes with an eye towards identifying addiction or misuse behaviors: 1) pain relief, 2) functional outcomes, 3) side effects, and 4) drug-related behaviors. As a mnemonic, these domains have been labeled the “Four A’s” (Analgesia, Activities of daily living, Adverse effects, and Aberrant drug-related behaviors). The Pain Assessment and Documentation Tool (PADT) was designed as a simple charting device based upon the 4 A’s concept. It was designed to focus on key outcomes and provide a consistent way to document progress in pain management therapy over time while being intuitive, pragmatic, and adaptable to clinical situations.
Treatment
| Treatment Modality or Technique | Pros and Cons | Patient Selection Issues |
| Motivational Interviewing (MI) |
Pros: · Ascertain patient motivation to control level of substance use, · Encourage patient to discuss reasons for seeking change and downside of status quo. · “Meet them where they are” with interventions. · Focuses on strengths of patient rather than weaknesses Cons: – N/A |
A basic approach suitable for initiation of discussion with all patients |
| Twelve-Step Programs |
Pros: · Long-standing source of support for patients highly necessary during cancer treatment. · Now offer programs with non-religious alternatives to Higher Power. · Incorporation of patient’s sponsor into treatment decision-making and monitoring may be beneficial Cons: · Discomfort with patients receiving controlled substances for pain and symptom management |
Meeting attendance may be challenging for those with advanced disease or who are not ambulatory
|
|
Recovery Support Techniques for Management of Pain 1. Frequent visits 2. Limited medication supply per prescription 3. Drug testing 4. Pill counts 5. prescription drug monitoring 6. Program checks |
Pros: · Provides limits to help patient to adhere to treatment and manage their medication supply Cons: · Risk of infantilizing or inconveniencing patients · Can be perceived as punitive by patients, family, and staff |
Essential for patients who are actively or have recently been using. Clinician should be prepared to ease restrictions as patient demonstrates adherence |
| Cognitive Behavioral Therapy (CBT) |
Pros: · Demonstrated efficacy for substance use disorders in healthy individuals · Focuses on strengths of patient rather than weaknesses Cons: · Difficult for patients with advanced disease or uncontrolled pain and other symptoms to fully engage at times |
Best suited for patients with adequate levels of comfort with therapy and willing/able to complete home practice. |
| Medication Management: Opioids (buprenorphine, methadone) |
Pros: · Relieves craving · Prevents withdrawal · With modifications to dosing regimens, can treat pain Cons: · Buprenorphine is a partial agonist that may not be effective for progressively worsening pain · Methadone has a long half-life and can accumulate in patients with poor clearance/metabolism/elimination due to medical problems such as liver disease and concurrent medications |
Patients with recent or active abuse and/or experience with MAT Patients with stable disease or survivors
Naltrexone is an opioid antagonist which, is unsuited for patients who are likely to have pain. May be useful in some long-term survivors. |
| Medication Management: Alcohol (disulfiram, acamprosate, long-acting benzodiazepines) |
Pros: · Relieves craving · Prevents withdrawal symptoms and delirium tremens Cons: · Drug effects may complicate or exacerbate side effects of cancer treatments (e.g., additive sedation) · Can be mistaken for or worsen cancer-related symptoms (e.g., nausea/vomiting) |
Best suited for highly-motivated patients with good social support and engaged family members who can assist with adherence
Naltrexone is an opioid antagonist sometimes prescribed for alcohol use. It is unsuited for patients who are likely to have pain. May be useful in some long-term survivors. |
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Bottom Line/Conclusion
Substance use is common and can be among the most disruptive of psychiatric problems when encountered in the oncology setting. Despite its prevalence and the threat it poses to the undermining of primary oncology treatment as well as pain and symptom management and palliative care efforts, expertise in its diagnosis and treatment is lacking among oncology professionals and even psycho-oncologists. However, clinicians need not be overly fatalistic; mobilizing some basic tools, psychosocial techniques and medications can impact substance use enough to assure that cancer treatment can be effectively delivered and that a person’s pain and other symptoms can be relieved.
References & Links
- Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelinesâ) for Adult Cancer Pain V.2.2024. ã National Comprehensive Cancer Network, Inc. 2024. All rights reserved. Accessed April 3,2024. To view most recent and complete version of the guideline, go online to NCCN.org. https://www.nccn.org/home
- McNally G and Sica A. Addiction in patients with cancer: Challenges and Opportunities. J Adv Pract Oncol. 2021 Sep; 12(7): 740–746.
- Kirsh KL, Passik SD. The Interface Between Pain and Drug Abuse and the Evolution of Strategies to Optimize Pain management while Minimizing Drug Abuse. Experimental and Clinical Psychopharmacology 2008, 16 (5): 400-404.
- Lundberg J, Passik SD. Alcohol and Cancer: A review for psycho-oncologists. Psycho-oncology. 1997; 6 (4):253-266.
- Passik SD, Portenoy RK, Ricketts PL. Substance abuse issues in cancer patients. Part 1: Prevalence and diagnosis. Oncology, 1998; 12(4):517-521.
- Passik SD, Portenoy RK, Ricketts PL. Substance abuse issues in cancer patients. Part 2: Evaluation and treatment. Oncology, 1998; 12(5):729-736.