Substance abuse in cancer patients who do not have histories of substance abuse is exceptionally rare. Opioids and other controlled substances can be prescribed judiciously for symptom management, without concern about misuse. When problematic drug-taking behavior is manifested by such patients, it is often the result of poor pain control. However, many people with cancer have a history of drug abuse or live among those who do. They have special needs that are often underappreciated because this problem is overlooked.[1] Nearly one-third of the population of the United States has used illicit drugs, and an estimated 6% to 27% have a substance abuse problem of some type.[2-5] The abuse of prescription opioids has grown rapidly since the mid-1980s and is now as frequent as the abuse of cocaine.[6] Because of the prevalence of substance abuse and the association between drug abuse and some types of cancer,[1] problems related to abuse and addictions are encountered in palliative care settings.

The population of patients who have histories of substance abuse or addiction is extremely heterogeneous, and the status of each patient will affect concerns central to his or her palliative care. Patients who are actively abusing alcohol, illicit drugs, or prescription drugs present problems distinct from those experienced by patients in drug-free recovery or patients in methadone maintenance programs. Appropriate diagnosis of substance abuse may be challenging because of the variability in abuse behaviors over time, the changes in comorbid physical and psychosocial factors that influence drug abuse, and the problems inherent in the nomenclature of drug abuse in the physically ill.

Patients who have histories of substance abuse present many clinical problems. Clinicians must control and monitor drug use in all patients. Compliance with treatments for the underlying disease may be so poor among cancer patients who are actively abusing drugs that the substance abuse actually shortens life expectancy by preventing the effective administration of primary therapy. Prognosis may also be altered by the use of drugs in a manner that negatively interacts with therapy or predisposes the patient to other serious morbidity.

Active or past substance abuse also may weaken social support networks. Among these supports is the patient’s relationship with the treatment team. Lack of mutual trust can characterize the relationships between substance-abusing patients and members of the treatment team. Concerns about drug abuse may lead clinicians to doubt the veracity of the history divulged by the patient, the report of symptoms, and compliance with therapy. A desire to build trust may lead clinicians to hide these concerns from the patient. Patients with histories of substance abuse may sense the mistrust, question the team’s good will, and have negative expectations that become self-fulfilling prophecies. Mistrust can disrupt assessment, management, and follow-up and can result in the failure of therapies intended to improve quality of life.

Thus, a history of substance abuse can undermine palliative care and increase the risk of morbidity or mortality among patients with progressive, life-threatening diseases. This potential can only be mitigated by a therapeutic strategy that addresses drug-taking behavior while implementing other therapies. To organize this strategy, clinicians who provide palliative care in the cancer setting must be knowledgeable about the basic concepts of addiction medicine.

References

1. Weissman DE, Haddox JD: Opioid pseudoaddiction--an iatrogenic syndrome. Pain 36 (3): 363-6, 1989.  [PUBMED Abstract]
   
   
2. Colliver JD, Kopstein AN: Trends in cocaine abuse reflected in emergency room episodes reported to DAWN. Drug Abuse Warning Network. Public Health Rep 106 (1): 59-68, 1991 Jan-Feb.  [PUBMED Abstract]
   
   
3. Gfroerer J, Brodsky M: The incidence of illicit drug use in the United States, 1962-1989. Br J Addict 87 (9): 1345-51, 1992.  [PUBMED Abstract]
   
   
4. Regier DA, Myers JK, Kramer M, et al.: The NIMH Epidemiologic Catchment Area program. Historical context, major objectives, and study population characteristics. Arch Gen Psychiatry 41 (10): 934-41, 1984.  [PUBMED Abstract]
   
   
5. Kessler RC, McGonagle KA, Zhao S, et al.: Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Results from the National Comorbidity Survey. Arch Gen Psychiatry 51 (1): 8-19, 1994.  [PUBMED Abstract]
   
   
6. Substance Abuse and Mental Health Services Administration.: Results From the 2001 National Household Survey on Drug Abuse: Volume I. Summary of National Findings. Rockville, Md: SAMHSA, Office of Applied Studies, 2002. DHHS Publication No. SMA 02-3758. 
   
   

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