A patient’s substance use disorder can complicate treatment for a hematologic condition, but physicians must view the comorbidity as an opportunity to provide support.
The most recent data from the 2022 National Survey on Drug Use and Health (NSDUH) national report estimates that 17.3% of the U.S. population aged 12 or older met criteria for having a substance (either drugs or alcohol) use disorder in the past year.1 Patients with hematologic disorders and substance use disorders are a unique population, but data on the prevalence of co-occurrence of these conditions are lacking.
With the percentage of the population facing substance use disorders on the rise, the likelihood that hematologists will encounter patients with a substance use disorder also increases, said Joseph A. Arthur, MD, associate professor in the Department of Palliative Care and Rehabilitation Medicine at the University of Texas MD Anderson Cancer Center.
“We have to be able to normalize it because it is a chronic condition like hypertension, diabetes, or kidney disease,” Dr. Arthur said. “It is important not to stigmatize or look down on these patients.”
ASH Clinical News recently spoke with several clinicians about situations where treating a hematologic condition may overlap with addressing a substance use disorder and how the field is learning to provide patients with the best care possible.
Be Curious
An important part of understanding the overlap of substance use disorders and hematology is accepting that some patients seeking treatment for hematologic conditions will have these disorders.
“There is a misconception across [hematology/oncology] to the degree to which patients might have active substance use,” said Jason A. Webb, MD, section chief of palliative care at Knight Cancer Institute at Oregon Health & Science University. “It behooves us to be curious about how people live their lives and cope with stressors.”
Dr. Webb said that when he is called in for a palliative care consultation, he is often the first person to ask patients whether they use substances like opioids, methamphetamines, or alcohol.
“As health care professionals, we can sometimes avoid asking hard questions about things we may not have the tools to manage,” Dr. Webb said. “We are not doing patients any service by avoiding those discussions. You have to be curious about how or if they use substances that could impair their access to or adherence to treatment.”
However, it is important not only to be curious but to have the conversation in a nonjudgmental manner, added Daniel C. McFarland, DO, director of the Psycho-Oncology Program at Wilmot Cancer Center at the University of Rochester.
“At the very beginning, how you ask the question sets the tone,” Dr. McFarland said. “If I say it in an accusatory way, there is no way someone will be comfortable talking to me about what is going on.”
If hematologists feel ill-equipped to have that conversation, Dr. Arthur said, they should try to engage colleagues in palliative care or pain specialties to assist in patient management.
An Opportunity, Not a Barrier
In fact, instead of seeing a substance use disorder as a barrier to care, hematologists should see it as an opportunity to support these patients. Often patients with acute hematologic malignancies will require hospital admission, and this provides an opportunity to interfere or break the cycle of that patient’s use, or at a minimum provide guidance on safety strategies, Dr. Webb said.
Safety guidance might include educating patients about using fentanyl test strips or obtaining naloxone.2
“Every hematologic malignancy team, hospital providing hematologic malignancies services, or any freestanding cancer hospital needs to invest in having addiction services expertise as part of their team of clinicians,” Dr. Webb said.
While there is some guidance on the management of alcohol withdrawal in hospitalized patients,3 few resources are available to guide clinicians in treating patients with cancer who are experiencing withdrawal from other substances, such as opioids. Awareness of the existence of the disorder, though, can allow for addiction medicine or psychiatric consultation and possible use of medications, such as methadone, to lessen the severity of withdrawal symptoms and improve a patient’s cancer care.2
“If symptoms of withdrawal are not managed during a hospital stay, those patients are going to leave the hospital,” Dr. Webb said. “If we can’t support a patient with a legitimate medical problem in an inpatient setting, we are at risk of not providing the highest quality oncology care that we can.”
Pain in Recovery
Clinicians should also be prepared to treat, support, and adequately manage pain in patients who are in recovery from substance use disorders.
Patients in recovery who are diagnosed with cancer may experience financial and time toxicity related to their cancer treatment and managing their recovery, Dr. Webb explained.
For example, a 2019 study looking at drive times to the nearest certified opioid treatment program across five U.S. states found that the average drive time was almost 40 minutes, ranging from 7.8 minutes in urban settings to 49.1 minutes in rural settings.4
Patients in recovery from an opioid use disorder may have to arrange their lives around frequent visits not only to a methadone clinic but also to cancer centers several days a week.5 Similarly, patients in recovery from alcohol use disorder may need to attend regular, if not daily, Alcoholics Anonymous meetings to maintain their sobriety.
In some cases, patients in recovery may have a disease that progresses to the point of requiring pain management, Dr. McFarland said. That can be a difficult issue to address.
Dr. McFarland discussed a patient he had with head and neck cancer who was scheduled to go through treatment that would involve several months of intense pain. When the discussion turned to use of opioids to manage that pain, the patient warned Dr. McFarland that his behavior would change and he would begin asking for more and more opioids.
“Like clockwork, that’s what he did,” Dr. McFarland said. “The patient’s daughter happened to be an internist, and once it was reasonable to do so, we were able to taper him off the pain medication, but it took planning and help from his family.”
Dr. Arthur said there are strategies to help manage these patients, including decreasing the time between follow-up appointments, limiting the opioid quantities prescribed at each visit, and having a plan to taper off as soon as feasible.
“You can also refer these patients to specialist clinicians like addiction medicine specialists or psychiatrists for co-management,” Dr. Arthur said.
Nonmedical Opioid Use
There is also growing recognition of broadly defined nonmedical opioid use (NMOU) among patients with cancer. NMOU can include use of opioids without a prescription or use with a prescription but not as prescribed.6
“I personally really like the term because it is clinically applicable and relevant,” Dr. McFarland said. “The issue is that drugs have multiple effects. If you have anxiety or insomnia, people learn that even if it wasn’t given for that specific indication, a drug like an opioid seems to address those symptoms as well.”
The term NMOU is recommended for discussing use outside of what is prescribed because it is not perceived as pejorative or stigmatizing, Dr. Arthur added.
Unlike addressing substance use disorder, often the way to address NMOU is to treat the underlying problem the patient is using the opioid to address, Dr. McFarland said.
“Clinicians need to get comfortable talking about this in order to get honest answers from patients,” Dr. McFarland said. “Talk to your patients about how they are using their medications and for what reasons.”
For example, patients may mention that their oxycodone helps them fall asleep, but there are better medications — that are not addictive — to help with sleep.
“If a patient is using this pill for sleep, it’s also important not to call that addiction, but instead medical misuse,” Dr. McFarland said.
Hematologists may be concerned about a burgeoning substance use disorder when the drug is negatively affecting a patient’s functioning or well-being or may suspect diversion when requests for the medication are not consistent with the clinical picture, Dr. McFarland said. These are indications for a referral to a specialist.
At the same time, hematologists who suspect misuse may be reluctant to provide addictive substances when they are indicated for a particular condition. Clinicians often see a history of addiction or substance misuse as an absolute contraindication to prescribing addictive substances. More often than not, it’s a relative contraindication that requires a conversation, Dr. McFarland said. Unfortunately, withholding or inadequately addressing symptom care is more likely to precipitate an addiction problem, as many patients will find what they need without a physician’s help. Substance use disorders are a chronic problem that are not readily solvable, especially in the face of urgent symptoms.
For this reason, harm reduction is an important concept that allows for management of the substance use issue while also addressing symptom care. The harm reduction model shifts the focus from fixing what is usually a recalcitrant issue to addressing how it is affecting the treatment of the hematologic issue.7
“A lot of doctors think they can control everything, but we certainly can’t,” Dr. McFarland said. “When you approach it like that, you can end up giving worse care.
“Clinicians have an obligation to treat pain. Despite the tragedy of the opioid crisis, whose roots are very much multifactorial, doctors are not the gatekeepers of substance use disorders. The origins [of these disorders] are more commonly biologic and societal.”
Survivorship
Substance use disorders continue to be relevant even as patients with cancer transition into survivorship. Survivorship care plans should address not only prevention or detection of new or recurrent cancers, but also the management of chronic conditions.8
“This continues to be a challenge across the whole spectrum of cancer care, especially as we see patients living longer,” Dr. Webb said. “It is important that survivorship models take into account the very large proportion of patients in the U.S. with substance use disorders.”
One recent study estimated that about 4% of adult survivors of solid tumor cancers had an active substance use disorder, with that rate increasing to about 9% among survivors of head and neck cancer.9 Although data are scarce in hematologic malignancies, one study evaluating patients with myeloproliferative neoplasms who were receiving opioids found that 5.9% met criteria for mild opioid use disorder (OUD) and 2.9% met criteria for moderate OUD.10 With as many as one-third of survivors reporting ongoing pain, practicing hematologists should be aware of opioid-related complications, including OUD, and can refer patients to clinicians specializing in complex pain treatment.11
Recently, the National Cancer Institute (NCI) and other Health and Human Services agencies announced the National Standards for Cancer Survivorship Care. In it, they identified key health system policies, processes, and evaluation indicators. Among the health system processes, it prioritized the need for cancer survivors to be “assessed for lifestyle behaviors and provided with recommended strategies for management and appropriate referrals or education as needed (e.g., smoking cessation, diet/nutrition counseling, promoting physical activity).”12
“From a policy standpoint, I encourage the NCI and others to look at addiction services as part of what we call comprehensive cancer care as part of whole-person-centered care,” Dr. Webb said.
The idea of changing behaviors to minimize the impact of cancer currently includes tobacco and alcohol use in addition to dietary practices, weight reduction, sun protection, and more.13 According to Dr. Webb, that same lens should also be applied to patients who have a history of OUD or methamphetamine use disorder. Those disorders affect outcomes.
“What if we worked to get someone into remission, only for them to return to use and die as a result of substance use disorder?” Dr. Webb said. “Have we adequately cared for that patient? I would argue we haven’t. Ensuring a survivorship model that includes addiction medicine services, or at least has a framework for good referrals, is imperative to the work we do.”
References
- Substance Abuse and Mental Health Services Administration. HHS, SAMHSA release 2022 National Survey on Drug Use and Health Data. November 13, 2023. Accessed August 23, 2024. https://www.samhsa.gov/newsroom/press-announcements/20231113/hhs-samhsa-release-2022-nsduh-data.
- Fitzgerald Jones K, Khodyakov D, Arnold R, et al. Consensus-based guidance on opioid management in individuals with advanced cancer-related pain and opioid misuse or use disorder. JAMA Oncol. 2022;8(8):1107-1114.
- Blackburn SC, Haas NL, Kocan MJ, et al. Alcohol withdrawal in hospitalized patients: Michigan Alcohol Withdrawal Severity (MAWS) Protocol. Ann Arbor (MI): Michigan Medicine University of Michigan. May 2024. Accessed August 23, 2024. https://www.ncbi.nlm.nih.gov/books/NBK604324/.
- Joudrey PJ, Edelman EJ, Wang EA. Drive times to opioid treatment programs in urban and rural counties in 5 US states. JAMA. 2019;322(13):1310-1312.
- Jones KF, Joudrey P, Meier D, et al. Juggling two full-time jobs - methadone clinic engagement and cancer care. N Engl J Med. 2023;389(22):2024-2026.
- Ulker E, Del Fabbro ED. Best practices in the management of nonmedical opioid use in patients with cancer‐related pain. Oncologist. 2020;25(3):189–196.
- Ganguly A, Michael M, Goschin S, et al. Cancer pain and opioid use disorder. Oncology (Williston Park). 2022;36(9):535-541.
- National Cancer Institute. National Standards for Cancer Survivorship Care. Accessed August 23, 2024. https://cancercontrol.cancer.gov/ocs/special-focus-areas/national-standards-cancer-survivorship-care.
- Jones KF, Osazuwa-Peters OL, Des Marais A, et al. Substance use disorders among US adult cancer survivors. JAMA Oncol. 2024;10(3):384-389.
- Geyer HL, Scherber RM, Mazza G, et al. Prevalence and risk factors for opioid-related complications in patients with myeloproliferative neoplasms: an international survey of 502 patients by the MPN Quality of Life Study Group. Blood. 2018;132(Suppl 1):4297.
- Geyer HL, Gazelka H, Mesa R. How I treat pain in hematologic malignancies safely with opioid therapy. Blood. 2020;135(26):2354–2364.
- Mollica MA, McWhirter G, Tonorezos E, et al. Developing national cancer survivorship standards to inform quality of care in the United States using a consensus approach. J Cancer Surviv. 2024;18(4):1190-1199.
- Institute of Medicine (US) Committee on Psychosocial Services to Cancer Patients/Families in a Community Setting; Adler NE, Page AEK, editors. Cancer care for the whole patient: meeting psychosocial health needs. Washington (DC): National Academies Press (US); 2008. https://www.ncbi.nlm.nih.gov/books/NBK4015/.
Substance Use, Pain, and Sickle Cell Disease
Sickle cell disease (SCD) and hemophilia are two classical hematologic disorders in which patients are often prescribed opioids for pain management.
Since awareness of the opioid epidemic has grown, individuals with SCD have reported increased barriers to the use of opioids for pain management.1 These barriers may be related, at least in part, to negative attitudes or perceptions among emergency providers that people with SCD are exaggerating their pain or are addicted to opioids.2
For example, studies have shown that nurses, emergency room physicians, and even hematologists may have incorrect perceptions about patients with SCD and their reliance on opioids,3,4 when in fact the estimated rate of opioid addiction in patients with SCD is similar to the opioid addiction rate among most chronic pain sufferers in the U.S.5
“The key message is that data currently support that people with SCD are no more likely to have substance use disorder than people in the general population,” said Sophie Lanzkron, MD, MHS, professor of medicine at Thomas Jefferson University in Philadelphia.
When dealing with patients with SCD and hemophilia, Dr. Lanzkron said, physicians must remember that opioids are often one of the only effective options that can be offered to patients.
“It’s not always a question of, ‘Is the patient addicted to opioids?’” Dr. Lanzkron said. “These medications are reinforcing. They make patients feel good, decrease the pain, and that’s why patients use them over and over.”
Better questions to address are whether clinicians are giving the appropriate medications to the appropriate patient populations and whether patients are receiving the right dose.
“If a patient is on opioids and still experiencing a pain of seven out of 10, then it’s not working, and we need to think about doing something different,” Dr. Lanzkron said.
However, distinguishing between true opioid misuse and patients using opioids to effectively manage pain is incredibly difficult, she said. This is often outside the purview of a clinician in an emergency room and is better addressed by specialists treating patients with their SCD.
If it’s suspected or discovered that the substance being used is outside of what is prescribed for SCD, like cocaine or methamphetamines, a multidisciplinary team should be involved.
“If we have a patient with a substance use disorder who continues to use, that may be someone I am more inclined to rapidly wean off opioids because of the danger of combining these substances,” Dr. Lanzkron said.
For patients who might be engaging in cannabis use, clinicians should explain the risks of combining these substances. One study showed that combining cannabis and opioids can increase anxiety and depression and lead to more severe opioid dependence.6 Additionally, although data are limited, studies have shown that marijuana use for SCD either worsened pain crises or offered little to no help.7
That being said, Dr. Lanzkron said that any clinician practicing in a major urban area is likely to see a patient with substance use disorder at some point.
“Our job is to not cause harm,” Dr. Lanzkron said. “If we see someone suffering from a vaso-occlusive event, we have to treat that pain.”
References
- Sinha CB, Bakshi N, Ross D, et al. Management of chronic pain in adults living with sickle cell disease in the era of the opioid epidemic. a qualitative study. JAMA Netw Open. 2019;2(5):e194410.
- National Heart, Lung, and Blood Institute. Opioid crisis adds to pain to sickle cell patients. September 15, 2017. Accessed September 19, 2024. https://www.nhlbi.nih.gov/news/2017/opioid-crisis-adds-pain-sickle-cell-patients.
- Pack-Mabien A, Labbe E, Herbert D, et al. Nurses’ attitudes and practices in sickle cell pain management. Appl Nurs Res. 2001;14:187-192.
- Shapiro BS, Benjamin LJ, Payne R, et al. Sickle cell-related pain: perceptions of medical practitioners. J Pain Symptom Manage. 1997;14(3):168-174.
- Jonassaint CR, O’Brien J, Nardo E, et al. Prevalence of substance use disorders in sickle cell disease compared to other chronic conditions: a population-based study of black American adults. J Gen Intern Med. 2023;38(5):1214-1223.
- Rogers AH, Bakhshaie J, Buckner JD, et al. Opioid and cannabis co-use among adults with chronic pain: relations to substance misuse, mental health, and pain experience. J Addict Med. 2019;13(4):287-294.
- Paulsingh CN, Mohamed MB, Elhaj MS, et al. The efficacy of marijuana use for pain relief in adults with sickle cell disease: a systematic review. Cureus. 2022;14(5):e24962.