Mrs. SR is an obese 74-year-old Caucasian female with a history of type II diabetes and locally advanced rectal adenocarcinoma diagnosed in May 2006, treated with neoadjuvant chemotherapy and concurrent radiation, followed by a rectosigmoid resection with diverting colostomy, reversal ileostomy, and adjuvant chemotherapy. Her course of the disease was further complicated by the development of post-treatment related chronic rectal pain with defecation.
She describes her rectal pain as “constant”, and so excruciating she is compelled to scream. She claims she has a bowel movement approximately eight times a day. Her routine is to take up to four tablets of Hydromorphone 8 mg in the morning to prepare for her first bowel movement and additional doses as needed during the day for an average of 80 mg of Hydromorphone in 24 hours. Her medications for symptom management include belladonna opium suppositories p.r.n., Hydromorphone 8 mg tablets p.o. q. 4 hours p.r.n., Gabapentin 600 mg p.o. t.i.d., and lidocaine 5% topical ointment t.i.d. p.r.n. to the affected area.
Mrs. SR is a retired switchboard operator who, five years ago after her initial cancer diagnosis, divorced her husband after 41 years of marriage. She has two adult children - a son and a daughter -, two grandsons, and two granddaughters. She is no longer speaking to her children and has minimal to no contact with her grandchildren. She recently obtained a restraining order against one of her grandsons for stealing money, jewelry, and medications from her. Mrs. SR lives on a very small pension and is very worried about her finances, and often finds she cannot afford to pay for her medications.
She had a history of a major depressive disorder prior to her cancer diagnosis, but failed to follow through with treatment. She feels her depression progressively worsened over the past five years starting with her cancer diagnosis. She endorses feelings of uselessness, worthlessness, helplessness, hopelessness, and has lost interest in activities she once enjoyed. She admits to being socially isolated and chooses to spend most of her time in bed watching TV.
Mrs. SR has been on opioids for the past eight years and denies any misuse even though she admits to often running out of her monthly supply on numerous occasions. At one point, Mrs. SR was requiring 360 Hydromorphone 8 mg tablets a month. Despite repeated counseling in regards to the opioids mechanisms of action and bio-availability, she refused to use a long acting opioid stating that her only severe pain is when she is having a bowel movement and does not want to be sedated all day long.
After our team became involved in Mrs. SR case, we started to explore the roots of her behaviour. Opioid diversion, addiction, pseudo-addiction, elderly abuse with family members stealing her money and medications along with chemical coping were all entertained. She denied addiction or diversion, but agreed to the existence of multiple intense emotional issues that were causing her to sense her pain more acutely. Mrs. SR was very worried how she was going to cope with her extreme pain.
We recommended alternative pain control measures such as cognitive behavioural therapy, group therapy and provided referrals to social work, neurology, psychiatry and chronic pain management. She initially agreed with this plan, but she failed to follow through with any of the consults.
Our team explained to Mrs. SR that she may be chemically coping and started limiting her monthly supply of opioids. It was also explained that no amount of opioids could relieve the kind of emotional pain she was experiencing. She was encouraged to pursue non-opioid management of her pain and keep her appointments with the aforementioned specialists.
After multiple setbacks, Mrs. SR reported at her latest clinic visit that she was taking methadone 10 mg p.o. q. 8 hours with Hydromorphone 8 mg p.o. q. 4 hours p.r.n. to a maximum of six tablets a day and utilizing alternative therapies. She is now following closely with psychiatry.
Pain is one of the most common symptoms encountered in cancer population and unfortunately it is the most undertreated. It is estimated that 5.5 million patients with terminal cancer experience moderate to severe pain, according to a report by World Health Organization in 2011(1).
There are multiple approaches to treat cancer and non-cancer pain, and opioids represent the gold standard for the pharmacological management of pain. Opioids relieve pain but stimulate the same mu receptors in the limbic system that trigger a reward response, exposing patients to euphoria and increasing the risk of addiction and chemical coping.
When prescribing opioids, the clinicians should be looking for the “happy medium” achieved by optimal pain relief with an acceptable quality of life for the cancer patients, with minimal opioid side effects such as euphoria, neurotoxity or constipation, to list just a few. However, this “happy medium” may take time to achieve and there is no accurate way to predict how a patient will respond to opioids once exposed.
A quite common phenomenon that can occur with opioids use is chemical coping, defined as an inappropriate use of opioids to cope with emotional distress or psycho-emotional pain, and not to relieve physical pain(2).
Chemical coping is an underdiagnosed condition, according to a retrospective study on 432 patients with only 4% of the patients diagnosed as chemical copers after the physical encounter with the clinicians, whereas 18% of them were diagnosed as such after chart review by the supportive care physicians who participated in the study(2).
Chemical coping is considered the “middle ground” between compliance and addiction. The literature review supports the observation that “all addicts are chemical copers but not all chemical copers are addicts”(3,4).
The most common risk factors for chemical coping identified in literature include:
1) Mood disorders. Markou et al. hypothesized that depression and withdrawal from opioids have similar neurobiological effects(5) and patients suffering from anxiety may use opioids for their calming effect.
2) Psychiatric diseases such as somatization or alexithymia. In the somatization disorder (also known as Briquet’s syndrome), patients have a history of somatic and pain complaints that usually start before the age of 30, are chronic in nature, cannot be fully explained by a general medical condition or substance use, and are not feigned as in malingering or factitious disorders. They have multiple pain symptoms, multiple gastrointestinal symptoms, a sexual symptom, and a neurological symptom. In alexithymia, patients have difficulties in identifying feelings, distinguishing between feelings and the bodily sensations of emotional arousal as well as describing their feelings to other people.
3) History of substance abuse.
4) History of smoking.
5) History of alcoholism with a positive CAGE questionnaire score. CAGE is an acronym that stands for: Have you ever felt you should Cut down on your drinking? Have people Annoyed you by criticizing your drinking? Have you ever felt bad or Guilty about your drinking? And finally, Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (Eye opener)? The No or Yes answers are scored 0 or 1 and a total score of 2 or greater is considered clinically significant. Kwon at al. found that CAGE positive individuals are at higher risk to develop chemical coping compared to their CAGE negative counterparts. In their study, 21 patients out of 50 with a positive CAGE questionnaire were chemical copers (42%), whereas only 16 patients out of 138 with a negative CAGE (12%) were chemically coping(2).
6) Cancer diagnosis. This criterion is based on findings that head and neck cancer is associated with a higher incidence of alcoholism and smoking than other types of cancer.
7) Age: younger patients were observed to be more likely to chemically cope(2).
8) Functional status, where a lower performance status was associated with a decreased risk of chemical coping(2).
9) Gender, where females are more likely to be classified as chemical copers than males. It is well known that females tend to self-medicate or abuse substances to alleviate anxiety, depression and stress, whereas males tend to use drugs or alcohol to avoid boredom and for sensation seeking(4). However, more research is needed.
Many chemical copers report higher pain scores to ensure their access to opioids and, indeed, they typically receive a higher morphine equivalent daily dose and often self-escalate the use of their pain medications. These patients, like the ones suffering from addiction, are preoccupied with opioids procurement at the expense of other social or professional goals, may perform doctor shopping (described as obtaining controlled substances from multiple healthcare practitioners without the prescribers’ knowledge of other prescriptions) or procuring opioids from multiple sources including the black market, typically show little interest in treating pain with non-pharmacological means and make little progress towards psychosocial goals. However, the same patients are able to comply with the physician - patient opioid agreements, the so called pain contracts, just enough so that they cannot be fired/removed from the practice despite their extremely concerning behaviors to the clinicians.
These behaviors are commonly seen in pseudoaddiction and addiction, and make the diagnosis of chemical coping very difficult. Addiction is seen as an aberrant use of a substance characterized by loss of control, craving, compulsive use and continued use despite harm, whereas pseudo-addiction represents a drug-seeking behavior that occur in the context of unrelieved pain that subsides when analgesia is achieved. Clinicians can differentiate between these patients by examining their ultimate goals. A pseudoaddict who may exhibit a drug-seeking behavior is actually seeking relief from an undertreated physical pain, a chemical coper is looking to ease the non-physical pain with opioids or other substances, whereas an addict is looking for nothing less but euphoria. Again, we are reinforcing the idea that “all addicts are chemical copers, but not all chemical copers are addicts”(4).
When chemical coping is suspected, the patient should be closely monitored for aberrant behaviors, pain symptoms, pain scores and opioid requirements. Frequent urine drug screenings should be performed to monitor for possible abuse, but also compliance with medical advice.
Even though Del Fabbro suggested that mild copers do not require any specific interventions(3), chemical coping can be a challenging condition to treat. Patients require extensive counseling on opioids benefits and side effects. The mainstay of the treatment is helping the patients understand that opioids are part of the treatment and not the treatment, and even more that opioids could be part of the problem rather than a part of the solution. Clinicians must have honest conversations with these patients and inform them of the risks, including accidental death from overdose, if inappropriately using or overusing the opioids.
Clinicians also need to acknowledge any progress made by a chemical coper on a functional or emotional level. Positive reinforcement is essential to encourage continued improvements and help them to stay “on the right track”.
Chemical copers may require referrals to psychology and psychiatry because of the intricate relationship between pain and psychiatric disorders. Pain will never be controlled if the underlying mental illness is not addressed.
Clinicians should also try to minimize the use of the short acting opioids that predispose the patient to excessive intake and use extended release opioids as the cornerstone of opioid therapy.
Occasionally, some patients, especially the ones approaching the spectrum of addiction, may require a referral to substance abuse specialists.
In conclusion, chemical coping is a condition that cannot be ignored and the authors of this article wanted to raise awareness about chemical coping and to encourage the development of trust essential to the physician-patient relationship. It is only through trust and good communication that chemical copers can reach the “happy medium” represented by optimal pain relief with minimal side effects. n