The Role of Policies in Cancer Pain, Health Disparities, and Substance Use

Abstract

Tens of thousands of cancer cases each year in the U.S. are attributable to smoking and alcoholconsumption. Many cancer survivors suffer from chronic pain caused by the cancer itself or by their cancer treatments. While several studies have examined how substances such as alcohol are used to self-medicate pain, none have assessed this relationship for cancer survivors experiencing chronic pain – sometimes dubbed “cancer pain.” Given the cancer risk that substances like alcohol pose, and cancer survivors’ vulnerability to second and recurrent cancers, there is a need to understand and address substance use among this subpopulation. Policies are an effective approach to reducing substance use and substance use-related adversehealth outcomes, offering population-level interventions that can target social and environmental determinants of health. Additionally, policies – when targeting structural impediments to health by increasing access to healthcare – may help narrow disparities in health for more vulnerable populations. However, care must be given that policies do not exacerbate health disparities or have unintentional consequences that could undermine any health benefits. As such, policy outcomes must be evaluated accurately and thoroughly. The goal of this dissertation was to connect cancer pain, substance use, and policy evaluationmethods. The first paper uses data from the Behavioral Risk Factor Surveillance System (BRFSS) to quantify the association between cancer pain and alcohol use. The second paper is methodologically focused, comparing several common regression modeling approaches (fixed effects, random effects, generalized estimating equations, autoregressive integrated moving average, and synthetic control method) to evaluating policies using time series purchasing data. The third paper uses these same purchasing data to evaluate the impact of Medicaid expansion on substance purchases, and whether the effects of expansion varied across racial and ethnic groups.