Alcoholism screening in patients with advanced cancer: impact on symptom burden and opioid use.
OBJECTIVE
Alcoholism is a devastating disease that can cause patient and family suffering and is frequently underdiagnosed. Preliminary studies suggest that it is associated with increased symptom expression and opioid dose escalation. The CAGE questionnaire is a widely used tool for alcoholism screening. The purpose of this study was to determine the frequency and characteristics of patients who screen positive for alcoholism in a palliative care outpatient clinic (PCOC).


METHODS
We reviewed 665 consecutive charts of patients referred to the PCOC and collected data regarding age, gender, and type of cancer. For the first 100 consecutive CAGE positive (CAGE+) and 100 consecutive CAGE negative (CAGE-) patients, time from advanced cancer diagnosis (AC) to PCOC was calculated, and symptoms (Edmonton Symptom Assessment Scale, ESAS) and Morphine Equivalent Daily Dose (MEDD) were collected.


RESULTS
CAGE was available for 598 of 665 (90%) patients. Of 598 patients, 100 (17%) were CAGE+. CAGE+ patients were younger (58 versus 60 years, p < 0.05), predominantly male (68% versus 47%, p < 0.0001), and with head/neck malignancies (24% versus 9%, p < 0.05). CAGE+ patients were referred earlier (5 +/- 27 months after AC, p < 0.0001). At baseline, pain, sleep, dyspnea, well-being, and total symptom distress were significantly worse among CAGE+ patients. Both groups showed similar improvement in symptoms. CAGE+ patients were more frequently on opioids upon referral (47/100 versus 29/100, p < 0.05) and follow-up (27/65 versus 16/68, p < 0.05). At follow-up, opioid doses did not show significant changes.


CONCLUSIONS
Seventeen percent of the patients were CAGE+. These patients were referred earlier to palliative care, had more symptom expression, and were more frequently on opioids. The palliative care team successfully improved symptom control in both groups without opioid dose escalation.
Parsons
Henrique A
HA
Department of Palliative Care and Rehabilitation Medicine, The University of Texas M.D. Anderson Cancer Center, Houston, Texas 77030, USA.
Delgado-Guay
Marvin Omar
MO
El Osta
Badi
B
Chacko
Ray
R
Poulter
Valerie
V
Palmer
J Lynn
JL
Bruera
Eduardo
E
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000437:Alcoholism / Q000175:diagnosis* / Q000453:epidemiology; D000554:Ambulatory Care Facilities; D000701:Analgesics, Opioid / Q000627:therapeutic use*; D015897:Comorbidity; D017281:Cost of Illness; D005260:Female; D006801:Humans; D008297:Male; D008403:Mass Screening / Q000379:methods; D008485:Medical Audit; D008875:Middle Aged; D009369:Neoplasms / Q000145:classification* / Q000503:physiopathology; D010166:Palliative Care; D013781:Texas / Q000453:epidemiology; D055815:Young Adult
D000701:Analgesics, Opioid
Arch Fam Med. 1998 Jan-Feb;7(1):33-7
9443696
Addiction. 1994 Nov;89(11):1357-65
7841843
J Palliat Care. 2005 Summer;21(2):69-79
16114805
Prim Care. 1993 Mar;20(1):121-30
8464934
World Health Organ Tech Rep Ser. 2007;(944):1-53, 55-7, back cover
17970166
Curr Opin Oncol. 1992 Jun;4(3):471-7
1498155
J Pain Symptom Manage. 2000 Mar;19(3):229-34
10760628
J Palliat Med. 2005 Oct;8(5):1062-6
16238524
Support Care Cancer. 2001 Sep;9(6):428-34
11585269
Palliat Med. 2005 Sep;19(6):466-76
16218159
Oncology (Williston Park). 1998 Apr;12(4):517-21, 524
9575525
JAMA. 1984 Oct 12;252(14):1905-7
6471323
Clin Invest Med. 2007;30(1):33-41
17716538
J Palliat Care. 2000 Autumn;16(3):16-21
11019503
J Pain Symptom Manage. 1992 May;7(4):246-9
1517647
J Palliat Care. 1991 Summer;7(2):6-9
1714502
Cancer. 2000 May 1;88(9):2164-71
10813730
Pain. 1989 May;37(2):203-209
2748193
J Psychosom Res. 1998 Sep;45(3):249-56
9776370
Support Care Cancer. 2001 May;9(3):162-8
11401100
JAMA. 1989 Jan 20;261(3):403-7
2909780
J Pain Symptom Manage. 1997 Jun;13(6):356-61
9204657
J Palliat Med. 2007 Aug;10(4):948-55
17803418
J Natl Cancer Inst. 1996 Apr 17;88(8):542-9
8606383
J Pain Symptom Manage. 1995 Nov;10(8):599-603
8594120