Chronic Pain After Cancer: The Role of Opioids – part 2

Chronic Pain Following Treatment for Cancer: The Role of Opioids – Ballantyne – 2003 – The Oncologist – Wiley Online Library – Jane C. Ballantyne –  Dec 2003

This is part 2 of a long article (part 1 here) making very reasonable arguments for using opioids after cancer treatment when chronic pain persists. Her views used to be reasonable, but now she’s one of the most adamant anti-opioid zealots.

Stable Pain Treatment

Ideal chronic opioid therapy, assuming the pain and disease are stable, uses a stable dose of opioid medication

Often, chronic pain is constant and unremitting, and in that case, long‐acting drugs and formulations given round the clock are useful. Round‐the‐clock dosing allows many patients to achieve maximum functionality, without the need to focus on the next dose of drug and without the swings in analgesic level associated with as‐required dosing.  

Some patients prefer not to receive round‐the‐clock opioid medication and need opioids only occasionally, and in that case, it is reasonable to prescribe the drugs to be used as needed.

In general, the choice of drug and dosing regimen should be based on the patient’s pain pattern, lifestyle, and preference.

Dose Escalation

it is preferable when treating chronic stable disease to avoid dose escalation whenever possible, and these are related to both efficacy and harm.

In the case of stable disease, dose increases are needed to overcome tolerance or apparent tolerance, and responses are variable.

How can a doctor tell if your “disease” is stable? It seems most logical to assume that pain will increase with aging because our bodies deteriorate over time, which would imply the worsening of any painful conditions as well.

Differences in opioid handling mean that some patients maintain stable pain levels using a stable and moderate opioid dose, while in others, opioid efficacy diminishes over time and dose escalation may or may not be effective

When there is no improvement, pursuing increasing pain with increasing opioid doses can be counterproductive.

What kind of “improvement” is she talking about? Improvement can apply to less pain, better concentration, better mood, better social life, etc.

…high doses may have toxic effects, including neuronal, hormonal, and immune effects, that are potentially important when high doses of opioids are used over a prolonged period and are relevant if the patient has a normal life expectancy

Toxic effects may be acceptable if the gain in quality of life produced by good analgesia is significant, but if dose escalation does not achieve this, possible toxicity should be taken into account.

So, “toxic effects may be acceptable”, but the low risk of addiction is not acceptable?

Loss of efficacy and toxicity may only arise in a small minority of cancer patients but is worth considering when dose escalation fails to produce the desired improvement in pain relief.

Just like addiction, this is a low risk considering opioids may be the only effective pain reliever for us.

If a dose escalation seems necessary, the increase in dose should be introduced with extreme caution.

First, disease escalation should be identified or excluded. The dose should be titrated upward as rapidly as possible to achieve a new stable level. The upward titration should not take more than 8 weeks.

If pain cannot be adequately controlled after a careful dose escalation, it may be helpful to switch to a different opioid as a means of restoring analgesic efficacy and reducing side effects when one drug is not working  [45–48].

The rationale for opioid rotation is that there is incomplete crosstolerance among different opioids acting at different opioid receptors [47].

If neither dose escalation nor opioid rotation is successful, it is reasonable to question whether opioids are effective at all.

This seems very reasonable. If my pain doesn’t improve from taking breakthrough medication, it means to me that this is a kind of pain that doesn’t respond much to opioids. But I still have many other pains that respond extremely well to opioids.

Patients who do not improve off opioids can have their opioid therapy restarted, but at much lower doses.

Failed Opioid Treatment

If opioid treatment is not providing overall benefit, it should be discontinued.

Duh! Do doctors really continue medications even though there is benefit?

This is true of ALL medical care, yet it’s always written as though it only applies to opioid therapy.

However, deciding when a patient is more harmed than helped by opioid treatment is not simple and presents one of the greatest challenges in pain management.

Yet, any politician or DEA agent or government agency can easily decide that any opioids are dangerous and should simply not be used. These folks are making medical diagnoses and decisions without any idea of what’s at stake.

Addiction is a potentially devastating, albeit rare, complication of long‐term opioid use

Ballantyne used to believe this, but she has certainly changed her mind since then because she’s now stressing how “addictive” opioids are, much “too dangerous” to use long-term.

Opioids are being taken away from the patients that need them because there is a small risk of addiction.

Physicians who prescribe long‐term opioids should be wary of persistent opioid‐seeking behavior and understand the complex relationships between noncompliance, inadequate pain relief, and addiction so that they can identify aberrant behaviors.

Typical features of noncompliance are summarized in Table 5.

Although noncompliance shares many of the features of addictive behavior, it may or may not indicate addiction.

Well, that was then, but now any deviation from doing exactly what the prescription label says is instantly and capriciously judged as “addicted”.

Occasionally, opioid‐seeking behavior is a manifestation of inadequate analgesia, in which case the behavior normalizes when pain is adequately treated.

The term pseudoaddiction is used to describe opioid‐seeking behavior that reverses when pain is adequately treated.

These days, no doctor is allowed to adequately treat pain because there are so many policies, rules, and laws against it.

It is clear that both efficacy and complications are dynamic, not stable, and that the prescribing physician must be able to ensure treatment benefit throughout a long course of treatment.

The concept of goal‐directed treatment is extremely helpful in this context because the established goals provide a basis for judging treatment efficacy.

I don’t know of any medical treatment that is not goal-directed. Without some goal, what is the purpose of medical care?

if the disease and pain are stable, a change in treatment goals is a possible marker of functional deterioration and should be interpreted as such.

Even in the presence of diminished analgesic efficacy, addictive features, or other complications, it may be reasonable to continue treatment provided treatment goals are met, particularly in the case of pain due to devastating disease.

Wow, Ballantyne used to be such a reasonable person. What happened to her to turn her so completely against any use of opioids?

Conclusion

When strict regulatory controls were placed on opioid use in the 1940s, there was a backlash against opioid use, and cancer pain became woefully undertreated. It has not been easy to rebuild confidence in the use of opioids as an effective, safe, and humane treatment for cancer pain.

It is not surprising, therefore, that principles of chronic pain management that incorporate constraints on opioid use are not easily adopted by oncologists who have been taught the different principles of opioid use for severe accelerating cancer pain.

Now that cancer survival has improved and many cancer patients suffer chronic pain, oncologists will need to incorporate the principles of chronic opioid pain management into their practice so that patients are not harmed by unrecognized complications of long‐term opioid therapy.