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Introduction
Substance Abuse in Cancer Survivors: An Epidemic We’re Not Talking About. Substance use disorders and cancer often go hand-in-hand. Many cancer patients and survivors struggle with alcohol, tobacco, or drug addictions. These addictions can start before, during, or after cancer treatment.
For some, a cancer diagnosis leads to anxiety, depression or other mental health issues. As a coping mechanism, patients may turn to or increase their use of substances.
Others who already had an addiction may find it worsens with the stress of cancer.
Substance abuse can negatively impact cancer screening, treatment, and prognosis. It can interfere with treatment plans, lower tolerance for therapies, and decrease odds of survival.
Despite these risks, addiction issues often go undiagnosed and unaddressed in cancer populations.
Raising awareness and improving support for those struggling with substance use disorders is key. With proper treatment and recovery services, patients can overcome addiction challenges and improve their lives during and after cancer.
Types of Substance Use Disorders
Substance use disorders in cancer patients and survivors can take many forms. The most common types include:
Alcoholism
Alcoholism, also known as alcohol use disorder, is characterized by an impaired ability to stop or control alcohol use despite adverse social, occupational, or health consequences. People with alcoholism may develop a high tolerance for alcohol, requiring more to achieve intoxication.
They may experience cravings and withdrawal symptoms when attempting to reduce or stop drinking. Alcoholism can range from mild to severe.
Smoking/Tobacco Use
Tobacco use, particularly cigarette smoking, is another prevalent substance abuse issue among cancer patients and survivors.
Nicotine, the primary addictive chemical in tobacco, activates reward pathways in the brain that can lead to dependence.
Quitting smoking can be extremely challenging due to nicotine withdrawal symptoms. Continued tobacco use during and after cancer treatment can negatively impact outcomes.
Illicit Drug Use
Some cancer patients also struggle with illicit drug use disorders involving substances like opioids, cocaine, marijuana, methamphetamines, and others.
Repeated use of these drugs can result in addiction, characterized by compulsive drug-seeking behavior, inability to stop despite harmful effects, and withdrawal symptoms during abstinence.
Like alcoholism and tobacco addiction, illicit drug use disorders exist on a spectrum from mild to severe.
Reasons for Substance Use in Cancer Patients
Cancer patients may turn to alcohol or drugs for various reasons. Two of the most common are using substances as a coping mechanism and having a pre-existing addiction. Additionally, some of the side effects of cancer treatments can lead patients to self-medicate with substances.
Coping Mechanism
Receiving a cancer diagnosis and undergoing treatment can be an incredibly stressful and traumatic experience. Patients often experience fear, anxiety, depression, and other difficult emotions while coping with cancer. Some turn to alcohol or drugs as a way to numb emotional pain, relieve stress, or escape from the reality of their diagnosis. Substance use may provide temporary relief, but ultimately makes it harder for patients to process their emotions and develop healthy coping strategies.
Pre-Existing Addiction
Some cancer patients come into treatment with a pre-existing addiction to alcohol, opioids, tobacco, or other substances. The physical toll of cancer and side effects of treatment can make it especially challenging to overcome addiction. Pre-existing substance dependence increases the likelihood that patients will continue using or relapse during cancer treatment. However, active substance abuse complicates treatment and reduces the likelihood of favorable outcomes.
Treatment Side Effects
Cancer treatments like chemotherapy, radiation, and surgery often produce difficult side effects including nausea, vomiting, pain, insomnia, depression, and anxiety. Some patients self-medicate with alcohol, marijuana, or opioids in an attempt to manage side effects on their own. However, substance use during treatment can interact negatively with medications and chemotherapy. Self-medication does not address the root causes of side effects, which are best managed by oncology experts.
Effects on Treatment and Prognosis
Substance use disorders can negatively impact cancer treatment and outcomes in several ways:
Certain substances like alcohol, tobacco, and illicit drugs can interact with cancer treatments, making them less effective. For example, alcohol can interact with certain chemotherapy drugs, increasing toxicity. Tobacco smoke contains carcinogens and can counteract the effects of radiation therapy in head and neck cancers.
Ongoing substance use during cancer treatment can lead to missed appointments, incomplete treatment regimens, and lower adherence to medications. This reduces optimal treatment benefits.
Substance use disorders are associated with higher rates of complications during cancer treatment. This includes increased infections, toxicity, and other side effects that can require hospitalization and treatment delays.
Continued tobacco and alcohol use after a cancer diagnosis is linked to higher recurrence rates and lower survival. Tobacco in particular increases the risk of secondary cancers.
Mental side effects of substance use like depression and anxiety can negatively impact quality of life during cancer treatment and long-term outcomes.
Pain management is more complex in those with substance use disorders. Finding an optimal pain relief regimen can be challenging.
The bottom line is that addressing any substance use disorders in cancer patients is key to maximizing treatment efficacy and prognosis. Screening, brief interventions, treatment referrals, and recovery support should be part of comprehensive cancer care.
Screening and Diagnosis
Healthcare providers should screen for substance use disorders both during cancer treatment and into survivorship. This allows for early detection and intervention. Screening tools include questionnaires about frequency, quantity, and negative effects of substance use. Some common screening tools include:
The Alcohol Use Disorders Identification Test (AUDIT) – screens for heavy drinking and alcohol dependence. It asks about alcohol consumption, drinking behavior, and alcohol-related problems.
The Drug Abuse Screening Test (DAST) – screens for drug abuse and dependence. It asks about drug use, drug-related problems, and dependence symptoms.
The Nicotine Dependence Syndrome Scale (NDSS) – assesses physical nicotine withdrawal symptoms and urges to smoke.
The CRAFFT Screening Test – screens for substance abuse risk in adolescents. It asks about behaviors like riding in a car with someone using substances and family or friends expressing concern over substance use.
If screening is positive, a full diagnostic evaluation should follow using criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). This evaluates if patients meet criteria for substance use disorders like alcohol, tobacco, cannabis, opioid, or stimulant use disorders based on symptoms like loss of control, social impairment, risky use, and physical dependence. Ongoing assessment during cancer treatment can identify emerging substance use issues.
Treatment
There are several evidence-based treatment options for substance use disorders in cancer patients and survivors:
Therapy
Cognitive behavioral therapy can help patients identify triggers, manage cravings, and develop healthy coping mechanisms. Therapists can provide motivation, accountability, and teach behavioral techniques.
Individual, group, and family counseling explores underlying issues and relationships that may contribute to substance use. Therapists help patients build communication skills and a strong support system.
Contingency management provides rewards for abstinence. This incentive-based approach reinforces positive behaviors.
Medication
Medications like buprenorphine, methadone, and naltrexone can reduce cravings and withdrawal symptoms. They are often used with therapy for a comprehensive approach.
Medications help manage any co-occurring psychiatric disorders, such as anxiety or depression, that may be contributing factors.
Rehabilitation
Inpatient or outpatient rehab provides a highly structured environment to focus solely on recovery. Individual and group therapy, counseling, and peer support teach long-term sobriety skills.
Partial hospitalization offers daytime rehab sessions and housing for nights and weekends. Intensive outpatient involves daily treatment sessions for several hours at a time. These options allow patients to continue cancer treatments.
Support Groups
12-step programs like Alcoholics Anonymous or Narcotics Anonymous offer peer support and sponsorship. Attending meetings helps build a sober network.
Group counseling allows patients to share challenges and solutions. Shared experiences provide motivation to stay committed to recovery.
Online support groups and forums can supplement in-person meetings. They provide 24/7 anonymous access to peer support.
Barriers to Treatment
Substance use disorders often go undiagnosed and untreated in cancer patients due to various barriers. Some of the key barriers include:
Denial
Many patients are in denial about having a substance abuse problem and do not seek help. Cancer patients in particular may rationalize their drug or alcohol use as a coping mechanism for their illness. Admitting they have an addiction can be extremely difficult.
Stigma
There is significant stigma surrounding substance abuse, especially for cancer patients who feel ashamed about not being “positive enough” during treatment. Many fear judgment from their doctors and loved ones if their addiction comes to light. This stigma prevents patients from being honest about their struggles.
Lack of Provider Training
Many oncology providers lack training in recognizing and treating substance use disorders. They may miss key signs and symptoms of addiction in their patients. Even when addiction is suspected, doctors often feel unprepared to provide intervention or connect patients to proper treatment resources. Better education for providers is critical.
Improving Care
Integrated and patient-centered care is key to improving outcomes for patients with cancer who have co-occurring substance use disorders. This involves education, integrated treatment approaches, and wrap-around support services.
Education
Educating healthcare providers on recognizing, screening, and treating substance use disorders can lead to earlier intervention. Training on motivational interviewing techniques can also improve engagement with patients who are reluctant to address substance use.
Patient and family education helps increase awareness of the risks of continued substance use and the benefits of treatment. Presenting addiction as a chronic disease and not a personal failing can help reduce stigma.
Integrated Treatment
Taking an interdisciplinary approach and coordinating care between oncology and addiction treatment providers leads to better outcomes. This allows concurrent treatment of both the cancer and substance use disorder.
Integrated treatment programs and services within cancer centers provide coordinated medical, psychological, and social support. This may include medication-assisted treatment for opioid use disorder.
Support Services
Wrap-around services including counseling, peer support groups, nutritional assistance, housing, transportation, and social work can address psychosocial needs and remove barriers to staying in treatment.
Support and resources tailored to cancer patients in recovery can help them cope with pain, emotional distress, and cancer-related effects without relapsing.
Support for families and caregivers also plays an important role in recovery.
Supporting Recovery
Recovery from substance use disorders is a lifelong process that requires ongoing support and care. Here are some ways to help support cancer survivors in recovery:
Ongoing Therapy
It’s important for cancer survivors with substance use disorders to continue therapy and counseling even after completing initial treatment. Ongoing therapy provides support, teaches coping strategies, and helps prevent relapse. Both individual and group counseling can be beneficial.
Support Groups
Joining a support group can provide community, accountability, and shared experiences. Support groups for cancer survivors, substance use disorders, or both can be helpful. These groups offer a judgement-free space to share challenges, receive encouragement, and make connections. Local support groups, 12-step programs, therapists, or treatment centers can help locate suitable options.
Preventing Relapse
Relapse is common in recovery. Stress, emotions, and cancer-related pain can increase risks for relapse in cancer survivors. Having a relapse prevention plan is essential, which may include identifying triggers, removing substances from the home, learning refusal skills, and connecting with supports. If relapse occurs, it’s important to get back on track with treatment and not get discouraged. Ongoing recovery takes perseverance.
Conclusion
Substance use disorders are unfortunately common among cancer patients and survivors. An estimated 13-42% of cancer patients have a substance use disorder, most commonly alcohol, tobacco, or prescription opioids. There are many reasons patients may turn to substance use, including managing cancer symptoms and treatment side effects, coping with emotional distress of a cancer diagnosis, or pre-existing addiction issues.
Substance use can negatively impact cancer treatment in various ways. It is associated with poorer treatment adherence, increased side effects, and worse prognosis and survival outcomes. Screening and diagnosis of substance use disorders is important to identify patients who may need intervention. Psychosocial treatment, support groups, medications, and residential rehab programs can help treat addiction in cancer patients.
However, many barriers exist that prevent patients from seeking or accessing substance abuse treatment. There is stigma attached to addiction, a lack of screening by oncology providers, and limited addiction treatment services integrated with cancer care. Progress still needs to be made in improving awareness, reducing stigma, coordinating care between oncology and addiction medicine, and increasing support tailored to the needs of cancer patients and survivors.
The high prevalence of substance use disorders among cancer patients is very concerning. Oncology providers should be aware of this issue and screen patients to provide help early on. Addressing and treating substance abuse can improve cancer treatment outcomes and quality of life. Comprehensive care that integrates addiction treatment is essential to supporting the whole patient and ensuring the best prognosis. Substance Abuse in Cancer Survivors: An Epidemic We’re Not Talking About