Conquering (or Not) Cancer Pain

Conquering Cancer Pain | Drug Topics – by Tzipora Lieder, RPh – Feb 2020

I think it’s a joke to talk about “conquering” any kind of pain. And if, like so many of us, you cannot conquer your pain, what does that say about you?

Military terms like “conquer” reformulate our suffering as a war, a battle we lose day after day, over and over again, and imply that we’re too weak (or stupid or lazy) to fight harder. The implication is that we’re too weak (or stupid or lazy) to fight hard and “conquer” the pain that plagues us.

But what does it mean to “win” this “battle with chronic pain” anyway?

In many articles like this, winning seems to be determined solely by whether or not we take opioid pain medication. All the other semi-effective semi-toxic medications used for chronic pain are seen as harmless, but if we take opioids, we are the “losers”. 

Only a loser takes opioids. A winner “conquers” their pain and doesn’t need them.

“Unrelieved pain impacts patients’ quality of life and comfort,”
-Alison Duffy, PharmD, oncology clinical specialist

This simple statement should be carved into every doctor’s brain so that they remember that their fundamental purpose is to relieve human suffering.

Pain Causes

Erica Rhein, PharmD, clinical pharmacist at UCHealth Anschutz Cancer Pavilion… categorizes pain as directly cancer-related or iatrogenic (Fig. 1).  

Determining the source of the pain can be tricky and involves listening closely to the patient and using imaging studies when appropriate.

But even if a definitive source cannot be specified, that is no reason not to ameliorate the pain. 

Are doctors only going to relieve pain that they can pin down and precisely understand? No one knows everything about how a human body might generate pain, but a lack of understanding is no reason not to treat it.

It’s simply unethical to refuse to treat pain just because the source of it cannot be found… yet.

I was lucky to find a doctor who was willing to treat my pain effectively long before we knew what exactly was causing it. Without the pain relief of opioids, I would not have been able to continue my search for its source, dragging myself to appointments all around my area and submitting to treatments from all kinds of specialists.

If I had not been prescribed opioids to manage my pain before I knew its cause, I would not have been capable of pursuing the search that led to finding the cause: EDS.

Ironically, I needed pain relief to search for the reason I needed pain relief.

Duffy recommends PQRST pain assessment (questioning the patient about Provoking factors, Quality, Region/Radiation, Severity, and Time). The patient’s description of the pain can provide important clues, Rhein said.

Of course, this requires a doctor to believe what the patient is reporting about their pain. Unfortunately, true listening and not making quick and easy assumptions takes far more time than doctors are allowed these days.

The most important clues may be exactly those that “defy logic”, like when my pain sporadically moved from one side of the body to the other. I was initially afraid to tell my doctor because it seemed so totally crazy. Yet, it was exactly the clue that led to understanding that my sacroiliac joint was unstable and excessively mobile, pinching the same nerves on first one side, then the other.

“Neuropathic pain tends to be hard for patients to localize and has descriptors like burning and shooting,” she explained, “while somatic pain is a lot of times easier for a patient to pinpoint.” There are often multiple sources for the pain requiring treatment with multiple modalities.

Analgesic Options

In this patient population, the usual go-to non-opioid options are fraught with complications.

It’s good to see this stated so plainly because too many doctors are now turning to all kinds of other drugs with nasty side effects rather than straightforwardly prescribing opioids.

NSAID use is problematic in patients with renal dysfunction due to their cancer (for example, multiple myeloma) or advanced age,

NSAIDs can interact with chemotherapeutic agents by increasing cumulative renal toxicity or by decreasing renal clearance of the chemotherapeutic agent so its toxicities are increased.

Additionally, the increased risk of bleeding associated with NSAIDs is problematic for patients whose cancer increases bleeding risk (eg, gastrointestinal cancers) or who have chemotherapy-related thrombocytopenia

Acetaminophen also has its concerns. Its dose is limited in patients with liver impairment due to cancer location, liver metastases, or chemotherapy

It can only be used sparingly in neutropenic patients with hematologic malignancies since acetaminophen can mask fevers.

If pain requirements are high, she said she prefers to use another agent. Even when acetaminophen is a safe option, it often is not enough for effective pain relief, Rhein said, so it is often used in conjunction with opioids as an opioid-sparing agent.

Opioids as the Backbone of Treatment

Rhein and Duffy agree that in oncology patients, opioids are often the best and safest option.

“Once patients are getting higher doses of opioids, even medications like morphine that are considered to be more affordable can become very expensive, so the cost is definitely something that we have to consider for our patients,” Rhein noted.

In my experience, there is no cheaper pain relief than simple generic opioids, without time-release or anti-abuse “features”. They cost mere pennies instead of the multiple dollars per pill charged for such enhanced and patented versions.

All the information in the media about the opioid epidemic has made some patients wary of taking opioids, Rhein said, and these patients must be educated.

Sadly, information is not what we get from the media. We get click-bait stories of impending opioid-related doom instead.

“There are certainly patients that have their pain sub-optimally managed because of their concerns about addiction, and some of those challenges are based on the hyperawareness in this country,” Duffy said.  [what we have is not “hyperawareness” but “media-hype-awareness”.]

I can’t help but think that if a person is in serious pain, they would gladly take any pill or potion that provided real relief.

I’ve been desperate enough to brew a tea containing whole dried earthworms because my acupuncturist believed would help me. I downed this foul concoction daily for 2 weeks before giving up.

When my pain erupts into a serious flare, my worries about long-term consequences evaporate. I’d happily take any medication that gave me true relief in the moment and worry about long-term consequences later.

Some people (without pain) seem to believe that a person can be tortured indefinitely and yet choose not to stop the ordeal because they’re worried that they may become addicted at some later time.

Patients with chronic or advanced cancer pain may require long-acting opioids such as extended-release morphine (MS Contin) or oxycodone (OxyContin).

Fentanyl patches are also an option [specially formulated to release the opioid into the skin, NOT a pill or powder like illicit fentanyl], according to Duffy, particularly for patients who have compliance issues or have swallowing difficulties due to head and neck or gastrointestinal cancers.

Counseling Points for Patients with Cancer

When counseling patients being treated for cancer pain, particularly with opioids, pharmacists should realize that these patients are often legitimately taking other sedating drugs such as benzodiazepines, Duffy said.

If only bureaucrats would stop practicing medicine and let doctors do their jobs.

If a patient happens to require both opioids and benzos, they are entitled to get them by their doctor’s prescription without interference from pharmacists who believe all the anti-opioid hype passing as medical advice these days.

Many patients on high doses of opioids also have multiple risk factors for constipation, such as chemotherapy, radiation, and hypercalcemia.

This is a mish-mash of “risk factors”: constipation is a side-effect of opioids, but chemotherapy, radiation, and hypercalcemia are cancer treatments, NOT opioid side effects, so this sentence seems to be trying to scare people.

For patients on more than 1 opioid, Duffy said, “make sure they understand the maintenance basal rate of their long-acting control and the bolus nature of the short-acting one.”

Clinicians should understand that drug therapy alone may not be adequate for pain management.

“There is a huge psychosocial component of the pain experienced in patients with cancer, and you often have to address that to have any hope of controlling the pain,” Rhein said.

I’m sad to see that even straightforward nociceptive pain generated by cancer is being muddled with references to psychological and social factors.

If there’s a knife in my side, my pain is not from anything else but the damn knife.