Substance Abuse In Cancer, Part 2

by National Cancer Institute

(Page 2 of 3)

Disease-related factors

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may also cause these changes; radiation therapy to stop brain metastases, for example, can cause the patient to become withdrawn and experience mental changes.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

The following issues refer to palliative care for patients who are actively abusing alcohol or other drugs, or who are in a drug-free recovery or methadone program.

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.

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