Conceptual model identifies factors to mitigate risk for opioid misuse during cancer care

Among cancer patients, psychological distress and accessibility of opioids often lead to chemical coping, a middle ground between addiction and proper adherence to a medication regimen. Chemical coping can diminish quality of life and interfere with pain and symptom management, as well as predispose individuals to developing substance use disorder. The findings are reported in the Harvard Review of Psychiatry (HRP).

Miryam Yusufov, Ph.D., a psychologist in the Department of Psychosocial Oncology and Palliative Care at the Dana-Farber Cancer Institute, a Harvard Medical School teaching hospital in Boston, and colleagues have developed the first conceptual model that integrates the risk factors that initiate and maintain chemical coping with opioids during cancer care. "This model will help care teams triage factors that require monitoring and potential risk mitigation . . . as well as those that require behavioral intervention," the research team notes.

Predisposing risk factors identified in four overlapping domains

Based on a search of medical literature in PubMed and MEDLINE, the team found that risk factors and treatment targets for chemical coping in cancer can be organized according to whether they are historical or current and whether they are malleable (amenable to intervention) or unmalleable. The researchers describe the evidence base for each risk factor, some of which fall into multiple domains:

• Historical and malleable factors: Depression, anxiety, posttraumatic stress disorder, and other psychological diagnoses; intolerance of distress
• Current and malleable factors: Chronic pain, psychological diagnoses, deficit in coping skills, opioid availability
• Historical and unmalleable factors: Family history of substance use disorder, including alcohol use disorder; personal history of substance use disorder; history of sexual victimization; childhood abuse
• Current and unmalleable factor: Age 16 to 45

"Therefore, patients with no misuse behaviors are still at risk for chemical coping based on these preexisting risk factors and long-term opioid therapy," the authors say.

Implications for clinical practice: Universal screening, patient education, and mental health care

Dr. Yusufov and her colleagues recommend screening all patients for risk of chemical coping before initiating opioid therapy. They point out that "it is less stigmatizing to address chemical coping risk than active misuse of opioids." For example, the Opioid Risk Tool (ORT) addresses family and/or personal history of substance use, history of sexual abuse/violence, and psychological disorders.

Given the recent upward trend in opioid-related hospitalizations among patients with cancer, the authors suggest clinicians may mitigate overdoses and deaths with patient education on naloxone and medication return policies upon therapy completion or regimen changes.

Finally, the proposed model can aid in selecting components for behavioral interventions and help clinicians determine when to refer patients to psychosocial support resources. This approach can maximize cost-effectiveness while minimizing risk.

"For example, if a patient presents with predominantly malleable factors, they may be an appropriate candidate for psychosocial support," Dr. Yusufov's team says. "If a patient presents with predominantly unmalleable factors, however, they may be a more appropriate candidate for continued monitoring throughout opioid therapy."