“How can you effectively manage pain in a patient with a history of substance abuse?” It’s a question many oncology nurses may ask themselves or colleagues, given the prevalence of the condition in the United States, where approximately 9% of Americans meet the diagnostic criteria for substance use disorder (SUD).

In their article in the April 2017 issue of the Clinical Journal of Oncology Nursing, Compton and Chang provided a guide for nurses caring for patients with SUD, including overview, diagnosis, and treatment of SUD as well as its implications for pain management and cancer treatment considerations when a patient with SUD is diagnosed with cancer.

Substance Use Disorders

Compton and Chang explained that according to the 2014 National Survey on Drug Use and Health, in a 30-day period in Americans aged 12 years or older:

53% reported having had at least one alcoholic drink
23% reported binge drinking (five or more drinks on one occasion)
10% reported using an illicit drug
8% reported using marijuana specifically
2.4% reported nonmedical use of prescription drugs, and of those, 58% were prescription opioids.

Although the majority of people in the statistics above do not develop problematic use patterns, Compton and Chang said, with repeated use, some do go on to develop SUD. About 9% of Americans meet the diagnostic criteria (6% for alcohol and 3% for illicit drugs), making it one of the most common chronic diseases in the United States. SUDs cost Americans approximately $400 billion annually.

Patients with SUDs typically have a more severe pain experience. Aggressive pain treatment helps prevent relapse and makes patients more likely to consider SUD interventions.

Abused drugs and alcohol activate the mesolimbic or “reward” pathway in the brain’s subcortex, which drives users to repeat the rewarding experience and facilitate addiction. The Diagnostic and Statistical Manual of Mental Disorders (DSM-V) contains diagnostic criteria for SUDs, separated by substance. Additionally, about 40% of patients with SUDs have a mental, behavioral, or emotional disorder that also meets DSM-V criteria. SUD screening tools are available for clinical practice.

SUDs are chronic diseases, Compton and Chang said, characterized by remissions and exacerbations, but there is no cure. Treatment includes pharmacotherapy as well as cognitive-behavioral therapy, complementary integrative therapy, counseling, family therapy, group support, and lifestyle changes. And stress is a primary precipitator of relapse, Compton and Chang said. Cancer and the changes that come with treatment are stressors that may lead patients to resume SUD behaviors.

SUDs in Patients With Cancer

Compton and Chang said that research has not shown the current prevalence of SUDs in patients with cancer. However, researchers suspect increased rates of cancer in patients with alcohol SUDs because of the effect of alcohol abuse on cells and body tissues. Compton and Chang cited several studies that found that 17% of patients with advanced cancer were diagnosed with alcoholism on a screening tool and that alcoholics were more likely to be taking potent opioids than patients who screened negative for an SUD. Additionally, 8% of patients with cancer were found to have opioid use disorder.

These statistics point to an important need for screening patients with cancer for SUDs. Compton and Chang said that oncology nurses should begin with taking a patient’s substance use history, including current use, last episode, signs of intoxication or withdrawal, family history of SUD, and psychiatric history. Nurses should watch for denial or vague or inconsistent responses.

Additionally, Compton and Chang cited that patients with SUDs are less able to make the necessary lifestyle changes to comply with cancer treatments, including missing appointments, not taking medications as prescribed, and having poor diets and sleep.

Terms Associated With SUDs

Aberrant drug use behavior: Taking a medication in a manner outside the boundaries of the prescribed treatment plan, such as using multiple pharmacies and providers, repeatedly losing medication, ore requesting early refills; these behaviors may or may not reflect an SUD.

Abuse: Misuse with consequences (mild to moderate SUD); potentially harmful consequences include accidents or injuries, blackouts, legal problems, and risky sexual behaviors.

Addiction: A chronic, relapsing, and progressive disease leading to significant impairment in all life domains (moderate to severe SUD)

Misuse: Use of prescribed medication for nonmedical use or for reasons other than prescribed (e.g., altering dosing or route of administration, combining substances); misuse may or may not reflect an SUD

Opioid-induced hyperalgesia: A state of nociceptive (pain) sensitization caused by exposure to opioids

Physical dependence: A state of neurophysiologic adaptation to a substance, evident in a drug class-specific withdrawal syndrome on abrupt cessation, rapid dose reduction, or administration of an antagonist; physical dependence may or may not reflect an SUD.

Pseudo-addiction: Opioid drug-seeking behaviors secondary to inadequate pain control

Substance use disorder: The clinical diagnosis of a problematic pattern of substance use behaviors leading to clinical impairment or distress, including the inability to control use, consequences related to use, and failure to meet major responsibilities at work, school, or home. SUDs are categorized as mild, moderate, or severe to indicate the level of severity and are preventable and treatable.

Therapeutic dependence: Drug-seeking behaviors secondary to anxiety about adequate medication supply

Tolerance: a state of neurophysiologic adaptation in which increased amounts of a substance are needed over time to achieve the desired effect; tolerance may or may not reflect an SUD.

For patients whose SUD is in remission, oncology nurses should note the duration and circumstances, as well as ongoing support (e.g., group, therapist). Oncology care teams are not equipped to treat addiction, but ongoing, regular check ins with cancer care offer oncology nurses the opportunity to support and encourage recovery.

Because the stress of a cancer diagnosis and treatment may cause patients to have an SUD exacerbation, the cancer care team should include the recovery program or sponsor, an addiction specialist, or support groups. Stress relief interventions may also help. If an exacerbation occurs, the goal is to minimize its extent and help patients return to recovery, Compton and Chang said.

Pain Management in Patients With SUDs

Research has shown that patients with SUDs typically have a more severe pain experience, Compton and Chang explained. Patients with current opioid SUDs have shown decreased pain tolerance and opioid-induced hyperalgesia, and this can be compounded by associated intoxication or withdrawal symptoms, sympathetic arousal or muscular tension, sleep disturbance, affective changes, or functional changes.

Although opioids for cancer-related pain have an abuse liability, Compton and Chang emphasized the importance of following the same principles of pain management as for patients without a history of SUDs. These include choosing long-acting opioids with a gradual onset of action, administering around the clock, and using patient-controlled analgesia in the inpatient setting, which has been shown to decrease total opioid requirements as well as drug-seeking behaviors. An opioid treatment agreement may be needed if opioids are self-administered.

Oncology nurses should acknowledge active addiction but respect and believe patients’ reports of pain, Compton and Chang stressed. Aggressive pain treatment in this population helps prevent relapse and make patients more likely to consider SUD interventions. Additionally, because opioid withdrawal is associated with increased pain sensitivity, nurses should ensure patients are on long-acting substitute medications to prevent withdrawal.

Nurses may encounter patients in SUD recovery who are reluctant to use therapeutic opioids for cancer pain management. Compton and Chang said the nurse’s role is to respect the decision but reassure patients that they can choose opioid treatment in the future if desired.

For more information about care and pain management in patients with SUDs, refer to the full article by Compton and Chang.

This monthly feature offers readers a concise recap of full-length articles published in the Clinical Journal of Oncology Nursing (CJON) or Oncology Nursing Forum. This edition summarizes “Substance Abuse and Addiction: Implications for Pain Management in Patients With Cancer,” by Peggy Compton, PhD, RN, and Yu-Ping Chang, PhD, RN, which was published in the April 2017 issue of CJON. Questions regarding the information presented in this article should be directed to the CJON editor at CJONEditor@ons.org. Photocopying of this article for educational purposes and group discussion is permitted.

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