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Table of Contents Introduction
Overview
Prevalance Among the Physically Ill
Defining Terms 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
Inpatient Treatment
Outpatient Treatment
Get More Information From NCI
Changes to This Summary (09/02/2005)
Questions or Comments About This Summary
About PDQ
Introduction
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.
Back to Top Overview
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.
Back to Top 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
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
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.
Back to Top Defining Terms for the Medically Ill
The following issues make assessing substance abuse among patients who are
receiving treatment for medical illness more difficult.
Undertreatment
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.
Back to Top 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.
Back to Top 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.
Back to Top 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.
Back to Top 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.
Back to Top 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.
Back to Top Get More Information From NCI
Call 1-800-4-CANCER
For more information, U.S. residents may call the National Cancer Institute's (NCI's) Cancer Information Service toll-free at 1-800-4-CANCER (1-800-422-6237) Monday through Friday from 9:00 a.m. to 4:30 p.m. Deaf and hard-of-hearing callers with TTY equipment may call 1-800-332-8615. The call is free and a trained Cancer Information Specialist is available to answer your questions.
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Back to Top 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.
Back to Top Questions or Comments About This Summary
If you have questions or comments about this summary, please send them to Cancer.gov through the Web site’s Contact Form. We can respond only to email messages written in English.
Back to Top 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. 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. 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.
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