The term “physical dependence,” “tolerance,” “substance abuse,” and “active versus recovering addict” are all terms to be familiar with when treating cancer patients. Physical dependence is defined as “the development of a physical withdrawal syndrome following abrupt cessation of a medicine or substance .”
Experiencing physical dependence does not mean an addiction necessarily but is a physical reaction to chronic use of medications. Tolerance can be defines as a normal physical response to medications that result in higher doses of the medicine to receive effectiveness over time . Substance abuse can be defined as the use and abuse of illegal substances or inappropriate use of controlled substances .
Treatment will vary based on the different types of pain, acute, chronic and end of life.
Understanding Acute Versus Chronic Pain
Acute pain is when a person is treated for all types of pain regardless of addiction history, but continued follow-up is recommended to prevent relapse.
Chronic pain in those with addiction is to maximize function while providing pain relief .
It is important for the prescribing physician to write all of the individual’s pain medication, while reducing the opioid dose to as low as possible. It is important for the physician to be aware of the patient’s tolerance level, and wean accordingly, if necessary.
End of life treatments goal is to receive aggressive management of pain regardless of addiction history due to terminal illness [1, 2].
The Importance of Pain Management
When working with pain management, there are several principles to consider. The first is to provide effective pain management. Pain medications need to be chosen on the basis of the financial means of the patient. Considering the level of pain the patient is in can determine the type of pain medicine and strength for effectiveness.
Perceptions can vary on the level of pain a patient is in, from person to person, and between physicians. Being able to effectively manage pain requires a standard numerical score of, 1-10, with 1 being the lowest, and 10 being the most severe. This allows for consistency on assessing if the pain medicine is effective .
A second principle is to provide pain relief 24 hours a day. Pain medicines are used on an as-need basis allows pain to escalate and then requires more than the allowed dosage to control the pain.
24 hour dosing can help suppress pain and provide consistent comfort for the patient.
This can be accomplished with long-acting opioids and short acting for breakthrough pain. Opioids can be adjusted based on the dosage amount that provides best pain control .
Another principle to treating pain is if the pain is due to a medical emergency, treat for the medical emergency .
If a patient is in an active addiction, and they are not at end-of-life treatment, it can be a clinical concern due to the patient’s potential drug seeking behaviors . Typically addicts who use opioids and other pain management medicines do require larger doses at more frequent intervals than the general populations.
According to Osama Alabdulhadi, MD a neuro-anesthetist in Saudi Arabia, life expectancies in cancer patients have lengthened, and the risk for developing an addiction is increasing . He recommends reviewing psychosocial history, family history and including drug tests when considering pain management options .
From 2004-2010 Dr Alabdulhadi, in collaboration with the Pain Management and Symptom Clinic of the London Regional Cancer Program followed 516 cancer patients with a median age of 62, and were followed for 32 months in total . The study revealed that 8.9% of the patients had at least 1 risk factor for substance abuse, and 21 patients had 1 or more behaviors that were strongly suggestive of addiction .
According to Dr Erica Weinberg at the Rouge Valley Health System in Canada supported the finding that opioid misuse and substance abuse are of a growing concern among cancer patients .
In a 2012 publication, she stated that cancer patients and families need to be screened for opioid misuse and abuse, even at end-of-life stages. Screening for chemical coping and emotional distress is imperative and working to treat pain management with non-pharmacological means if able [2, 3].
Role of Prescription Painkillers
Breakthrough cancer pain is one of the hardest pain to treat. As many as 86% of hospice patients and 63% of non-hospice cancer patients report breakthrough pain . A study in 1990 that looked at the addiction development of cancer patients when prescribed pain medication found that of 24,000 patients studied, only 7 became addicted to the pain medication .
When cancer patients take pain management medicines, it is most often to combat the physical pain. Rarely do cancer patients take the medicines due to craving the substance or to cope with life stress or provide euphoria [3, 4]. Addiction seems to be more common when patients use it for the drugs psychological effects.
Prescription painkillers are medicines such hydrocodone, morphine, oxycodone, etc. . They relieve pain by the release and rush of the chemical dopamine which results in pain relief and euphoria. The euphoria is typically creates a pattern of abuse and addiction .
It is recommended that cancer patients and families receive education about painkillers and potential addiction consequences. Talking with patients about the benefits of the drug as well, pain relief, which can often outweigh the potential side effects if the cancer pain is severe enough.
Educating families on the signs and symptoms of dependence and addiction is beneficial. Signs including, secretive behaviors, taking higher doses than prescribed, forging prescriptions or frequenting various doctors to obtain more medicines . If a caregiver or loved one begins to notice these signs it is imperative to talk with the patient’s oncologist to let them know.
In conclusion the frequency of a cancer patient developing an addiction from painkillers is rare, but can occur. Knowing the side effects of medications, talking with the patient’s provider and getting education on what to look for can help the family and patient know how to manage an addiction if it develops.
Community Discussion – Share Your Thought Here!
Do you have experience with a loved one who has had cancer and developed a painkiller addiction due to treatment? What advice would you offer to others who find themselves in a similar situation?
About the Author: Libby Lyons, MSW, LCSW, CEDS, is a Certified Eating Disorder Specialist (CEDS) who works with individuals and families in the area of eating disorders. Mrs. Lyons works in the metropolitan St. Louis area and has been practicing in the field for 11 years. Libby is also trained in Family Based Therapy (FBT) to work with children-young adults to treat eating disorders. Mrs. Lyons has prior experience working with the United States Air Force, Saint Louis University, Operating Officer of a Private Practice, and currently works with both Saint Louis Behavioral Medicine Institute within their Eating Disorders Program and Fontbonne University
: Prater, C. D., Zylstra, R. G., & Miller, K. E. (2002, August). Successful Pain Management for the Recovering Addicted Patient. Retrieved December, 2016, from https://www.ncbi.nlm.nih.gov/pubmed/15014719/
: Katie, Johnson (2014). Risk for Substance Abuse in Patients With Cancer Pain. Retrieved December 2016, from http://www.medscape.com/viewarticle/770058
: Addiction Fears Prevent Cancer Patients from Getting Pain Relief. (n.d.). Retrieved December, 2016, from http://www.drugaddictiontreatment.com/addiction-in-the-news/addiction-news/addiction-fears-prevent-cancer-patients-from-getting-pain-relief/
: The Tragedy of Needless Pain. (n.d.). Retrieved December, 2016, from https://www.scientificamerican.com/article/the-tragedy-of-needless-pain/
: Rustøen, T., Geerling, J. I., Pappa, T., Rundström, C., Weisse, I., Williams, S. C., . . . Wengström, Y. (2013, February). A European survey of oncology nurse breakthrough cancer pain practices. Retrieved December, 2016, from https://www.ncbi.nlm.nih.gov/pubmed/22742829
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Reviewed By: Jacquelyn Ekern, MS, LPC on June 28, 2017.
Published on AddictionHope.com