Substance use, substance use disorders, and treatment in adolescent and young adult cancer survivors—Results from a national survey
See editorial on pages 3064-3066, this issue.
Abstract
Background
Substance use can exacerbate cancer-related morbidity and mortality in adolescent/young adult (AYA) cancer survivors and place them at increased risk for adverse health outcomes. The objective of this study was to assess substance use, misuse, and substance use disorders [SUDs], as well as receipt of treatment for SUDs, among AYA cancer survivors.
Methods
The authors used data from the National Survey of Drug Use and Health (2015-2018) to identify a nationally representative sample of AYAs aged 12 to 34 years. Outcomes assessed past-year tobacco, alcohol, marijuana, and illicit drug use; misuse of prescription opioids; SUDs; and SUD treatment. Multiple logistic regression was estimated to compare outcomes between 832 AYAs who reported a cancer history (survivors) and 140,826 AYAs who did not, adjusting sequentially for sociodemographic characteristics and health status.
Results
In regressions adjusting for sociodemographic characteristics, survivors were more likely than a noncancer comparison group of peers to use alcohol (6% relative increase; P = .048) and illicit drugs (34% relative increase; P = .012), to misuse prescription opioids (59% relative increase; P < .001), and to have a marijuana (67% relative increase; P = .011), illicit drug (77% relative increase; P < .001), or prescription opioid (67% relative increase; P = .048) SUD. When further adjusting for health status, survivors were still 41% more likely (P < .001) to misuse prescription opioids than noncancer peers. Among those with SUDs, survivors were more likely than peers to receive treatment (unadjusted, 21.5% vs 8.0%; adjusted, P < .05).
Conclusions
AYA survivors were as likely as or more likely than noncancer peers to report substance use problems. These findings underscore the importance of interventions to reduce substance use and improve SUD treatment among AYA cancer survivors.
Lay Summary
- The authors assessed substance use, misuse, and substance use disorders, as well as the receipt of treatment for substance use disorders, among adolescent and young adult (AYA) cancer survivors.
- In a nationally representative AYA sample, cancer survivors, despite their increased risk for morbidity and early mortality, were as likely as or more likely than peers without cancer to experience substance use problems.
- In particular, survivors had a significantly higher rate of prescription opioid misuse than peers.
- However, only 1 in 5 AYA survivors who experienced substance use disorders received treatment.
- These findings underscore the importance of interventions toward reducing substance use and improving access to treatment among AYA survivors.
Introduction
In 2019, there were approximately 678,000 adolescent and young adult (AYA) cancer survivors in the United States, and this number continues to increase.1 Adolescence and young adulthood represent challenging developmental periods, which are often characterized by experimentation with risky health behaviors, including substance use.2 AYA cancer survivors are at an increased risk for morbidity and early mortality secondary to their cancer and its treatment.3 Despite increased vulnerabilities, AYA cancer survivors continue to engage in risky health behaviors, particularly substance use.2, 4 Substance use, a leading cause of death among the AYA population, can exacerbate existing vulnerabilities to cancer-related morbidity and mortality in survivors and place them at further risk for adverse health outcomes.5-8 For example, in addition to risk of addiction, chronic opioid use in adult cancer survivors is associated with tumor progression, infertility, and neurotoxicity.7
Health-promoting behaviors, including avoidance of substance use, have been recommended for this high-risk population.9, 10 To better inform interventions to prevent and reduce substance use, it is crucial to understand the current prevalence of substance use, misuse, and addiction among AYA cancer survivors compared with the general population. However, the existing studies examining the association between AYA survivorship and substance use have been based primarily on a small sample of survivors or larger cohort studies that are not population-based.11-16 To date, national estimates of the prevalence of substance use among AYA cancer survivors in the United States have been lacking. Furthermore, few previous studies have had the sample size to investigate misuse of addictive prescription drugs, substance abuse or dependence (ie, substance use disorder [SUD]), or treatment for SUD among AYA cancer survivors.
To address this gap in current knowledge, we identified a US nationally representative sample to provide population-based estimates of the prevalence of substance use (including misuse of prescription drugs), SUD, and receipt of treatment for SUD among AYA cancer survivors compared with the AYA general population without a cancer history.
Materials and Methods
Data Source and Study Sample
We used data from the 2015 to 2018 National Survey of Drug Use and Health (NSDUH), a nationally representative, cross-sectional survey administered by the US Substance Abuse and Mental Health Services Administration. The survey, which incorporates a multilevel, stratified, hierarchical sampling procedure for all 50 states and the District of Columbia, is 1 of the major sources of substance use, SUD, and SUD treatment data among US noninstitutionalized civilians aged ≥12 years. The response rate of the NSDUH ranged from 67% to 69% during the study period.17, 18
We included adolescent respondents aged 12 to 17 years and young adult respondents aged 18 to 34 years at survey completion. Age cutoffs available in the NSDUH prevented our ability to extend our analysis to age 39 years.17, 19 The National Cancer Institute defines a person as a cancer survivor from the time of cancer diagnosis until the end of life.20 Therefore, we considered an AYA as a cancer survivor if they had a cancer history, defined as responding yes to the survey question asking whether a health care professional had ever told them that they had cancer. AYAs who reported a history of cancer were further asked about the type of cancer and whether they had cancer in the preceding year. A noncancer comparison group was constructed, comprising all AYAs in the same age range who reported that they never had cancer.
Outcomes
Substance use
Respondents were asked whether they had used a specific class of substances or a prescription drug in any way undirected by a health care provider over the past year (for details, see section 1 in the Supporting Materials).17 Answers were dichotomized to indicate whether, within the past year, respondents reported: 1) tobacco use, 2) alcohol use, 3) marijuana use, 4) illicit drug use, 5) prescription opioid misuse, or 6) other psychotherapeutic drug misuse. Misuse of prescription drugs was defined as use not guided by a health care provider, including: use without a prescription or use in larger amount, longer duration, or more frequently than instructed.17
Substance use disorder
SUD was defined as past-year abuse or dependence on a substance, according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria (for details, see section 2 in the Supporting Materials).21 Because of data limitations, we could not use similar criteria for tobacco; therefore, we created an indicator for past-month dependence on nicotine (see section 2 in the Supporting Materials) as a proxy measure of tobacco use disorder.
Treatment for substance use disorder
Respondents were asked whether they received any treatment for the use of alcohol or drugs (excluding tobacco) over the past year and where treatment was received. We then determined whether, within the past year, respondents received: 1) treatment in a medical setting (ie, physician's office; mental health clinic; hospital, including emergency department; alcohol or drug rehabilitation facility), 2) treatment at a self-help group (ie, Alcoholics Anonymous, Narcotics Anonymous), or 3) any treatment for alcohol or drug use.22
Covariates
The sociodemographic characteristics we assessed included: age, sex, race/ethnicity, family income, and health insurance status. Health status included self-reported overall health status, the number of noncancer medical conditions, and past-year depression. To measure overall health status, we created a dichotomous indicator (self-reported health status fair or poor vs excellent, very good, or good). The NSDUH asked whether respondents were ever told by health professionals that they had noncancer medical conditions; using these questions, respondents were categorized into those who had none, 1, or ≥2 noncancer medical conditions. Depression was measured by whether the respondent experienced a major depressive episode within the past year.
Statistical Analysis
Descriptive statistics were reported to characterize the analytic sample and estimate the prevalence of substance use, SUD, and receipt of SUD treatment. Bivariate comparisons using adjusted Wald tests were performed to determine whether the prevalence differed between survivors and the noncancer comparison group. Multiple logistic regressions were then estimated to compare the outcome between survivors and the noncancer comparison group, adjusting for sociodemographic factors followed by health status. To determine which health status factors had the largest impact, regression models were adjusted for health status factors individually and then combined. All models also adjusted for survey year fixed effects. Among those reporting misuse of prescription opioids, adjusted Wald tests were performed to compare the reason for misuse and the source of the opioids for last misuse between survivors and the noncancer comparison group.
Pooled, weighted regression models were estimated using the svy command in Stata statistical software to account for the NSDUH survey design elements.23 Sampling weights were applied in all analyses to adjust for sampling selection and potential nonresponse or coverage bias.18 The results were presented as marginal effects (MEs) with 95% CIs. The ME was interpreted as the predicted difference in the percentage of survivors who responded yes for the outcome variable compared with the noncancer comparison group, holding all other predictors in the regression at their observed values.
For a sensitivity analysis, we repeated the analyses after excluding survivors who reported having cancer in the past year to test the robustness of results among longer term survivors (see section 3 in the Supporting Materials and Supporting Tables 1 and 2). In another sensitivity analysis, we restricted comparison peers to a randomly selected group of respondents without a cancer history who were matched to each survivor on age and sex using propensity matching (for details, see section 4 in the Supporting Materials and Supporting Tables 3-5).24
The Institutional Review Board at Emory University did not require a review for this study.
Results
Sample Characteristics
Of the 143,716 AYAs identified, we excluded 2058 individuals with missing values in covariates. The final sample comprised 141,658 AYAs, including 832 survivors (weighted, N = 697,990) and 140,826 peers in the noncancer comparison group (weighted, N = 95,252,742).
Compared with AYA respondents without a cancer history, cancer survivors were more likely to be older, female, non-Hispanic White, and covered by public health insurance (P < .01) (Table 1). Survivors also were more likely than peers in the noncancer comparison group to report poor overall health status, at least 1 noncancer medical condition, and a major depressive episode in the past year (P < .05). Among survivors, the most common types of cancer included gynecologic (26.7%), hematologic (18.4%), and skin (17.3%) cancers. Approximately one-fifth of survivors experienced cancer in the past year.
Characteristic | Comparison Group (N = 140,826), % | Survivors (N = 832), % | P a |
---|---|---|---|
Sociodemographic factors | |||
Age, y | <.001 | ||
12-17 | 24.9 | 6.7 | |
18-25 | 35.2 | 26.0 | |
26-34 | 39.9 | 67.3 | |
Female (vs male) | 49.8 | 68.3 | <.001 |
Race/ethnicity | <.001 | ||
Non-Hispanic White | 54.9 | 72.3 | |
Non-Hispanic Black | 13.5 | 7.7 | |
Hispanic | 21.7 | 14.6 | |
Non-Hispanic other | 9.8 | 5.5 | |
Health insurance status | <.001 | ||
Uninsured | 12.8 | 11.6 | |
Public insurance | 26.8 | 34.9 | |
Private insurance | 57.4 | 52.2 | |
Other insurance | 3.1 | 1.3 | |
Annual family income | 0.878 | ||
<$20,000 | 19.6 | 19.4 | |
$20,000-$75,000 | 46.9 | 45.9 | |
>$75,000 | 33.5 | 34.7 | |
Health status | |||
Fair/poor (vs excellent/very good/good) self-reported overall health status | 6.5 | 21.2 | <.001 |
No. of noncancer medical conditionsb | <.001 | ||
0 Chronic conditions | 80.9 | 66.0 | |
1 Chronic condition | 16.8 | 20.6 | |
≥2 Chronic conditions | 2.3 | 13.4 | |
Depression in past y | 10.9 | 20.7 | <.001 |
Cancer-related factors | |||
Cancer in the past y | — | 22.1 | — |
Cancer site/typec | |||
Leukemia, lymphoma, other blood | — | 18.4 | — |
Thyroid | — | 8.5 | — |
Melanoma, other skin | — | 17.3 | — |
Cervical, ovary, uterus | — | 26.7 | — |
Kidney, bladder, colon-rectal | — | 4.4 | — |
Breast | — | 4.6 | — |
Other cancer type | — | 22.1 | — |
- a An adjusted Wald test was used to compare values between survivors and the noncancer comparison group.
- b Noncancer medical conditions include hypertension, heart disease, diabetes, asthma, HIV/AIDS, hepatitis, chronic bronchitis or chronic obstructive pulmonary disease, cirrhosis, and/or chronic kidney disease.
- c Percentages do not add up to 100% because respondents may have had more than 1 cancer type.
Substance Use
In bivariate analyses, past-year tobacco use (38.4% vs 32.9%; P = .02), alcohol use (78.9% vs 63.6%; P < .001), illicit drug use (11.0% vs 7.7%; P = .03), and prescription opioid misuse (12.1% vs 5.8%; P < .001) were higher among survivors than among noncancer comparison peers, respectively (Table 2).
Outcome Variablea | Unadjusted Percentageb | Adjusted Percentage Point Difference, ME (95% CI) | |
---|---|---|---|
Adjusted for Sociodemographic Factorsc | Adjusted for Sociodemographics and Health Statusd | ||
Any tobacco use | |||
Noncancer comparison group | 32.9 | Ref | Ref |
Survivors | 38.4e | −0.2 (−3.8, 3.4) | −2.2 (−6.0, 1.6) |
Any alcohol or drug use | |||
Noncancer comparison group | 66.8 | Ref | Ref |
Survivors | 82.3f | 5.4 (1.7, 9.2)g | 4.1 (0.4, 7.8)e |
Alcohol use | |||
Noncancer comparison group | 63.6 | Ref | Ref |
Survivors | 78.9f | 4.0 (0.04, 8.0)e | 3.2 (−0.8, 7.2) |
Marijuana use | |||
Noncancer comparison group | 24.3 | Ref | Ref |
Survivors | 27.8 | 2.6 (−0.8, 6.0) | 0.6 (−2.6, 3.8) |
Illicit drug use | |||
Noncancer comparison group | 7.7 | Ref | Ref |
Survivors | 11.0e | 2.6 (0.6, 4.6)e | 1.5 (−0.4, 3.5) |
Prescription opioid misuse | |||
Noncancer comparison group | 5.8 | Ref | Ref |
Survivors | 12.1f | 3.5 (2.1, 4.8)f | 2.4 (1.0, 3.7)f |
Other prescription psychotherapeutic drug misuse | |||
Noncancer comparison group | 7.2 | Ref | Ref |
Survivors | 9.5 | 1.2 (−1.0, 3.5) | 0.4 (−1.8, 2.6) |
Nicotine dependence (past mo) | |||
Noncancer comparison group | 9.1 | Ref | Ref |
Survivors | 14.4f | 0.3 (−1.5, 2.2) | −1.1 (−3.0, 0.8) |
Substance use disorder (past y) | |||
Noncancer comparison group | 11.1 | Ref | Ref |
Survivors | 14.3 | 2.1 (−0.4, 4.6) | 0.1 (−2.5, 2.6) |
Alcohol use disorder | |||
Noncancer comparison group | 7.7 | Ref | Ref |
Survivors | 8.9 | 0.4 (−1.7, 2.6) | −0.6 (−2.7, 1.6) |
Marijuana use disorder | |||
Noncancer comparison group | 3.2 | Ref | Ref |
Survivors | 5.0 | 2.0 (0.5, 3.6)e | 1.4 (−0.2, 3.0) |
Illicit drug use disorder | |||
Noncancer comparison group | 1.3 | Ref | Ref |
Survivors | 3.6f | 1.0 (0.4, 1.6)f | 0.5 (−0.2, 1.1) |
Prescription opioid use disorder | |||
Noncancer comparison group | 0.9 | Ref | Ref |
Survivors | 2.3 | 0.6 (0.005, 1.2)e | 0.2 (−0.4, 0.8) |
Other psychotherapeutic drug use disorder | |||
Noncancer comparison group | 0.8 | Ref | Ref |
Survivors | 1.1 | 0.2 (−0.5, 0.9) | −0.2 (−0.9, 0.5) |
- Abbreviations: ME, marginal effects; Ref, reference category.
- a N = 832 survivors; N = 140,826 in the comparison group.
- b Adjusted Wald tests were used to compare measurements between survivors and the noncancer comparison group.
- c Regression models were adjusted for sociodemographic factors and survey year.
- d Regression models were adjusted for sociodemographic factors, health status, and survey year.
- e P < .05.
- f P < .001.
- g P < .01.
In regression models controlling for sociodemographic factors, survivors remained 6%, 34%, and 59% more likely than noncancer comparison peers to use alcohol (ME, 4.0 percentage points; P = .048), to use illicit drugs (ME, 2.6 percentage points; P = .012), and to misuse prescription opioids (ME, 3.5 percentage points; P < .001), respectively. After further adjusting for health status, particularly depression, there was no difference in the percentage of survivors and noncancer comparison peers reporting alcohol and illicit drug use (Table 2; see also sections 5 and 6 in the Supporting Materials). However, differences in past-year misuse of prescription opioids remained significant, with survivors 41% more likely to report misuse compared with the noncancer comparison group (ME, 2.4 percentage points; P < .001).
The reason for prescription opioid misuse for the majority of survivors was to relieve physical pain (64% vs 54% in the noncancer comparison group; P = .127) (Fig. 1A). Another notable reason among survivors was addiction (7% vs 3% in the noncancer comparison group; P = .243). Among those reporting misuse of prescription opioids, 45% of survivors obtained opioids from health care providers compared with 27% of those in the noncancer comparison group (P = .015) (Fig. 1B).
Substance Use Disorders and Treatment
After adjusting for sociodemographic factors, survivors were 67%, 77%, and 67% more likely than their peers in the noncancer comparison group to have a marijuana (ME, 2.0 percentage points; P = .011), illicit drug (ME, 1.0 percentage points; P < .001), and prescription opioid (ME, 0.6 percentage points; P = .048) use disorder (Table 2; also see Supporting Fig. 1 in section 5 of the Supporting Materials). These differences became nonsignificant when further adjusting for all health status factors. Differences in marijuana and illicit drug use disorders were only partially accounted for when adjusting for each health status factor individually, whereas there was no difference in having an opioid use disorder when any of the health status factors were adjusted (see Supporting Table 6 in section 6 of the Supporting Materials).
Among those with an SUD, survivors were more likely than individuals in noncancer comparison group to report any treatment (21.5% vs 8.0%; P = .01), including treatment in a medical setting (20.3% vs 7.1%; P = .01) and self-help treatment (17.4% vs 4.8%; P = .01) (Table 3). These differences persisted even in fully adjusted models (P < .05).
Outcome Variablea | Unadjusted Percentageb | Adjusted Percentage Point Difference, ME (95% CI) | |
---|---|---|---|
Adjusted for Sociodemographic Factorsc | Adjusted for Sociodemographics and Health Statusd | ||
Any treatment | |||
Noncancer comparison group | 8.0 | Ref | Ref |
Survivors | 21.5e | 6.0 (1.7, 10.3)e | 4.9 (0.4, 9.4)f |
Treatment in a medical setting | |||
Noncancer comparison group | 7.1 | Ref | Ref |
Survivors | 20.3f | 5.7 (1.6, 9.8)e | 4.6 (0.4, 8.8)f |
Self-help treatment | |||
Noncancer comparison group | 4.8 | Ref | Ref |
Survivors | 17.4f | 4.8 (1.8, 7.9)e | 4.3 (1.2, 7.4)e |
- Abbreviations: ME, marginal effects; Ref, reference category.
- a N = 107 survivors; N = 14,440 in the comparison group.
- b Results from adjusted Wald tests were used compare measurements between survivors and the noncancer comparison group.
- c Regression models were adjusted for sociodemographic factors and survey year.
- d Regression models were adjusted for sociodemographic factors, health status, and survey year.
- e P < .01.
- f P < .05.
Sensitivity Analyses
Our findings remained similar in analyses that excluded survivors who reported having cancer in the past year (see section 3 of the Supporting Materials) and in analyses that used an age-matched and sex-matched comparison group (see section 4 of the Supporting Materials).
Discussion
This study provides the first national estimates of substance use, misuse of addictive prescription drugs, and SUDs among AYA cancer survivors in the United States versus a control group of peers without cancer. To our knowledge, this is also the first assessment of the receipt of treatment for SUD among this high-risk population. We observed significantly higher rates of alcohol and illicit drug use, as well as prescription opioid misuse, among AYA survivors compared with the noncancer comparison group. In addition, an increased proportion of survivors reported marijuana, illicit drug, and prescription opioid SUDs compared with the noncancer comparison group. These survivor-comparison differences were largely explained when adjusting for health status; however, even in fully adjusted models, survivors were still 41% more likely to misuse opioids. This is particularly important because survivors are at increased risk for cancer-related morbidity and early mortality that can be exacerbated by substance use.6-8, 25, 26
Several studies have examined substance use patterns in AYA and adult survivors of pediatric cancer. Of the existing studies, the majority have been limited by a single institution,12, 13, 27 a restricted geographic area,10, 11 or small sample sizes.12, 27 Larger studies of survivors of pediatric cancer have depended on cohorts that were not population-based.14 Many of these studies reported that young cancer survivors were equally or less likely to use tobacco, alcohol, or illicit drugs and to experience substance-related disorders compared with the general population or siblings.11, 13, 14 Our estimates may have differed from these studies because of differences in study design, measures of substance use and SUDs, and sampling approach for data collection. For example, a previous study reported no difference in current or past cigarette use between adolescent survivors of pediatric cancers and their siblings14; however, this finding was based on survivors who agreed to participate in a cohort study and were retained in the follow-up, potentially leading to sampling bias. Our study contributes to current knowledge by using a nationally representative sample to generate reliable estimates of substance use problems in the United States AYA survivor population with diverse racial/ethnic and socioeconomic backgrounds.
There are several reasons why AYA cancer survivors may report increased substance use. According to the chemical coping theory, which refers to the excessive or inappropriate use of medication to manage psychological distress, cancer-related adverse health complications in survivors can trigger substance use.28-30 In our models that adjusted for health status to account for differences in physical and mental health care needs, the estimated survivor-comparison differences in substance use and SUD were reduced and often became nonsignificant. Future research should explore the pathways through which poor overall and mental health status lead to increased risk of substance use, misuse, and disorders among AYA survivors. Specifically, survivors may use alcohol or drugs to self-medicate symptoms of mental health problems or to cope with stress because of cancer-related chronic illness,31 which are potential pathways that merit future exploration.
Even in fully adjusted models, a larger proportion of AYA survivors reported misuse of opioids compared with the noncancer comparison group. This finding, in part, may reflect survivors' increased need for opioids for pain avoidance because chronic pain is more prevalent among survivors than among peers without cancer.28, 32 In our study, 64% of AYA survivors reported that the main reason for misusing prescription opioids was to relieve physical pain. Furthermore, in the midst of the opioid abuse epidemic, it is possible that overprescribing of opioid medications, together with survivors' limited knowledge of safe use of opioids, put young survivors at a particularly high risk for misusing opioids.33, 34 Consistent with this explanation, a recent study demonstrated a substantially higher opioid prescribing rate among nonelderly adult cancer survivors than among those without cancer.35 Our data also showed that 45% of AYA survivors who misused prescription opioids obtained the drug from health care providers, a rate higher than that of peers without cancer (27%). In addition, prescription opioid misuse during survivorship may be a result of drug dependence originated from opioid use earlier in the trajectory of cancer.35 More research is needed to fully understand the root causes of the increased substance use in AYA cancer survivors and to explore nonpharmacologic approaches for pain management among these survivors.
Interestingly, our data showed that AYA survivors were 1 to 2 times more likely than individuals in the noncancer comparison group to receive treatment for SUD. Future research should explore potential reasons for the higher utilization of SUD treatment among survivors versus peers without cancer. It is possible that survivors have increased engagement in the health care system, providing more opportunities for identification of and intervention for substance use problems. It is also possible that survivors' substance use problems may have been destigmatized as part of their cancer care. Nonetheless, it is important to note that only 1 in 5 (21.5%) AYA cancer survivors with an SUD received any treatment for this condition, suggesting the need for future efforts to increase survivors' engagement in SUD treatment.
Our findings also underscore the need for efforts to prevent and reduce substance use among AYA survivors. Significant efforts are needed to enhance communication to raise young survivors' awareness of their heightened risks for adverse health complications compared with their peers and the risks associated with substance use.36 Efforts are also needed to teach AYA survivors new coping skills to manage cancer-related distress.29 Moreover, oncologists who regularly see survivors should be encouraged to critically assess aberrant drug-taking behaviors, including misuse of opioids, among their patients and, when necessary, to refer patients for treatment of substance use problems.28, 35 Importantly, these efforts should be integrated into primary care and school-based health clinics because, as survivors become further from treatment, they may not see oncology specialists as frequently. Additional efforts may include integrating behavioral health services and substance abuse specialists into survivor care for AYA patients.28, 37
This study had limitations. Specifically, information on cancer treatment and time since cancer diagnosis was not available in our data set; therefore, our analysis may include survivors who are actively undergoing therapy and has limited ability to determine substance use patterns in long-term survivors. However, our findings were similar when respondents who had cancer in the past year were removed from the sample. Similarly, we had no data on age at cancer diagnosis, thus we could not differentiate whether the AYAs with a cancer history in our sample were survivors of pediatric or AYA cancer. In addition, our analysis was limited by the age groups available in the NSDUH survey; therefore, our age range differed from that in the National Cancer Institute definition of AYA, which includes individuals aged 15 to 39 years.19 Furthermore, we could not distinguish substance use problems that were preexisting or that developed after a cancer diagnosis, and the use of pooled cross-sectional data meant causality could not be established. Like all survey data-based studies, bias in self-reported measures might exist; respondents may underestimate or overestimate their substance use. Moreover, the NSDUH assesses SUDs based on DSM-IV criteria, which may underestimate the prevalence of DSM-V–based disorders.38 However, there should not be differential bias among survivors and noncancer peers in the NSDUH. Another limitation is that our data lack in-person diagnostic assessment with trained professionals, which is an ideal type of SUD assessment. Finally, the NSDUH lacks data on common mental health disorders other than depression, such as anxiety disorders and psychosis. Accordingly, we were unable to adjust for all mental health conditions that might confound the relation between cancer experience and substance use. Despite these data limitations, the NSDUH allowed for nationally representative analyses of substance use problems and treatment among the US AYA cancer survivor population.
This study revealed that AYA cancer survivors, despite their increased risk for morbidity and early mortality, were as likely as or more likely than AYAs without cancer to experience substance use problems. In particular, survivors had a significantly higher rate of prescription opioid misuse than their noncancer peers. This analysis also demonstrated that only 1 in 5 AYA cancer survivors who experience SUD received treatment. Future studies are needed to further explore the cause of increased use of addictive substances in AYA cancer survivors and to identify effective interventions to reduce substance use, prevent misuse of opioids, and improve access to SUD treatment for this high-risk population.
Funding Support
No specific funding was disclosed.
Conflict of Interest Disclosures
The authors made no disclosures.
Author Contributions
Xu Ji: Conceptualized and designed the study, carried out the analyses, interpreted data, drafted the initial article, and revised the article. Janet R. Cummings, Ann C. Mertens, Hefei Wen, and Karen E. Effinger: Conceptualized the study, interpreted data, and reviewed and revised the article. All authors approved the final version as submitted and agree to be accountable for all aspects of the work.