Undertreated pain can drive behaviors that look like addiction but are not.— Antonia Corrigan, MSN, ANP-C, ACHPN
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Managing cancer pain in patients with substance use disorder presents a unique challenge for oncologists, requiring a balance between effective symptom management and mitigation of the risks of substance misuse. During the 2024 JADPRO Live, Antonia Corrigan, MSN, ANP-C, ACHPN, emphasized the importance of understanding substance use disorder, its impact on patient outcomes, and strategies for safe prescribing.1
“By adopting a patient-centered approach, leveraging multidisciplinary resources, and addressing both physical and psychosocial dimensions, oncologists can improve outcomes while minimizing harm,” said Ms. Corrigan, Chief APP in the Department of Supportive Oncology at Atrium Health Levine Cancer in North Carolina.
Understanding Substance Use Disorder in Oncology
As Ms. Corrigan explained, understanding substance use disorder and differentiating it from other behaviors, such as substance misuse or tolerance, are essential for providing effective, compassionate care. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), substance use disorder is characterized by the recurrent use of substances that cause clinically significant impairment, including health issues, social disruptions, and an inability to meet major responsibilities. Key diagnostic criteria include the following:
- Tolerance: Using larger amounts of a substance over time to achieve the same effect
- Withdrawal: Experiencing physical or psychological symptoms when the substance is abruptly stopped
- Persistent Use Despite Harm: Continuing to use a substance despite its clear negative effects on health, work, or relationships.
Ms. Corrigan highlighted the importance of identifying substance use disorder behaviors while avoiding misdiagnoses. For example, tolerance or physical dependence is common with long-term opioid therapy and does not necessarily indicate addiction.
“Physical dependence is not the same as substance use disorder,” she clarified. “All patients on chronic opioids will develop some level of dependence, and withdrawal symptoms will occur if the drug is abruptly stopped or tapered too quickly.”
Substance misuse often stems from untreated symptoms such as anxiety, insomnia, or poor health literacy. This behavior differs from substance use disorder in intent and context. For example, a patient may take extra pain medication to manage unrelieved discomfort or to help with sleep, not as a sign of addiction.
“Substance misuse can occur in patients without substance use disorder,” Ms. Corrigan emphasized. “You have to understand why they’re using the substance—are they self-medicating for untreated anxiety or depression?”
Clear distinctions among terms such as “tolerance,” “dependence,” and “addiction” are critical. Tolerance refers to a diminished effect of a drug over time, whereas dependence reflects the physical symptoms of withdrawal when the drug is stopped. Substance use disorder, however, involves compulsive substance use despite significant harm. Recognizing these nuances helps clinicians avoid stigmatizing patients and ensures appropriate treatment strategies.
Impact of Substance Use Disorder on Cancer Outcomes
Up to 35% of patients with cancer have coexisting substance use disorder, and managing their care requires addressing both their substance use behaviors and their cancer-related needs. “Behaviors related to untreated pain are similar to those of substance use disorder,” Ms. Corrigan explained. “The opioid crisis has made prescribers fearful, but we must treat the patient and not let personal bias guide treatment.”
Patients with substance use disorder face higher risks of treatment noncompliance, unrelieved symptoms, and reduced quality of life. These challenges stem from the complex interplay of untreated pain, fear of stigmatization, and financial or social barriers.
Substance use disorder can also exacerbate physical comorbidities, such as liver damage or infections, further complicating cancer treatments. Chronic alcohol use, for example, weakens the immune system and can worsen outcomes in patients undergoing chemotherapy or radiation therapy.
However, not all behaviors that appear to reflect addiction are rooted in substance use disorder. Patients with poorly managed pain or high levels of anxiety may exhibit behaviors such as requesting early refills, escalating medication use without consulting their provider, and having persistently high pain ratings despite long-acting opioid therapy.
“Undertreated pain can drive behaviors that look like addiction but are not,” Ms. Corrigan explained. “We need to ask: Is this about addiction, or are we failing to manage their pain effectively?”
Understanding the root cause of such behaviors can help avoid mislabeling patients and ensure they receive the care they need, she added. The perception of pain in patients with cancer often extends beyond physical discomfort, encompassing psychological, social, and spiritual dimensions. This “total pain” framework, coined by Dame Cicely Saunders, underscores the need for a holistic approach to pain management:
- Psychological factors such as depression and anxiety can amplify pain.
- Social issues such as financial stress or lack of support can exacerbate distress.
- Spiritual concerns, including fears about mortality or loss of purpose, can deepen suffering.
By addressing these interconnected factors, oncologists may improve pain control and overall outcomes for patients with substance use disorder. “Treating total pain means treating the whole patient,” Ms. Corrigan added. “Pain is subjective, and the context of the patient’s life matters just as much as the diagnosis.”
Strategies for Safe Prescribing
According to Ms. Corrigan, managing cancer pain in patients with substance use disorder requires balancing effective symptom relief with minimizing the risks of misuse. By establishing clear expectations, leveraging adjuvant therapies, and fostering multidisciplinary collaboration, oncologists can navigate this complex landscape while prioritizing patient safety.
The first visit is critical to set expectations around pain management, according to Ms. Corrigan, including plans for eventual tapering of opioids after treatment completion. Early, transparent communication helps patients to understand the trajectory of their care and prevents surprises later.
In addition, regular follow-ups are essential. Short prescription intervals (eg, 2 weeks) ensure frequent check-ins, allowing providers to assess pain, monitor for misuse, and adjust treatment plans as needed. Most patients appreciate the predictability and the opportunity to build trust with their care team.
A multimodal approach to pain management, which includes adjuvant medications and nonpharmacologic interventions, may also reduce reliance on opioids, especially in patients with substance use disorder.
- Adjuvant Medications:
- Gabapentin or pregabalin for neuropathic pain
- Duloxetine or venlafaxine for both neuropathic pain and underlying anxiety or depression
- Acetaminophen or nonsteroidal anti-inflammatory drugs when compatible with the treatment regimen.
- Nonpharmacologic Interventions: Therapies such as acupuncture, physical therapy, cognitive behavioral therapy, and occupational therapy can provide additional pain relief while addressing psychosocial aspects of the patient’s experience. “Sometimes, just getting a patient out of bed and into a chair is the first step toward improvement,” shared Ms. Corrigan. By incorporating these strategies, oncologists may reduce opioid dosages while maintaining effective pain control, particularly for patients with complex comorbidities or financial constraints.
Collaboration with addiction medicine, psychiatry, palliative care, and social work is also valuable. According to Ms. Corrigan, addiction specialists can assist with co-management of substance use disorder, psychiatrists and counselors can address mental health conditions that often accompany cancer and substance use disorder (such as depression and anxiety), and social workers can help navigate financial barriers and connect patients to community resources. However, not all patients will have access to or adhere to referrals. In these cases, frequent follow-ups and direct provider engagement are key to maintaining continuity of care.
Although careful tapering of opioids may be a necessary part of managing patients with cancer who have substance use disorder, abrupt deprescribing can have devastating consequences. “Deprescribing in patients with substance use disorder is dangerous and not indicated without close clinical monitoring,” said Ms. Corrigan. “It increases the risk for relapse, poor quality of life, and even suicide.”
When deprescribing is necessary, clinicians should follow evidence-based guidelines, such as deprescribing algorithms, to ensure the process is gradual and supportive. Close monitoring, including in-person visits every 2 weeks, helps patients feel cared for and prevents abrupt changes in treatment plans.
Compassion Is Key
Above all, successful pain management for patients with substance use disorder requires a compassionate and nonjudgmental approach. Listening to patients, validating their experiences, and focusing on solving immediate problems builds trust and encourages adherence to treatment.
“Listen to your patients, talk to them, and ask yourself: What can I fix today?” Ms. Corrigan concluded. “That mindset makes all the difference.”
DISCLOSURE: Ms. Corrigan reported no conflicts of interest.
REFERENCE
1. Corrigan A: Safe prescribing in the cancer patient with substance use disorder. 2024 JADPRO Live. Presented November 14, 2024.
