Frequency, Predictors, and Medical Record Documentation of Chemical Coping Among Advanced Cancer Patients.
BACKGROUND
In this prospective study, we determined the frequency of opioid-related chemical coping among advanced cancer patients, as diagnosed by palliative medicine specialists. We also determined predictors for chemical coping and the concordance between the physician's diagnosis and documentation in the medical records.


METHODS
Palliative medicine specialists evaluated and diagnosed consecutive patients seen for chemical coping. The proportion of patients identified as chemically coping was compared with the proportion documented in the medical records. Demographic data; cancer diagnosis; history of smoking; substance abuse; psychiatric disease; morphine equivalent daily dosage; Cut-down, Annoyed, Guilty, and Eye-opener (CAGE) questionnaire scores; and Edmonton Symptom Assessment System scores were also collected.


RESULTS
A total of 432 patients were evaluated. Overall, 76 patients (18%; 95% confidence interval [CI]: 14%-21%) were diagnosed as chemically coping. Documentation of chemical coping in the medical records was reported for only 15 patients (4%; 95% CI: 2%-6%). CAGE positivity (odds ratio [OR]: 2.89), younger age (OR: 0.97 per year), better performance status (OR: 0.68 per point), pain (OR: 1.20 per point), and well-being (OR: 1.28 per point) were found to be significant predictors of chemical coping by protocol definition. After recursive partitioning, 21 of 50 patients (42%) who were CAGE positive and had an Eastern Cooperative Oncology Group performance status ≤2 were diagnosed as chemically coping.


CONCLUSIONS
Approximately 18% of palliative care patients seen were diagnosed as chemically coping by palliative medicine specialists. The frequency of documentation in the medical records was significantly lower. Better and safer ways for physicians to assess and report chemical coping are needed.


CONCLUSIONS
Cancer pain is a multidimensional symptom for which opioids are the mainstay of treatment. However, opioids can have a double effect resulting in drug-seeking behaviors. Chemical coping occurs when a patient uses opioids in a nonprescribed way to cope with various stressful events. This can lead to misuse of opioids and complications including neurotoxicities, respiratory depression, and death. Proper diagnosis and documentation is needed to ensure proper management of pain and to avoid unnecessary harm. The findings of this study suggest that ∼18% of advanced cancer patients seen by a palliative care service were diagnosed as chemical coping, but only 4% were documented in the medical records.
Department of Internal Medicine, Kangdong Sacred Heart Hospital, Hallym University, Seoul, Republic of Korea; Departments of Palliative Care and Rehabilitation Medicine, Biostatistics, and Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA; Division of Hematology-Oncology, Department of Internal Medicine, Daejeon St. Mary's Hospital College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea; Department of Palliative Care, Mercy Medical Group, Dignity Health Medical Foundation, Sacramento, California, USA.
Jung Hye
JH
Kwon
Department of Internal Medicine, Kangdong Sacred Heart Hospital, Hallym University, Seoul, Republic of Korea; Departments of Palliative Care and Rehabilitation Medicine, Biostatistics, and Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA; Division of Hematology-Oncology, Department of Internal Medicine, Daejeon St. Mary's Hospital College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea; Department of Palliative Care, Mercy Medical Group, Dignity Health Medical Foundation, Sacramento, California, USA.
Kimberson
K
Tanco
Department of Internal Medicine, Kangdong Sacred Heart Hospital, Hallym University, Seoul, Republic of Korea; Departments of Palliative Care and Rehabilitation Medicine, Biostatistics, and Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA; Division of Hematology-Oncology, Department of Internal Medicine, Daejeon St. Mary's Hospital College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea; Department of Palliative Care, Mercy Medical Group, Dignity Health Medical Foundation, Sacramento, California, USA.
Ji Chan
JC
Park
Department of Internal Medicine, Kangdong Sacred Heart Hospital, Hallym University, Seoul, Republic of Korea; Departments of Palliative Care and Rehabilitation Medicine, Biostatistics, and Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA; Division of Hematology-Oncology, Department of Internal Medicine, Daejeon St. Mary's Hospital College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea; Department of Palliative Care, Mercy Medical Group, Dignity Health Medical Foundation, Sacramento, California, USA.
Angelique
A
Wong
Department of Internal Medicine, Kangdong Sacred Heart Hospital, Hallym University, Seoul, Republic of Korea; Departments of Palliative Care and Rehabilitation Medicine, Biostatistics, and Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA; Division of Hematology-Oncology, Department of Internal Medicine, Daejeon St. Mary's Hospital College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea; Department of Palliative Care, Mercy Medical Group, Dignity Health Medical Foundation, Sacramento, California, USA.
Lisa
L
Seo
Department of Internal Medicine, Kangdong Sacred Heart Hospital, Hallym University, Seoul, Republic of Korea; Departments of Palliative Care and Rehabilitation Medicine, Biostatistics, and Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA; Division of Hematology-Oncology, Department of Internal Medicine, Daejeon St. Mary's Hospital College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea; Department of Palliative Care, Mercy Medical Group, Dignity Health Medical Foundation, Sacramento, California, USA.
Diane
D
Liu
Department of Internal Medicine, Kangdong Sacred Heart Hospital, Hallym University, Seoul, Republic of Korea; Departments of Palliative Care and Rehabilitation Medicine, Biostatistics, and Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA; Division of Hematology-Oncology, Department of Internal Medicine, Daejeon St. Mary's Hospital College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea; Department of Palliative Care, Mercy Medical Group, Dignity Health Medical Foundation, Sacramento, California, USA.
Gary
G
Chisholm
Department of Internal Medicine, Kangdong Sacred Heart Hospital, Hallym University, Seoul, Republic of Korea; Departments of Palliative Care and Rehabilitation Medicine, Biostatistics, and Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA; Division of Hematology-Oncology, Department of Internal Medicine, Daejeon St. Mary's Hospital College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea; Department of Palliative Care, Mercy Medical Group, Dignity Health Medical Foundation, Sacramento, California, USA.
Janet
J
Williams
Department of Internal Medicine, Kangdong Sacred Heart Hospital, Hallym University, Seoul, Republic of Korea; Departments of Palliative Care and Rehabilitation Medicine, Biostatistics, and Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA; Division of Hematology-Oncology, Department of Internal Medicine, Daejeon St. Mary's Hospital College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea; Department of Palliative Care, Mercy Medical Group, Dignity Health Medical Foundation, Sacramento, California, USA.
David
D
Hui
Department of Internal Medicine, Kangdong Sacred Heart Hospital, Hallym University, Seoul, Republic of Korea; Departments of Palliative Care and Rehabilitation Medicine, Biostatistics, and Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA; Division of Hematology-Oncology, Department of Internal Medicine, Daejeon St. Mary's Hospital College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea; Department of Palliative Care, Mercy Medical Group, Dignity Health Medical Foundation, Sacramento, California, USA ebruera@mdanderson.org.
Eduardo
E
Bruera
D000368:Aged; D005260:Female; D006801:Humans; D008297:Male; D008499:Medical Records; D008875:Middle Aged; D009020:Morphine / Q000008:administration & dosage / Q000009:adverse effects*; D009369:Neoplasms / Q000150:complications / Q000188:drug therapy / Q000503:physiopathology; D010146:Pain / Q000188:drug therapy / Q000209:etiology / Q000503:physiopathology*; D065126:Palliative Medicine; D011795:Surveys and Questionnaires
D009020:Morphine
CAGE; Cancer pain; Chemical coping; Clinical records documentation; Medical records reporting; Opioids