Severe opioid toxicity and somatizationof psychosocial distress in a cancer patient with a background of chemical dependence

Lawlor, Peter G.; Walker, Paul; Bruera, Éduardo; Mitchell, Stephanie

doi:10.1016/s0885-3924(97)00081-x

Cited by 61 publications

(40 citation statements)

References 11 publications

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“…25 It has been suggested that patients with addictive disorders are at greater risk for somatization and chemical coping. 7,12,26,27 Our results showed that CAGEϩ patients presented to the PCC with higher symptom expression compared to CAGEϪ patients. Positive screening for alcoholism may function as a surrogate to detect a tendency to somatization.…”

Section: Alcoholism Screening In Patients With Advanced Cancer 965mentioning

confidence: 60%

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Alcoholism Screening in Patients with Advanced Cancer: Impact on Symptom Burden and Opioid Use

Parsons

Delgado-Guay

Osta

et al. 2008

Journal of Palliative Medicine

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100

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Purpose: 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 (CAGEϩ) and 100 consecutive CAGE negative (CAGEϪ) 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 CAGEϩ. CAGEϩ patients were younger (58 versus 60 years, p Ͻ 0.05), predominantly male (68% versus 47%, p Ͻ 0.0001), and with head/neck malignancies (24% versus 9%, p Ͻ 0.05). CAGEϩ patients were referred earlier (5 Ϯ 19 versus 13 Ϯ 27 months after AC, p Ͻ 0.0001). At baseline, pain, sleep, dyspnea, well-being, and total symptom distress were significantly worse among CAGEϩ patients. Both groups showed similar improvement in symptoms. CAGEϩ patients were more frequently on opioids upon referral (47/100 versus 29/100, p Ͻ 0.05) and followup (27/65 versus 16/68, p Ͻ 0.05). At follow-up, opioid doses did not show significant changes. Conclusion: Seventeen percent of the patients were CAGEϩ. 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.

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Section: Alcoholism Screening In Patients With Advanced Cancer 965mentioning

confidence: 60%

“…6 Some reports suggest that patients with a tendency to cope chemically express higher symptom distress. [7][8][9] Substance abuse including alcoholism are frequently underdiagnosed among cancer and palliative care patients. 10,11 Its detection is important because it has been described as a poor prognostic factor for cancer pain control.…”

Section: Introductionmentioning

confidence: 99%

Alcoholism Screening in Patients with Advanced Cancer: Impact on Symptom Burden and Opioid Use

Parsons

Delgado-Guay

Osta

et al. 2008

Journal of Palliative Medicine

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100

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“…However, in the case of toxicity associated with chronic opioid use in cancer patients, the literature reports suggest a predominance of the hyperactive subtype or agitated delirium. [62][63][64][65] It is certainly possible that opioid-induced hypoactive delirium is underdiagnosed, especially when regular cognitive screening is not conducted. 66 Opioid-induced neurotoxicity has received increasing recognition in the last decade.…”

Section: Delirium and Cognitive Dysfunction: The Role Of Opioidsmentioning

confidence: 99%

“…108,109 The patient's agitation and the inability of staff to communicate with the patient can lead to a reflex response on the part of some physicians, who might resort to a prompt increase in opioid dose, which, in turn, could further aggravate the situation, especially if the opioid is already contributing to the delirium. 63 Cognitive impairment also introduces a major impediment to the process of patient counseling, often at a critical juncture in the cancer illness trajectory. 110 Inability of the cognitively impaired patient to give informed consent often hinders participation in research studies.…”

Section: Impact Of Opioid-associated Cognitive Effects On Patient Famentioning

confidence: 99%

The panorama of opioid‐related cognitive dysfunction in patients with cancer

Lawlor

2002

Cancer

104

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BACKGROUNDOpioids have an essential role in the management of pain in cancer patients, particularly those with advanced disease. Cognitive dysfunction is a recognized complication of opioid use. However, misconceptions and controversy surround the nature and prevalence of its occurrence. A projected increase in the aging cancer population highlights the need for a better understanding of this phenomenon.METHODSA critical appraisal of the literature evidence in relation to the pattern, pathophysiology, assessment, impact, and management of cognitive dysfunction due to opioid use in cancer pain management is given.RESULTSStudies in cancer patients with less advanced disease reveal subtle evidence of cognitive impairment, largely related to initial dosing or dose increases. In advanced cancer, opioid‐induced cognitive dysfunction usually occurs in the form of delirium, a multifactorial syndrome. The presence of both cognitive impairment and delirium frequently is misdiagnosed or missed. Potential risk factors include neuropathic and incidental pain, opioid tolerance, somatization of psychologic distress, and a history of drug or alcohol abuse. Elevation of opioid metabolites with renal impairment may contribute to cognitive dysfunction. Recognition of opioid‐related cognitive dysfunction is improved by objective screening. Successful management requires either dose reduction or a change of opioid, in addition to addressing other reversible precipitants such as dehydration or volume depletion.CONCLUSIONSOpioid‐related cognitive dysfunction tends to be subtle in the earlier stages of cancer, whereas delirium, a more florid form with behavioral disturbance is likely to be present in the advanced cancer population. In patients with advanced disease, an optimal management approach requires careful clinical assessment, identification of risk factors, objective monitoring of cognition, maintenance of adequate hydration, and either dose reduction or switching to a different opioid. Cancer 2002;94:1836–53. © 2002 American Cancer Society.DOI 10.1002/cncr.10389

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“…3 The presence of alcoholism has been associated with poor pain control; patients who have a history of alcoholism are more susceptible to addiction and are poorly compliant with treatments. This group of patients is referred earlier to palliative care, expresses more symptom distress, and is more frequently on opioids.…”

Section: Introductionmentioning

confidence: 99%

The Frequency of Alcoholism in Patients With Advanced Cancer Admitted to an Acute Palliative Care Unit and a Home Care Program

Mercadante

Porzio

Caruselli

et al. 2015

Journal of Pain and Symptom Management

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Context. Cancer patients with a history of alcoholism may be problematic. The frequency of alcoholism among patients with advanced cancer has never been reported in Italy or other European countries.Objectives. The aim of this prospective study was to determine the frequency of alcoholism, assessed with a simple and validated instrument, among patients with advanced cancer who were referred to two different palliative care settings: an acute inpatient palliative care unit (PCU) of a comprehensive cancer center in a metropolitan area and a home care program (HCP) in a territorial district, localized in the mountains of Italy.Methods. A consecutive sample of patients admitted to an inpatient PCU and to an HCP was assessed for a period of eight months. Each patient who agreed to be interviewed completed the Cut down, Annoyed, Guilty, Eye-opener (CAGE) questionnaire. Patients were then interviewed informally to gather information about their history with alcohol.Results. In total, 443 consecutive patients were surveyed; data from 249 to 194 patients were collected in the PCU and HCP, respectively, in the eight-month period. The mean age was 66.4 (SD 12.7) years, and 207 were males. The mean Karnofsky level was 54.2 (SD 14.6). Eighteen patients were CAGE positive (4.06%). Males (Pearson Chi-squared, P ¼ 0.027) and younger patients (analysis of variance test, P ¼ 0.009) were more likely to be CAGE positive. Informal interviews revealed that 17 patients (3.83%) were alcoholics or had a history of alcoholism, and that alcoholism was strongly correlated with CAGE (Pearson Chisquared, P < 0.0001). Conclusion. Only a minority of patients were CAGE positive, with a similar frequency in the PCU and HCP settings. CAGE-positive patients were more likely to be male and younger, independent of diagnosis and performance status. CAGE was positively correlated with informal interviews for detecting alcoholism. As CAGE patients express more symptom distress, it is important to detect this problem with a simple tool that has a high sensitivity and specificity and is easy to use even in patients with advanced disease. J Pain Symptom Manage 2015;49:254e257.

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Severe opioid toxicity and somatizationof psychosocial distress in a cancer patient with a background of chemical dependence

Cited by 61 publications

References 11 publications

Alcoholism Screening in Patients with Advanced Cancer: Impact on Symptom Burden and Opioid Use

Alcoholism Screening in Patients with Advanced Cancer: Impact on Symptom Burden and Opioid Use

The panorama of opioid‐related cognitive dysfunction in patients with cancer

The Frequency of Alcoholism in Patients With Advanced Cancer Admitted to an Acute Palliative Care Unit and a Home Care Program

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