NATIONAL HARBOR, MD. – Opioid misuse, and substance abuse in general, is a growing problem among cancer patients and survivors, according to a panel of experts at the annual meeting of the American Academy of Pain Medicine.
With the number of cancer survivors – people who can live for years and decades after diagnosis – on the rise, clinicians are seeing a corresponding growth in risk for pain medication addiction, they said. In addition, earlier cancer diagnoses can mean more patients may commence cancer therapy with a history of substance abuse.
"We’re starting to see a lot more in the way of substance abuse of every stripe. ... There are a lot of folks making it to tertiary cancer care centers with a history of addiction," said Steven D. Passik, Ph.D., a professor of clinical psychiatry at Vanderbilt University in Nashville, Tenn.
He gave the example of a female patient who had a preexisting polysubstance abuse problem and lived with metastatic breast cancer for 11 years. "When I first started in this field, this woman’s life expectancy would have been measured in months, and now it’s measured in years to decades," he said, introducing the challenges of tailoring long-term pain management programs for patients who are at risk of substance abuse.
Oncologists had not dealt much with substance abuse, because cancer is primarily a disease of older people, and addiction problems tend to manifest by age 35, Dr. Passik said. Oncologists and pain management physicians "will now have to worry about a small but very labor-intensive subpopulation of the cancer population. But you have to identify them," he continued, adding that "screening for substance abuse in the cancer setting ... has still not taken root."
Screening Tool Introduced
Dr. Dhanalakshmi Koyyalagunta, a pain management specialist at the University of Texas M.D. Anderson Cancer Center in Houston, said that clinicians there started using the short form of the SOAPP (Screener and Opioid Assessment for Patients With Pain) tool a little more than 2 years ago. This is a five-question assessment. Dr. Koyyalagunta said that clinicians at M.D. Anderson use a score of 4 or more as an indication that an individual is at high risk for substance abuse.
A review of 524 charts with completed SOAPP data found that more than a quarter of cancer patients (29%) were at high risk, she said, noting that the high-risk group included 43% of patients aged 18-35 years, 27% of patients older than 35 years, 72% of smokers, 40% of those who were unemployed, 60% of those with a history of drug use, and 32% of those with a history of alcohol abuse.
Although the true prevalence of substance abuse in the overall population of long-term cancer survivors is unknown, clinicians do know that there is a high incidence of comorbid anxiety and depression, added Dr. Koyyalagunta. It is very important to address any depression, anxiety, or other comorbid psychiatric conditions along with the pain, she said: "There’s a lot of chemical coping associated with these comorbidities."
The best treatment approach is to put together a multidisciplinary team that can develop an integrated treatment plan, said Diane M. Novy, Ph.D., a professor of pain medicine at M.D. Anderson. For example, a psychologist or social worker can address coexisting conditions such as affective disorders; acute stress related to cancer and cancer treatment; family problems; and work-related issues.
No Self-Titration for Pain Management
Pain management in cancer patients, particularly in older patients, tends to rely on self-titration: Take as much as you need, observed Dr. Passik. "It doesn’t hurt low-risk people to have a self-titration model, but you can’t apply that to high-risk people. That’s the recipe for a public health disaster," he warned.
Add in the need for long-term treatment, and problems associated with opioid exposure "now have ample time to play themselves out in terrible fashion," he said. Any opioid treatment strategy that he might use in high-risk patients with an expected 3-6 months of life would be inappropriate for a high-risk patient who was likely to survive for many years, he observed.
"All of us do have trouble with how we handle these patients long term," agreed Dr. Koyyalagunta. "We see a fair number of patients, and it may not be as easy as in the chronic pain setting, where you may have an exit strategy or have an alternative plan – especially in patients with active cancer."
Nonetheless, strategies and tools from the noncancer chronic pain world can be used in the cancer setting, said Dr. Koyyalagunta. These include assessment and differential diagnosis, screening, informed consent, ongoing psychiatric care, frequent outpatient visits, and documentation. "It’s pretty much the same set of principles, but adapting it to a cancer setting," she said.