Managing Pain in Cancer Patients and Survivors

Managing Pain in Patients and Survivors: Challenges Within the United States Opioid Crisis in: Journal of the National Comprehensive Cancer Network Volume 17 Issue 5.5 (2019) – Author: Judith A. Paice – May 2019

“Unrelieved pain is a public health crisis, and opioid misuse and overdose deaths are emergencies.

These 2 crises have converged, and unintended consequences of efforts to squelch the opioid crisis have led to challenges in pain management, including further stigma and unrelieved pain for patients with cancer, especially survivors,” explained Judith A. Paice, PhD, RN, Director of the Cancer Pain Program.  

Abstract

Advances in cancer treatment have led to a growing number of survivors.

At least 40% of those survivors live with chronic pain and need pain control medication.

These days they are expected to make do with non-opioid “alternative medicine”, like aromatherapy or massage or other worthless CDC-suggested alternates.

This coincides with an epidemic of opioid misuse and overdose deaths, resulting in restrictive practices that can impact patients who experience severe pain.

Oncologists and other healthcare professionals who treat patients with cancer need to balance considerations of opioid misuse with effective pain control and become better educated about risk factors and management of opioids in cancer survivors.

“Simple solutions helped create the current crisis, but comprehensive, complex solutions are needed to resolve these 2 public heath crises.”

At least 40% of all cancer survivors suffer from chronic pain.

Pain management is a survivorship issue and needs to be addressed safely.

It’s not just cancer patients for whom “pain management is a survivorship issue”. There’s literally NO DIFFERENCE between cancer and non-cancer pain.

One consequence of measures to control the opioid epidemic is a scarcity of opioids for patients with significant cancer-related pain, whether due to cutbacks in manufacturing or increased restrictions on prescribing.

It’s my hope that because the public has so much sympathy for cancer patients, they’ll urge lawmakers and other anti-opioid champions to relax their restrictions.

Perhaps the plight of cancer patients denied pain control will be able to restore sanity to pain management in general.

The Scope of the Problem

Deaths due to drug overdose are more likely to occur in young persons and in men, according to the Centers for Disease Control and Prevention

“Doctors and patients should know that it is not the fentanyl patch that is causing these deaths from fentanyl overdoses,” she told listeners.

In an effort to address the opioid crises, the CDC published a Guideline for Prescribing Opioids for Chronic Pain in 2016.

Dr. Paice and other experts in the field took issue with these guidelines because, although they specifically exclude people with pain during active cancer treatment and end-of-life care, there are many individuals with cancer who experience pain yet do not fall neatly into these categories.

“These guidelines leave cancer survivors in a gray zone. Two of the recommendations in particular are problematic: setting the maximum equivalent dose at 50 morphine equivalents and limiting treatment for 3 days or less in most cases,” she said.

I’m horrified that any cancer patient would be subject to such draconian limits on literally life-saving medication. Constant pain is so stressful on the physical body that it could kill someone already debilitated by their poisonous chemotherapy.

Substance Use Disorder

Few data are available on opioid addiction in patients with cancer. An older study estimates that up to 7.7% of patients with cancer are addicted.

That’s odd because many studies of prescribed opioid use show addiction rates much lower.

In an editorial in Journal of Oncology Practice, Dr. Paice underscored the stigmatization associated with opioid use and the cutbacks in manufacturing of opioids and noted that >440 state bills were proposed in 2018 to deal with the crisis using education and new guidelines.

Few of these bills exempted patients with cancer, she said.

ASCO Practice Guideline

ASCO issued their Practice Guideline on Management of Pain in Survivors of Adult Cancers in 2016. [See Chronic Pain Management in Adult Cancer Patients]

Some of the posttreatment pain syndromes cited in the ASCO guideline were not widely recognized before 2016.

Chemotherapy, hormonal therapy, and radiation therapy are each associated with an array of chronic pain syndromes.

Stem cell transplantation–mediated graft-versus-host disease can cause a variety of pain syndromes, including arthralgia, dyspareunia, dysuria, eye pain, oral pain, paresthesias, and scleroderma-like skin changes.

A number of pain syndromes have also been described after surgery.

Figure 1. –
Integrative interventions from the NCCN Guidelines for Adult Cancer Pain.

Figure 2.
Interventional therapies from the NCCN Guidelines for Adult Cancer Pain.

Weaning From Opioids

Patients should be weaned from opioids when they are no longer beneficial.

This should be the obvious action for anyone for any medication.