Cancer and Substance Use Disorders: Learning to Navigate Both Diseases Simultaneously

Sunday, 17 November 2019

Amy Velasquez, MSN
Navigation, University of Kansas Health Systems, Kansas city, KS, USA

The outpatient Palliative Care Program embedded in an outpatient oncology clinic noticed that a number of their patients had a history of Substance Use Disorders (SUD), and were finding this out by aberrant behaviors. Aberrant behaviors can be defined as taking medications outside treatment plan, losing medications, requesting early refills and or using medications like opioids to help calm the nerves, give energy or help sleep not related to pain (Comptom & Chang, 2017). The nurses were spending a large amount of time on the phone, dealing with “lost and or stolen” prescriptions and early refills. Patients were running out of medications sooner than expected and or taking them other than how they were prescribed. It was not until the Palliative Care team educated themselves about SUD, and implemented the use of an assessment tool to identify who is risk of addiction did aberrant behaviors subside. This problem proved that cancer clinicians are not being properly educated on SUD, and in order to assess cancer patients’ risk of addiction education needed to be instituted which in return should decrease aberrant behaviors.

The Center for Disease Control (CDC) estimated in 2017, 70,237 people died due to a drug overdose that is almost 200 people a day. Most are related to opioid prescriptions (Centers for Disease Control and Prevention , 2018). Due to the opioid epidemic and these alarming statistics, people are coming into a diagnosis of cancer with a concurrent Substance Use Disorder (SUD). Historically it was assumed that cancer patients would not misappropriate their controlled substances and assessing risk of addiction seemed useless and somewhat uncouth; whereas chronic non-cancer patients were and are routinely assessed for risk of addiction (Arthur et al., 2018).

The literature review made it clear that needing controlled substances during cancer treatment does not produce drug addicts. Unfortunately, due to the opioid epidemic there are more and more people being diagnosed with cancer that also have a concurrent SUD (Barclay, Owens, & Blackhall, 2014). There are guidelines and education on how to assess risk of addiction in the chronic pain arena and guidelines in hospice and palliative care but not specific to the oncological setting (Comptom & Chang, 2017).

Methods

A survey was sent to 240 Physicians, Physician Assistants, Nurses and Advanced Practice Nurses across multiple different cancer sites within the same health system. The survey had to gain the approval of the Chief Nursing Officer (CNO) and the Chief Executive Officer (CEO). The survey had eight questions and six were on a Likert scale and two questions required narrative answers. One question was specifically for clinicians with prescribing privileges. The questions of this survey identified the baseline knowledge cancer clinicians have regarding SUD, their overall confidence in assessing for risk of addiction and if they felt it important to do so. In addition, if the clinicians had done any focused reading or attended any education sessions regarding SUD in their career.

Results of the Survey

The official trademark Survey Monkey was used and sent one time on November 23, 2018 by email. The nurse was able to analyze the data daily. A total of 82 clinicians responded to the survey out of 240; this resulted in a 34% response rate. Reviewing the survey daily allowed the nurse to come to an early conclusion that there was insufficient to no education about SUD provided to the clinicians; and clinicians did not feel comfortable assessing for risk of addiction.

Implementation of Project

An educational offering, Nursing Grand Rounds, was prepared for the entire cancer center health system. The main objectives encompassed the pathophysiology of addiction, the difference between tolerance, dependence and chemical coping. The results of the survey were discussed and an introduction of the Opioid Risk Tool was presented. Case studies were reviewed and showed how interventions made by assessing risk of addiction and identifying SUD improved patient care. Fourteen clinicians attended the presentation and were asked to complete a post presentation survey.

Findings

Deficit of Education

The initial survey that was sent to 240 clinicians identified a definite lack of education and knowledge about SUD as well as a scarcity of clinicians assessing risk of addiction in any of their cancer patients. A Likert scale was used when asking if clinicians are confident when talking to their patients and what is their knowledge base regarding SUD. On a Likert scale 1-10, one being not comfortable and 10 being very comfortable, the average response was a 4.2. More importantly, when asked if they have done any focused reading or attended any courses about SUD, 73 % stated no and only 27% stated yes.

Lack of Screening Tools

When asked if the clinicians currently use a screening tool the response was; always 9.7%, rarely 24% and never 14%. When asked if they would use a screening tool, 42% responded likely, 25.6% responded very likely and 6% responded unlikely.

Nursing Grand Rounds

The clinicians that attending the implementation part of the project stated that the education would empower them to change their practice.

Conclusion

Two main factors arose in determining the clinician’s perceived ability to care for cancer patients who may have a SUD. First clinicians are not properly educated about SUD and are not required to complete education. Second, the majority of clinicians do not screen for risk of addiction but do show interest in using a screening tool in the future. The above findings in this project support the gaps found in literature about SUD and cancer. Clinicians are not trained to assess for risk of addiction in cancer patients and there are no standardization across the spectrum of cancer to do so (Carmichael et al., 2016). Future efforts should be placed on creating standards of care to assess all cancer patients for risk of addiction and provide clinicians with education and tools to make this happen.