Substance use risk and controlled substances discussions in cancer care: Observations from audio-recorded...

Patients with advanced cancer frequently experience pain and psychological distress, often requiring controlled substances such as opioids and benzodiazepines. Although access to these medications increases risk of substance misuse, little is known about how clinicians and patients discuss controlled substance use during cancer care. Understanding these conversations may inform safer prescribing, improve patient outcomes, and support management of substance use disorder (SUD) risk. We aimed to characterize discussions of controlled substance use in oncology visits, including who initiated conversations, clinician responses, and verbalized SUD risk factors.

Five coders reviewed 826 audio-recorded oncology visits from a prior clinical trial. Encounters were coded for substance type, initiator (patient, clinician, both, neither), clinician/patient response style (avoidant, concerned/emotional, engaged, neutral, resistant), and substance misuse risk factors.

Mean patient age was 59.5 years; most were female (55.8%), White (81.7%), and married (71.7%). Substance-related content appeared in 14.6% of counters (n = 121; 92 unique patients). Mentioned substances included opioids and sedative-hypnotics (benzodiazepines/sleep aids), with oxycodone referenced in 67 visits. Patients initiated discussions more frequently (n = 51) than clinicians (n = 33), though not significantly, χ²(1, N = 95) = 33.00, p = 0.078. For the remaining encounters, neither initiated (n= 24) or both initiated (n=13). Among patient-initiated discussions, clinician response types were engaged (n = 25), neutral (n = 10), avoidant (n = 12), concerned/emotional (n = 1), or resistant (n = 3). Common substance misuse risk factors included inadequate pain management (n = 28), medication concerns (n = 17), dose escalation (n = 11), psychological concerns (n = 11), and substance misuse/drug-seeking (n = 5).

Despite widespread prescribing of controlled substances in oncology, discussions remain infrequent, and clinician responses to SUD-related concerns are often insufficient. These findings highlight opportunities to improve communication and risk management in cancer care.