Addiction in patients with cancer is not well described. Patients with substance use disorders (SUDs) and cancer experience worse outcomes; however, no guidelines exist for identifying and successfully managing these issues in oncology. With the goal to improve patient safety and outcomes, an interprofessional work group at a major academic cancer hospital initiated a trial screening process for identifying substance abuse issues in an oncology population. Simultaneously, guidelines for patients with cancer and SUDs were created.
AT A GLANCE
- Substance use contributes to adverse outcomes; however, addiction is not well studied in the oncology population.
- An interprofessional team approach improves identification and customized management of patients with coexisting cancer and SUDs.
- Substance use assessment and screening is necessary for the implementation of patient-centered harm-reduction interventions.
Substance use and addiction in the oncology population is not well understood and may significantly compromise the ability of healthcare professionals to deliver high-quality cancer care. The extent of the problem in patients with cancer is not well known, with patients potentially presenting with current or past substance use disorders (SUDs) and/or developing these problems during treatment of their malignancy. Patient support systems, including caregivers, family, and friends, are also at risk for medication diversion or SUDs.
The prevalence of substance use and abuse in patients with cancer has been reported as lower than the general population; however, underreporting may exist (Arthur et al., 2016). Prevalence of substance use among patients with advanced prostate cancer was reported as 12% (n = 8,484) in patients aged 66–74 years and 7% (n = 5,763) in patients aged 75 years or older. Those with substance use had worse outcomes, including greater health service use and increased mortality (Jayadevappa & Chhatre, 2016). The Veterans Health Administration reported that 482,688 veterans received a cancer diagnosis during fiscal year 2012, and, of these, 32,037 (7%) had a SUD diagnosis. Veterans with both cancer and SUD diagnoses had more comorbid medical and psychiatric disorders, and used more medical and mental health services (Ho & Rosenheck, 2018).
The opioid epidemic is a public health crisis. It has also led to increased concern about opioid abuse/addiction and diversion in patients with cancer (Carmichael, Morgan, & Del Fabbro, 2016). The National Comprehensive Cancer Network (2019) adult cancer pain guidelines recommend risk assessment prior to and during cancer treatment based on a detailed patient evaluation and/or use of a screening tool, such as the Screener and Opioid Assessment for Patients with Pain-Revised, the Opioid Risk Tool, and the Current Opioid Misuse Measure. To date, no screening tools have been validated in the oncology setting.
Patients may experience poor outcomes driven by addiction, such as increased healthcare use and costs from complications directly related to substance use and/or disease progression from nonadherence to cancer treatments. This article discusses the experiences of an interprofessional workgroup whose focus was to improve outcomes among patients in a hematology-oncology unit at the Ohio State University Comprehensive Cancer Center–Arthur G. James Cancer Hospital and Richard J. Solove Research Institute (The James). Members of this quality improvement project team included a service line administrator, ambulatory (outpatient) nurse practitioner, pharmacist, social workers, patient care resource managers (RN case managers and clinical nurse leaders), and an inpatient nurse practitioner. Additional providers regularly consulted included hematology physicians, a pain management nurse practitioner, and addiction medicine specialists. The harm-reduction philosophy guided the workgroup—this was identified in early literature reviews. A systematic screening process was developed to characterize the extent of patient-reported substance misuse or addiction. Simultaneously, an action plan was created focusing on harm-reduction guidelines for patients with cancer and substance use issues. The goals of this project were to ensure patient safety and improve outcomes.
The interprofessional project team began meeting regularly in January 2017. The first step of the project was to improve understanding of commonly used terminology (see Figure 1). The next goal was to identify patients at high risk for a SUD. The project team modified the National Institute on Drug Abuse’s (NIDA) Quick Screen to use as a screening tool. This adapted screening tool assessed a patient’s self-reported use of alcohol, tobacco, prescription drugs, marijuana, and recreational/illegal drug on a scale assessing frequency of use, with responses ranging from “never” to “daily or almost daily.” In 2019, NIDA introduced the Tobacco, Alcohol, Prescription medication, and other Substance use (TAPS) tool. The NIDA Quick Screen and TAPS-1 are very similar; both are four-question tools that screen for tobacco use, alcohol use, prescription medicine misuse, and illicit drug use in the past year (NIDA, 2019).
The modified tool was trialed for six months (from March to August 2017) within two ambulatory lymphoma clinics at The James. This included the HIV/AIDS cancer clinic. In clinic, patients were scheduled for various types of appointments, including initial consultations, treatment, and routine follow up. A total of 283 screening tools were completed. Unfortunately, demographic data were not collected when patients were screened. Eighty-five patients (30%) formerly used tobacco, with 41 patients (15%) currently reporting use. Twelve patients (4%) reported alcohol use daily. Five patients (2%) reported misusing prescription medication previously, and 13 patients (5%) reported previous illicit drug use, with no patients reporting current daily use (see Table 1).
The project team also created best practices/harm-reduction guidelines for substance use/abuse issues in oncology, establishing strategies to minimize risk. Strategies included limiting controlled medication prescriptions to the primary oncology team, considering use of a contract (controlled medication management form), and performing routine urine toxicology screens for patients being prescribed controlled medications. In addition, the state’s prescription monitoring database program should be checked prior to every eligible prescription. IV access may be limited outside of treatment if concern for IV drug use exists (i.e., removing peripherally inserted central catheter line and avoiding Mediport® placement).
Addiction is a disease, not a character flaw (Botticelli, 2016). Unfortunately, patients with cancer are not excluded from substance misuse or addiction. Patients with cancer and an SUD are more challenging to effectively treat because of complex malignancy and chemotherapy-related issues. Patients with cancer and an SUD also experience issues with noncompliance and nonadherence, and are at increased risk for serious complications, such as infections.
The pilot screening period revealed a small but clinically significant number of patients reporting a current or past history of SUDs. Four percent of patients reported daily alcohol, with 19% of patients reporting current or past marijuana use, and 6% of patients reporting current or past intentional prescription misuse. The pilot period data established an estimate of the extent of the substance misuse or addiction problem in a population of patients in the hematology/oncology unit. The data allowed the project team to identify target areas to improve outcomes in this population. Harm-reduction guidelines are recommended for all patients (see Figure 2).
The interprofessional project team identified a hospital-wide unmet need, which led to the development of an innovative harm-reduction program within the Survivorship Department of The James. As part of the program, the role of a health behavior counselor was created. The counselor added addiction and recovery expertise to the clinical care of patients with cancer. In addition, the program provided holistic care, including psychosocial resources and clinical support, with the goal of ensuring completion of cancer treatment and successful transition into recovery and survivorship. A six-month substance use screening pilot in the ambulatory lymphoma clinics was completed in February 2019. Demographic data will be collected to further characterize the respondents.
This quality improvement project had several limitations. The NIDA Quick Screen has not been reported for use in an oncology population. The modified screening tool used did not specify the amount of alcohol consumed. The TAPS screen established five or more drinks for men and four or more drinks for women to identify potential problem use and those at higher risk of an alcohol use disorder. During the pilot screening period, the screening tool may have been inadvertently administered to patients more than one time; however, no results indicated whether current use, past use, or misuse were on repeated patients.
Nurses are in a unique position to identify and manage of patients with cancer affected by substance addiction. A harm-reduction approach in oncology care offers a unique strategy to minimize risk while positively influencing cancer care outcomes. Frontline oncology nurses are encouraged to lead the interprofessional collaboration and provide communication required to achieve optimal outcomes for this complex population. Little has been published on how to successfully address SUDs in the oncology population. Currently, opioids are receiving the most attention; however, it is important to identify and address all SUDs. Addressing addiction in oncology requires a comprehensive and compassionate team approach.
About the Author(s)
Gretchen A. McNally, PhD, ANP-BC, AOCNP®, is a nurse practitioner, Ashley Sica, MSN, RN, CNL, is a patient care resource manager, and Tracy Wiczer, PharmD, BCOP, is a specialty practice pharmacist, all at the Ohio State University Comprehensive Cancer Center–Arthur G. James Cancer Hospital and Richard J. Solove Research Institute in Columbus. The authors take full responsibility for this content and did not receive honoraria or disclose any relevant financial relationships. McNally can be reached at email@example.com, with copy to CJONEditor@ons.org.
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