When Ineffective Pain Control Means Chemical Coping

Patients with intense pain levels typically require higher opioid doses, and a portion of these patients will not achieve relief, despite dose escalation. When this occurs, and no obvious cancer-related reason is found, other factors should be considered, such as delirium, depression or anxiety, pseudoaddiction, or chemical coping.

What Is Chemical Coping?

Chemical coping refers to the use of medication in an excessive or inappropriate way to manage the psychological or spiritual distress associated with having cancer, and typically does not include the craving and behavioral issues associated with addiction (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4522949/). Often underdiagnosed, chemical coping is not the same as substance abuse, which is defined as a reward/relief primary chronic neurologic disease, or pseudoaddiction, which is characterized by uncontrolled nociceptive input (https://www.cambridge.org/core/journals/palliative-and-supportive-care/article/chemical-coping-versus-pseudoaddiction-in-patients-with-cancer-pain/61D172F11267783A7298F6223F58E514). Evidence supports that as many as 18% of patients with cancer being seen for palliative care services are using their opioid prescriptions for coping (http://theoncologist.alphamedpress.org/content/20/6/692.long), rather than strictly for pain management.

Complications of chemical coping include neurotoxicities (sedation, delirium, seizures, hyperalgesia, cognitive changes), addiction, overdose, a poorer quality of life, and increased use of other substances, diversion, and death.

Risk factors for chemical coping include a history of smoking, substance abuse, alcoholism, or depression. Studies have found correlation between chemical coping, opioid dose escalation, and higher pain report levels. Research supports that younger patients are more likely to chemically cope. Studies report mixed conclusions related to the correlation to certain cancer diagnoses or gender (http://theoncologist.alphamedpress.org/content/20/6/692.long).

Signs that coping may be occurring include frequent reports of lost prescriptions, multiple early refill requests, and repeated reports of running out of opioids. Escalation of pain despite opioid rotations or in the absence of disease progression, and unexpected urine toxicology results (too little of the prescribed opioid, or multiple drug metabolites), and obtaining opioid prescriptions from multiple providers are also warning signs. These patients may present as overly drug focused, demonstrating little motivation for non-drug pain management therapies, or may self-escalate their opioid dosing between clinic visits (http://ascopubs.org/doi/full/10.1200/jco.2013.52.5170).

Management begins with early identification of at-risk patients through screening tools and thorough history-taking. The CAGE, CAGE-AID, and SOAPP-R screening assessment tools are quick mechanisms to identify those requiring further evaluation (see sidebar). Once chemical coping is identified, sensitive communication to address the underlying issues causing the misuse, education about the risks of opioid abuse, counseling, and significant caregiver support are priorities. Affected patients require close monitoring, through more frequent visits or telephone contacts, and an interdisciplinary and personalized treatment plan that includes periodic urine toxicology screening.

Early screening, identification of at-risk patients, and intervention to control opioid dose escalation, the complications of opioid toxicity, and, as importantly, to address the underlying suffering causing chemical coping is crucial to the effect management of patients with cancer pain.