Drug Addiction Stigma Is Like Old Cancer Stigma

Not Long Ago, Cancer Was Unspeakable

Nick Mulcahy

March 25, 2019

ORLANDO, Florida — There was a time not long ago in the United States when cancer patients kept their diagnoses secret and cancer wasn't even discussed in the mainstream media, according to Judith Paice, PhD, RN, director, Cancer Pain Program, Northwestern University, Chicago, Illinois.

"I remember when Betty Ford revealed that she had breast cancer, and that was a revelation — she was exquisitely brave because you didn't talk about it," Paice said, referring to the cultural landmark event in 1974. Married to President Gerald Ford, she was the first lady of the United States at the time.

Paice discussed the topic of cultural taboos and misconceptions about disease as part of a presentation here at the National Comprehensive Cancer Network (NCCN) Annual Meeting.

Paice, a widely published expert on cancer pain, was encouraging an audience of oncologists, nurses, scientists, and industry representatives to broaden their perspective about the current opioid crisis in the United States and to avoid punitive or fear-based attitudes.

She argued that clear thinking about substance use disorders would help protect past "hard-earned gains" in improving cancer pain management.

Clear thinking is needed, agreed Rene Rubin, MD, director, Hahnemann Hospital Cancer Center, Philadelphia, Pennsylvania, who attended the NCCN meeting.

Rubin spoke up after Paice's presentation, relating her annoyance at being targeted via email by the Pennsylvania Department of Health as a "high prescriber" of opioids compared to other physicians.

There is no mechanism for response — rather, the emails say, "Do not reply," explained Rubin. As a result, she is left with the unsettling feeling of being monitored — but not fairly or intelligently.

The recipients of opioid prescriptions are "usually my stage IV cancer patients," she later told Medscape Medical News.

"None of this helps. It's a waste of time and money," Rubin said.

The oversight has become so burdensome, added Rubin, that oncologists are starting to avoid prescribing opioids.

"A lot of my colleagues will not write a script for analgesics. They tell patients to go to a pain clinic," she said, adding that this is costly and inconvenient for cancer patients.

Paice echoed this observation: "We are seeing more fear from healthcare professionals regarding prescribing of opioids — fear that their licenses will somehow be affected."

Dirty and Blame Worthy

Paice also sees a lot of misplaced energy, funds, and regulations. For that reason, she wanted to start at square one in discussing the "twin epidemics" of uncontrolled pain and opioid misuse.

One of the "unintended consequences" of efforts to reduce opioid overdoses has been the further stigmatization of substance use disorder, Paice explained.

"The way we looked at cancer in the past is similar to the way we look at substance use disorder now," she said.

"We used to blame the person with cancer — we used to think it was dirty" and even infectious, continued Paice. "Now we clearly understand better.

"We have some of those same attitudes towards people with substance use disorders," she continued.

If one can't be compassionate toward people with substance use disorders who experience relapse, one might consider from a societal point of view control of diabetes or hypertension, she suggested. Fewer than 60% of diabetes patients and 40% of hypertension patients optimally adhere to treatment, according to research.

Speaking to the NCCN audience, Paice asked: "How many of you intended to get up a little earlier today to exercise? But you hit the snooze button.

"Adherence to healthy living may not always be consistent — unfortunately, relapsing is really common in people with substance abuse disorder," she said.

Ask Patients About Risk Factors for Misuse

The prevalence of addiction among people with cancer is not well established, said Paice.

A 10-year-old study indicates it is between 0% and 7.7%. "Frankly, I think that is underestimated," she commented.

For some malignancies, such as lung cancer and head and neck cancers, which are associated with smoking and alcohol overuse, the prevalence of addiction is likely to be "much higher," she said.

There is a need to educate all patients and to assess their risks for substance use disorders "so we can assure them, if it is appropriate, that it is safe to use opioids," said Paice.

She advised that clinicians ask patients about risk factors, including, in addition to smoking and alcohol use, current and past use of recreational drugs and family history. She also advised that clinicians ask the most difficult question: "Have you ever been sexually abused?"

Paice acknowledged that she only started asking the last question in recent years. "I've been shocked about how many people have been," she testified. "This is a very strong risk factor for addiction," Paice told the NCCN audience.

Risk mitigation is the next step, after identifying risk. Prescription drug monitoring programs at the state level are helpful in providing information about how patients access analgesics, and they allow physicians to look for red flags, such as attempts to fill prescriptions at multiple pharmacies.

Paice also recommended urine toxicology as a means of assessing possible use of unprescribed drugs, and even considering the use of agreements or contracts with patients, which are not legally binding but help create accountability.

Paice said physician response to signs of addiction should not be, "Get out of my practice," but instead should be a conversation with the patient that includes discussion about help with addiction.

Paice and Rubin have disclosed no relevant financial relationships.

National Comprehensive Cancer Network (NCCN) Annual Meeting: Presented March 22, 2019.

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