Kwon Jung Hye, Tanco Kimberson, Park Ji Chan, Wong Angelique, Seo Lisa, Liu Diane, Chisholm Gary, Williams Janet, Hui David, Bruera Eduardo
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.
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
Oncologist. 2015 Jun;20(6):692-7. doi: 10.1634/theoncologist.2015-0012. Epub 2015 May 1.
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.
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.
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.
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.
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.
在这项前瞻性研究中，我们确定了经姑息医学专家诊断的晚期癌症患者中与阿片类药物相关的化学应对行为的发生率。我们还确定了化学应对行为的预测因素以及医生诊断与病历记录之间的一致性。
姑息医学专家对因化学应对行为前来就诊的连续患者进行评估和诊断。将被确定为存在化学应对行为的患者比例与病历记录中的比例进行比较。还收集了人口统计学数据、癌症诊断、吸烟史、药物滥用史、精神疾病史、吗啡等效日剂量、戒酒、烦恼、内疚和眼睁（CAGE）问卷评分以及埃德蒙顿症状评估系统评分。
共评估了432例患者。总体而言，76例患者（18%；95%置信区间[CI]：14% - 2%)被诊断为存在化学应对行为。病历中仅报告了15例患者（4%；95% CI：2% - 6%）存在化学应对行为的记录。根据方案定义，CAGE阳性（比值比[OR]：2.89）、年龄较小（OR：每年0.97）、较好的体能状态（OR：每分0.68）、疼痛（OR：每分1.20）和幸福感（OR：每分1.28）被发现是化学应对行为的显著预测因素。经过递归划分，50例CAGE阳性且东部肿瘤协作组体能状态≤2的患者中有21例（42%）被诊断为存在化学应对行为。
接受姑息治疗的患者中约18%被姑息医学专家诊断为存在化学应对行为。病历记录的发生率显著更低。需要有更好、更安全的方法供医生评估和报告化学应对行为。
癌症疼痛是一种多维度症状，阿片类药物是其主要治疗手段。然而，阿片类药物可能产生双重作用，导致觅药行为。当患者以非规定方式使用阿片类药物来应对各种应激事件时，就会发生化学应对行为。这可能导致阿片类药物滥用及包括神经毒性、呼吸抑制和死亡在内的并发症。需要进行正确的诊断和记录，以确保对疼痛进行恰当管理并避免不必要的伤害。本研究结果表明，接受姑息治疗服务的晚期癌症患者中约18%被诊断为存在化学应对行为，但病历中仅有4%有记录。
