Treating Substance Use Disorder in Patients with Cancer

Recent studies find that nearly one in 10 adults suffers from a substance use disorder at some point in their lives. What do you do if a patient embarking on cancer treatment is also struggling with substance use?

Understandably, managing a patient’s substance use disorder concurrently with cancer treatment may feel overwhelming for oncology providers. However, there are many strategies and tools to help patients through this challenging journey.

Starting a dialogue with patients

The stigma associated with substance use can hold patients back from discussing these issues. One of the most important parts of the assessment process is engaging and building a relationship with the patient. Some methods to encourage patients to be comfortable talking about substance use include:

Creating a safe space. “Some patients know they have an issue and will admit it right away while others may not realize it is a problem and will normalize their use,” says certified oncology social worker Jane Dabney, LISW-S, OSW-C. “When talking to patients about substance use disorder, I try to explain that it’s an illness like many other chronic medical conditions. It’s not a character flaw.”

Asking open-ended questions. “If you’re asking a patient about alcohol use, it is important to ask how they use alcohol,” explains Dabney. This is more open ended than asking if they use alcohol. “Usually, they’ll open up and they might say ‘I have five drinks a day’. What’s tricky in assessing alcohol use is that it’s socially acceptable to use and some providers may not see it as a problem. However, if the patient is drinking to excess or self-medicating a mental health issue, that could be cause for concern and require further assessment. We want to make sure that we identify and address any underlying issues.”

Approaching patients with compassion. Helping patients understand that you’re raising the issue out of care for them can go a long way. Additionally, body language and tone can mean a lot in the conversation. “Providers may not have had much training in discussing substance use and may find it uncomfortable. They may worry that raising the issue could harm their relationship with their patient,” explains Dabney. “I found that addressing it with compassion is important and letting the patient know that you’re concerned about their use and how it will impact their ability to cope with cancer treatment. “

For example, it can be risky for a patient starting high-dose chemotherapy when they’re heavily using alcohol. “We need to educate them about the impact it can have on their cancer treatment. It is important to let them know that we’re concerned about keeping them safe and that there are programs that can safely help them through withdrawal,” says Dabney.

Engaging family members. “For patients about to receive in-home care such as Hickman line maintenance, those can be opportunities to get the perspective of others in the home,” explains Cleveland Clinic Lutheran Hospital's Chief of Psychiatry and Medical Director of the Alcohol and Drug Recovery Center David Streem, MD. “You might ask the family member whether they have any concerns about their loved one’s drinking or drug use and if that’s a common occurrence.”

Actively listening. Tools like screening questionnaires are part of the assessment process along with the clinical interview. During patient interviews, focus on fully hearing your patient. “I find that the best way to make sure patients feel listened to is if you slow the visit down,” says Dr. Streem. “The evidence is clear that if you sit down, even if you spend the exact amount of time with a patient, they perceive that you spent more time with them.”

Exploring treatment options and approaches

Clinicians at Cleveland Clinic bring a multidisciplinary approach to treating substance use disorder.

Teaching coping skills. “From a psychosocial perspective, we look at whether the patient is self-medicating for depression, anxiety or other mental health issues,” says Dabney. “Our goal is to treat that mental health issue in a more productive way. If their coping mechanism is drinking for example, we need to help them put some tools in their toolbox to replace that, particularly as they begin cancer treatment.”

Providing hospital stabilization. If a patient has a chemical dependency, the social work team will refer them to the Alcohol and Drug Recovery Center at Cleveland Clinic or residential treatment at Glenbeigh Hospital & Outpatient Center.

In addition to providing intensive outpatient programs in Ohio City and Fairlawn, the center can admit patients for medical hospital service, including ICU care, if they’re facing serious health issues such as significant liver dysfunction or kidney failure. Those conditions are beyond the capabilities of a traditional inpatient rehabilitation center to manage safely.

Managing co-occurring conditions. It’s not uncommon for patients to arrive at the center in a rough state, physically and emotionally. “When people don’t feel physically well, it affects their judgment and ability to make decisions,” says Dr. Streem. “Psoriasis is one example of this. Alcohol makes psoriasis much worse. When someone is on a binge, they’re often not taking their psoriasis medication. They’re covered in psoriasis plaques, they’re suffering from gastritis and they haven’t slept normally in weeks. They feel terrible and are often ashamed.

“My approach has always been to get them physically feeling better and then help them make better decisions about their life. We get their psoriasis under better control, get their stomach settled down, improve their nutrition and support them with hydration. Then when they’re feeling well, we can sit down and talk about how to address the substance use going forward and how the medical team can be helpful.”

Offering medical treatment. Medical treatment of substance use disorders has changed the field. Depending on the substance in question, the center can support patients with FDA-approved medications in combination with counseling and other therapies. Most commonly, these medications are used for opioid addiction or alcohol use disorder. These treatments can usually be offered while a patient is undergoing cancer treatment.

Even in cases where a patient has no functional GI tract due to radiation or an opiate use disorder, there are medications like buprenorphine that can be administered sublingually or subcutaneously. “It may require a little creative thinking, but there are plenty of tools in terms of medication-assisted treatment,” says Dr. Streem.

Providing group therapy. “Non-psychiatric physicians often don’t realize how powerful the group effect is for treating substance use disorder,” says Dr. Streem. “It’s extremely evidence based. Therapists who run group therapy for substance use disorder are specially trained in managing and subtly directing the group process for maximum impact.”

Dr. Streem notes that patients with social anxiety disorder may find group therapy challenging, so addressing this anxiety quickly is extremely important. SSRIs are the cornerstone of anxiety treatment, but can take up to four weeks to take effect. “You have to provide an individualized look at how to address anxiety in each patient,” Dr. Streem says. “Establish a relationship and trust with the patient and emphasize that nothing they experience in the group is going to be harmful.”

Offering family supports. Substance use disorder affects the whole family, so providing resources such as Al-Anon to aid the loved ones of those with this condition is essential. “Often family members are very angry about their loved one’s addiction problem,” says Dr. Streem. “That’s understandable, but people struggling with raw emotions associated with their own recovery rarely benefit from hearing how angry their parents, spouses or children are about their own addiction. Usually that increases the shame they feel, and that’s a dangerous situation when unpleasant emotions have been managed by substance use in the recent past.”

Education of patients, families and care teams is a key part of improving treatment of this disease. Organizations like the Substance Abuse and Mental Health Services Administration provide recovery support and education. “Substance use disorders are not choices. They are conditions that are mostly driven by genetics, and then cemented by substance exposure,” explains Dr. Streem. “This is not an acute illness; it’s a problem people must respect and manage throughout their lives, not unlike diabetes, epilepsy and other conditions.”

Understanding treatment outcomes

Success rates increase the more times that a person undergoes treatment for substance use disorder. Dr. Streem points out that this is a very different way of thinking than what occurs in oncology.

“With cancer, patients usually have no choice but to jump into treatment. With addiction treatment, it’s very much the reverse of that,” Dr. Streem says. “It’s not a linear path. People often dip their toe into treatment, and this can be disconcerting when a patient isn’t taking advantage of all the resources available to them. For most oncologists, that’s a difficult idea to wrap their head around because cancer treatment is so different from that.”

Patience is crucial with treating substance use disorder. On average, patients go through addiction treatment five times before they achieve a year of sobriety. “That doesn’t mean treatment doesn’t work; quite the opposite,” says Dr. Streem. “Each time through treatment, patients learn new coping skills and can manage their recovery more effectively. Often, they learn new things that, in prior treatments, they didn’t even realize were a problem for them.”

To learn more, watch The Realities of Addiction podcast.