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Substance Abuse Issues In Cancer (PDQ®)     
Last Modified: 09/02/2005
Patient Version
Table of Contents

Prevalance Among the Physically Ill
Physical dependence
Substance abuse
Defining Terms for the Medically Ill
Sociocultural influences
Disease-related factors
Redefining abuse and addiction for the medically ill
Risk in Patients Without Substance Abuse Histories
Risk in Patients With Substance Abuse Histories
Treatment of Patients With Substance Abuse Histories
Involve a multidisciplinary team
Set realistic goals for therapy
Treat related psychiatric disorders
Prevent or minimize withdrawal symptoms
The impact of tolerance
Treat chronic pain
Recognize drug abuse behaviors
Use nondrug approaches
Taking a substance abuse history
Inpatient Treatment
Outpatient Treatment
Get More Information From NCI
Changes to This Summary (09/02/2005)
Questions or Comments About This Summary
About 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

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

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.

People who have a history of drug abuse may revert to the use of an illegal drug when their pain is not adequately treated. Some of these patients may develop an addiction to prescribed drugs.

Sociocultural influences

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.

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.

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

The patient may benefit from nondrug approaches, such as learning about the complexities of the medical system, communicating with the medical staff, and learning relaxation and coping techniques.

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.

Inpatient Treatment

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.

Outpatient Treatment

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.

Get More Information From NCI

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Changes to This Summary (09/02/2005)

The PDQ cancer information summaries are reviewed regularly and updated as new information becomes available. This section describes the latest changes made to this summary as of the date above.

Links to the NCI Dictionary of Cancer Terms were added to this summary.

Questions or Comments About This Summary

If you have questions or comments about this summary, please send them to through the Web site’s Contact Form 4. We can respond only to email messages written in English.

About PDQ

PDQ is a comprehensive cancer database available on NCI's Web site.

PDQ is the National Cancer Institute's (NCI's) comprehensive cancer information database. Most of the information contained in PDQ is available online at NCI's Web site 2. PDQ is provided as a service of the NCI. The NCI is part of the National Institutes of Health, the federal government's focal point for biomedical research.

PDQ contains cancer information summaries.

The PDQ database contains summaries of the latest published information on cancer prevention, detection, genetics, treatment, supportive care, and complementary and alternative medicine. Most summaries are available in two versions. The health professional versions provide detailed information written in technical language. The patient versions are written in easy-to-understand, nontechnical language. Both versions provide current and accurate cancer information.

The PDQ cancer information summaries are developed by cancer experts and reviewed regularly.

Editorial Boards made up of experts in oncology and related specialties are responsible for writing and maintaining the cancer information summaries. The summaries are reviewed regularly and changes are made as new information becomes available. The date on each summary ("Date Last Modified") indicates the time of the most recent change.

PDQ also contains information on clinical trials.

A clinical trial is a study to answer a scientific question, such as whether one method of treating symptoms is better than another. Trials are based on past studies and what has been learned in the laboratory. Each trial answers certain scientific questions in order to find new and better ways to help cancer patients. Some patients have symptoms caused by cancer treatment or by the cancer itself. During supportive care clinical trials, information is collected about how well new ways to treat symptoms of cancer work. The trials also study side effects of treatment and problems that come up during or after treatment. If a clinical trial shows that a new treatment is better than one currently being used, the new treatment may become "standard." Patients who have symptoms related to cancer treatment may want to think about taking part in a clinical trial.

Listings of clinical trials are included in PDQ and are available online at NCI's Web site 5. Descriptions of the trials are available in health professional and patient versions. Many cancer doctors who take part in clinical trials are also listed in PDQ. For more information, call the Cancer Information Service 1-800-4-CANCER (1-800-422-6237); TTY at 1-800-332-8615.

Glossary Terms

Uncontrollable craving, seeking, and use of a substance such as a drug or alcohol.
anxiety (ang-ZY-uh-tee)
Feelings of fear, dread, and uneasiness that may occur as a reaction to stress. A person with anxiety may sweat, feel restless and tense, and have a rapid heart beat. Extreme anxiety that happens often over time may be a sign of an anxiety disorder.
brain metastasis (...meh-TAS-tuh-sis)
Cancer that has spread from the original (primary) tumor to the brain.
cancer (KAN-ser)
A term for diseases in which abnormal cells divide without control. Cancer cells can invade nearby tissues and can spread to other parts of the body through the blood and lymph systems. There are several main types of cancer. Carcinoma is cancer that begins in the skin or in tissues that line or cover internal organs. Sarcoma is cancer that begins in bone, cartilage, fat, muscle, blood vessels, or other connective or supportive tissue. Leukemia is cancer that starts in blood-forming tissue such as the bone marrow, and causes large numbers of abnormal blood cells to be produced and enter the blood. Lymphoma and multiple myeloma are cancers that begin in the cells of the immune system. Central nervous system cancers are cancers that begin in the tissues of the brain and spinal cord.
chronic pain (KRAH-nik payn)
Pain that can range from mild to severe, and persists or progresses over a long period of time.
clinical trial
A type of research study that tests how well new medical approaches work in people. These studies test new methods of screening, prevention, diagnosis, or treatment of a disease. Also called a clinical study.
depression (dee-PREH-shun)
A mental condition marked by ongoing feelings of sadness, despair, loss of energy, and difficulty dealing with normal daily life. Other symptoms of depression include feelings of worthlessness and hopelessness, loss of pleasure in activities, changes in eating or sleeping habits, and thoughts of death or suicide. Depression can affect anyone, and can be successfully treated. Depression affects 15-25% of cancer patients.
diagnosis (DY-ug-NOH-sis)
The process of identifying a disease, such as cancer, from its signs and symptoms.
disorder (dis-OR-der)
In medicine, a disturbance of normal functioning of the mind or body. Disorders may be caused by genetic factors, disease, or trauma.
The amount of medicine taken, or radiation given, at one time.
Any substance, other than food, that is used to prevent, diagnose, treat or relieve symptoms of a disease or abnormal condition. Also refers to a substance that alters mood or body function, or that can be habit-forming or addictive, especially a narcotic.
Monitoring a person's health over time after treatment. This includes keeping track of the health of people who participate in a clinical study or clinical trial for a period of time, both during the study and after the study ends.
Use of a syringe and needle to push fluids or drugs into the body; often called a "shot."
National Cancer Institute
The National Cancer Institute, part of the National Institutes of Health of the United States Department of Health and Human Services, is the Federal Government's principal agency for cancer research. The National Cancer Institute conducts, coordinates, and funds cancer research, training, health information dissemination, and other programs with respect to the cause, diagnosis, prevention, and treatment of cancer. Access the National Cancer Institute Web site at Also called NCI.
NCI, part of the National Institutes of Health of the United States Department of Health and Human Services, is the Federal Government's principal agency for cancer research. It conducts, coordinates, and funds cancer research, training, health information dissemination, and other programs with respect to the cause, diagnosis, prevention, and treatment of cancer. Access the NCI Web site at Also called National Cancer Institute.
A health professional trained to care for people who are ill or disabled.
opioid (OH-pee-OYD)
A drug used to treat moderate to severe pain. Opioids are similar to opiates such as morphine and codeine, but they do not contain and are not made from opium.
A patient who visits a health care facility for diagnosis or treatment without spending the night. Sometimes called a day patient.
palliative care (PA-lee-uh-tiv...)
Care given to improve the quality of life of patients who have a serious or life-threatening disease. The goal of palliative care is to prevent or treat as early as possible the symptoms of a disease, side effects caused by treatment of a disease, and psychological, social, and spiritual problems related to a disease or its treatment. Also called comfort care, supportive care, and symptom management.
PDQ is an online database developed and maintained by the National Cancer Institute. Designed to make the most current, credible, and accurate cancer information available to health professionals and the public, PDQ contains peer-reviewed summaries on cancer treatment, screening, prevention, genetics, complementary and alternative medicine, and supportive care; a registry of cancer clinical trials from around the world; and directories of physicians, professionals who provide genetics services, and organizations that provide cancer care. Most of this information, and more specific information about PDQ, can be found on the NCI's Web site at Also called Physician Data Query.
Medical doctor.
prescription (prih-SKRIP-shun)
A doctor's order for medicine or another intervention.
prevention (pree-VEN-shun)
In medicine, action taken to decrease the chance of getting a disease or condition. For example, cancer prevention includes avoiding risk factors (such as smoking, obesity, lack of exercise, and radiation exposure) and increasing protective factors (such as getting regular physical activity, staying at a healthy weight, and having a healthy diet).
progressive disease
Cancer that is growing, spreading, or getting worse.
quality of life
The overall enjoyment of life. Many clinical trials assess the effects of cancer and its treatment on the quality of life. These studies measure aspects of an individual’s sense of well-being and ability to carry out various activities.
radiation therapy (RAY-dee-AY-shun THAYR-uh-pee)
The use of high-energy radiation from x-rays, gamma rays, neutrons, protons, and other sources to kill cancer cells and shrink tumors. Radiation may come from a machine outside the body (external-beam radiation therapy), or it may come from radioactive material placed in the body near cancer cells (internal radiation therapy). Systemic radiation therapy uses a radioactive substance, such as a radiolabeled monoclonal antibody, that travels in the blood to tissues throughout the body. Also called radiotherapy and irradiation.
A treatment plan that specifies the dosage, the schedule, and the duration of treatment.
rehabilitation (REE-huh-BIH-lih-TAY-shun)
In medicine, a process to restore mental and/or physical abilities lost to injury or disease, in order to function in a normal or near-normal way.
The return of signs and symptoms of cancer after a period of improvement.
screening (SKREEN-ing)
Checking for disease when there are no symptoms. Since screening may find diseases at an early stage, there may be a better chance of curing the disease. Examples of cancer screening tests are the mammogram (breast), colonoscopy (colon), Pap smear (cervix), and PSA blood level and digital rectal exam (prostate). Screening can also include checking for a person’s risk of developing an inherited disease by doing a genetic test.
social worker
A professional trained to talk with people and their families about emotional or physical needs, and to find them support services.
supportive care
Care given to improve the quality of life of patients who have a serious or life-threatening disease. The goal of supportive care is to prevent or treat as early as possible the symptoms of a disease, side effects caused by treatment of a disease, and psychological, social, and spiritual problems related to a disease or its treatment. Also called palliative care, comfort care, and symptom management.
surgery (SER-juh-ree)
A procedure to remove or repair a part of the body or to find out whether disease is present. An operation.
An indication that a person has a condition or disease. Some examples of symptoms are headache, fever, fatigue, nausea, vomiting, and pain.
symptom management
Care given to improve the quality of life of patients who have a serious or life-threatening disease. The goal of symptom management is to prevent or treat as early as possible the symptoms of a disease, side effects caused by treatment of a disease, and psychological, social, and spiritual problems related to a disease or its treatment. Also called palliative care, supportive care, and comfort care.
therapeutic (THAYR-uh-PYOO-tik)
Having to do with treating disease and helping healing take place.
therapy (THAYR-uh-pee)
urine (YOOR-in)
Fluid containing water and waste products. Urine is made by the kidneys, stored in the bladder, and leaves the body through the urethra.

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