Cancer Survivors With Chronic Pain Face Uncertainty

Cancer Survivors With Chronic Pain Face Uncertainty – Pain Medicine News – Mar 2017

Reading this article made so furious I had to stop, breathe deeply, and wait for my anger to subside several times.

Towards the end, a couple of doctors do say a few sensible things, but most of the article exhibits the usual misunderstandings/propaganda about opioids and pain. Unfortunately, these people are the ones making rules for us.

New opioid regulations rankle many in cancer community

Last fall, the CDC released a draft of its guidelines for prescribing opioids for chronic pain. nTo counteract the problem, it urged physicians to prescribe the drugs only when other pain management strategies prove ineffective  

The recommendations were intended for primary care physicians treating patients with “chronic pain outside of end-of-life care, … regardless of whether they have a current or previous diagnosis of cancer.”

But the inclusion of cancer patients alongside those with chronic conditions such as low back pain rankled many in the cancer community who believe survivors of the disease might be prevented from obtaining these effective, albeit problematic, options for easing lingering pain

This gives them a taste of what “regular” pain patients go through when they’re no longer protected by the palliative care exemption.

The American Cancer Society (ACS) sent a letter to the CDC expressing its concerns over the weak clinical evidence supporting many of the recommendations, and what it saw as a lack of transparency in the development of the guidelines. The ACS warned that the proposal could have “the potential to significantly limit cancer patient access to needed pain medicines.

The question of who gains access to opioids for pain is complicated by uncertain science, competing compassions and corporate influence.

It seems increasingly obvious that personal/organizational biases (compassions) and money (corporate influence) are running healthcare in the country.

Survivors Stranded?

Although cancer patients undergoing active treatment are excluded from the recommended limits, cancer survivors are not, a point the CDC specifically notes: “Patients within the scope of this guideline include cancer survivors with chronic pain who have completed cancer treatment, are in clinical remission, and are under cancer surveillance only.”

This seems to spotlight the arbitrary nature of the restrictions. The same person with the same deadly disease may qualify for opioid pain relief while they are at death’s door, but then have their pain relief snatched away when physical signs of their deadly disease fade, even though it’s a direct result of “successful” treatment. 

This demonstrates that anything that cannot be measured is not considered quite real.

With that, the CDC has drawn a bright line in a gray zone.

Medical professionals agree that opioids are appropriate for cancer pain. They also agree that abuse and overprescribing of the drugs is a serious problem.

There is less agreement about how to consider cancer survivors with chronic pain.

Surveys suggest that up to 40% of cancer survivors live with pain, although the prevalence decreases with time after treatment. That compares to the approximately 11.2% of U.S. adults overall who have chronic pain

But does a cancer survivor’s pain differ from that of someone with fibromyalgia or arthritis, and should this determine what drugs they receive?

Many physicians who specialize in pain management say cancer survivors with chronic pain should receive special considerations, but they differ in their rationale.

  • Some emphasize the severity of pain and the fact that it often originates from cancer or cancer treatment.
  • Others say closer monitoring by physicians makes addiction less of a concern in this population.

Although some cancer survivors rebound fully, others never return to their precancer health, said Natalie Moryl, MD, an internist in palliative care and pain management at Memorial Sloan Kettering Cancer Center, in New York City.

Some patients endure incapacitating pain stemming from malignancy or cancer treatment and may need more aggressive pain management than the CDC recommends, Dr. Moryl said. Nerves may be cut during removal of a lung cancer and cause continuing severe neuropathic pain, for example.

“As we’re treating these patients for active cancer, we support them with pain medications throughout their treatment. If they still have the same pain after treatment is over and the cancer is cured or in remission, they still should have access to appropriate analgesia,” Dr. Moryl said.

Notice that Dr. Moryl is assuming that “appropriate analgesia” will be opioids, not some woo-woo alternative therapy other pain patients are forced to waste their time, money, and effort on.

“I feel that these cancer survivors should not be fully under the umbrella of nonmalignant pain, at least not automatically.”

Mark Fleury, PhD, a policy principal of emerging science at the ACS Cancer Action Network (ACS CAN), said the goal of his group is that “cancer patients and survivors who have pain have their pain addressed by whatever is the most scientifically valid way to have that done.”

Welcome to the world of chronic non-cancer pain patients.

Why should only cancer patients have their pain treated effectively?

And yet, once they are in remission, and still have pain and still need the effective relief of opioids, they are denied because the pain is no longer directly attributable to the cancer, just the treatment of it. And that’s apparently not enough to “qualify for opioids”.

Upon remission, cancer survivors instantly convert to being “regular” chronic noncancer pain patients and must deal with the horror of constant unalleviated pain.

These ridiculous policies have led more than one person with chronic pain to wish cancer upon themselves.

Safety and Efficacy Data Are Scarce

No study lasting more than one year has compared the effectiveness of opioids with placebo or nonopioid therapies for chronic pain.

Even the term “lack of evidence” is up to interpretation when it comes to opioids.

For Dr. Fleury, it simply means the experiments have yet to be conducted. For the CDC, it means that until proven otherwise, the fewer opioids the better

ACS CAN is concerned that recent public discourse has focused solely on the harms of opioids,

Dr. Fleury said. With new regulations and proposed laws, “there’s an underlying assumption that nobody really needs opioids for more than a week or two, and that’s not reality,” he said.

“Unfortunately, we have a lot of active cancer patients and survivors and folks at the end of life who benefit greatly from these, and I think that portion of the story is getting lost.”

In Dr. Fleury’s view, the determining factor should be the clinical circumstances, and he cited the CDC for support. During a press briefing for the release of the guidelines, Dr. Fleury recalled, someone asked why cancer patients were exempted.

The CDC’s response was not because malignant and nonmalignant pain are biologically distinct, but rather that cancer patients are under much closer clinical management. To Dr. Fleury, this rationale suggests that if the clinical relationship between physician and cancer patient is maintained into survivorship, there’s no reason that the risk–benefit calculation for opioid use should change.

Do Guidelines Promote Barriers or Responsible Oversight?

Not long ago, Florida was the capital of pill mills—sham pain management clinics that sold opioid pills to just about anyone with cash on hand. The crackdowns on these outfits that begun in 2010 have made even above-board physicians in the state hesitant to prescribe opioids, Dr. Craig said.

Moreover, some pharmacies have stopped carrying opioids in high quantities or at all, fearing both robberies by drug seekers and scrutiny by the Drug Enforcement Administration. For some patients in rural areas, this might mean driving to several pharmacies in search of one able and willing to fill an opioid prescription. (Under Florida law, pharmacies cannot confirm whether they have opioids in stock over the phone.)

“And the problem is, you’re probably not doing super-great,” Dr. Craig said. “You’ve had treatment; you’ve had chemotherapy and other things. So now you’re off to another place.” The challenge of filling prescriptions means physicians at his cancer center sometimes have to adjust the dosage or potency of opioid prescriptions to fit the availability at pharmacies.

Patients with chronic pain need accurate information on the risks and benefits of these drugs before they start taking them, Mr. Golbom said.

Cancer is a magic word when it comes to opioid prescriptions, but for those whose cancer is in remission, staying on opioids may foster a dangerous problem. Little research has been done on the prevalence of opioid addiction specifically among cancer survivors. 

Opioids are inherently addictive; the body develops tolerance to the drugs and requires higher and higher doses. Combined with scant evidence of their long-term effectiveness, extended opioid therapy simply isn’t good medicine, they say.

And why do they say “opioid therapy simply isn’t good medicine”?

#1: The majority of people taking opioids for prolonged periods continue to report moderate to severe pain, said Michael Von Korff, MD, ScD, a senior investigator at Group Health Research Institute, in Seattle.

Chronic pain patients given opioids are always told not to expect that opioids will relieve pain completely, yet here they are telling us that we shouldn’t take them for that reason.

This is like telling a person on fire that “Stop, drop and roll” won’t prevent burns completely, so they shouldn’t bother doing it at all.

#2: Yet many physicians and patients continue to believe that the drugs work well for chronic pain.

This is like marveling that people continue to believe that “Stop, drop and roll” works well when you’re on fire.

These kinds of statements with their ridiculous assumptions infuriate me. Is the author a callous sadist or an ignorant fool?

Number of Cancer Survivors Growing

Cancer patients are not exempt from these risks [of extended opioid therapy], said Jane Ballantyne, MD, professor of anesthesiology and pain medicine at the University of Washington, in Seattle, and president of Physicians for Responsible Opioid Prescribing (PROP).

The idea that cancer patients are somehow protected from opioid addiction is a holdover from a time when cancer was typically a terminal illness. As more and more people live longer past cancer treatment, more restraint in the use of opioids may be necessary even for cancer-related pain, Dr. Ballantyne said.

The American Cancer Society is huge and powerful and the PROP folks might be poking a sleeping bear here. I can’t imagine folks who’ve lived through cancer will take kindly to being told they’re just addicts because they’re taking (or took in the past) opioids.

Cancer survivors may require ongoing pain management, Dr. Ballantyne said, but that’s all the more reason to find alternatives to opioids.

They talk about “finding alternatives” as though there were such things available.

People without pain probably believe that all the woo-woo methods being touted by medical groups are comparable to opioids, thanks to all the propaganda about their effectiveness.

“If you do long-term opiate treatment, not only does it not work ultimately; you’ll also become so tolerant that when you need it because you’ve got to the terminal phase, it may not work,” she said.

Why is this person allowed to tell me that opioids are not working when the life I’m living proves they absolutely are?

Why are any doctors ever allowed to tell us what we’re feeling? Feelings are internal sensations undetectable from the

Feelings are internal sensations undetectable from the outside. No one else can decide for me or tell me whether my opioids are working or not, whether I’m in pain or not, or whether I’m stupid enough to believe they can.

“To me that’s a tragedy. The perspective we’re all coming around to is that in many cases there are no medical solutions for pain, and just filling [prescriptions for] opiates is not that solution. In fact, it makes things worse.”

But there ARE solutions for the symptoms.

“Probably most concerning is we’ve just started to see a wave of state legislation and regulation that basically used the CDC guidelines as inspiration, and quite frankly, most of the nuance and exceptions get lost when they get picked up as state legislation,” Dr. Fleury said.

“I fear that the CDC guidelines will be adopted by either third-party payors or medical boards that dictate what should or shouldn’t be done,” Dr. Craig added. “We’re trying to deal with the current environment, and adding another layer will just make things much more worse for our patients.”

Dr. Craig predicted that “the key will be implementation. As they say, the devil is in the details—the wording and the nuances. Someone could misapply it.”

Despite research indicating that it is a chronic, complex disease of the brain, addiction remains inexorably tied to moral failing and shame. Dr. Moryl’s cancer pain patients tell her of the embarrassment of having their local pharmacists discuss the risk for addiction within earshot of their neighbors.

“Can you guarantee that any of the regulatory changes to reign in this unprecedented epidemic aren’t going to create some issues, some inconveniences for patients using opioids for palliative care?Probably not,” Dr. Von Korff said.

I would say “abolutely not”. Overdoses are still increasing AND pain patients are suffering.

“I don’t know anybody who isn’t concerned about avoiding these unintended consequences. But the status quo isn’t an option. There are too many people dying.”

But the people dying are NOT pain patients! 

None of the opioid restrictions can touch heroin/fentanyl users.

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