Jamie H. Von Roenn, MD
Addressing the evolving needs of cancer survivors at various stages of their illness and care, Palliative Care in Oncology is guest edited by Jamie H. Von Roenn, MD, Vice President of Education, Science, and Professional Development at ASCO.
The problem of pain management facing clinicians today is twofold: how to ensure safe and effective treatment for patients with cancer in chronic pain, while avoiding the overuse of opioid medications and the potential for substance use disorder and diversion. According to the American Cancer Society, up to 50% of patients undergoing treatment and between 70% and 90% of patients with advanced disease experience some degree of pain.1
What’s more, the burden of unrelieved pain from cancer and its treatment falls more on survivors who are nonwhite, less educated, older, and/or have comorbidities. A recent study examining the influence of sociodemographic factors and the physical and mental health comorbidities on barriers to cancer pain management found that belonging to a minority group resulted in greater odds of experiencing patient-level barriers, including not believing pain could be relieved or treated, concern about becoming addicted to pain medication, and family members not wanting the survivor to take pain medication.2
In addition, the study found racial or ethnic disparities in provider- and system-level barriers to pain management in cancer survivors. For example, minority survivors were significantly more likely than white survivors to report feeling uncomfortable talking with their doctor about their pain. Regarding system-level factors, the study found that minority groups are disproportionately socioeconomically disadvantaged and at increased risk of experiencing financial and environmental barriers to pain management.
Compounding the dilemma of how best to provide effective pain management and reduce untreated pain in all cancer survivors is an unprecedented opioid epidemic in the United States, which has resulted in over 165,000 deaths since 1999 from prescription opioid overdoses3 and has led to restrictive regulations on both the state and national levels regarding the use of prescription opioid medications. In March 2016, the Centers for Disease Control and Prevention (CDC) issued prescribing guidelines to address the epidemic of deaths and overdoses caused by opioid painkillers.4 The recommendations call for using immediate-release opioids instead of extended-release/long-acting opioids and prescribing the lowest effective dosage for the shortest time possible—ie, 3 to 7 days.
The tragedy of opioid abuse and overdosing isn’t going to go away with the current laws…. The fallout from these restrictions is making it more difficult to provide cancer pain relief that is quick, effective, and safe.— Daniel B. Hinshaw, MD
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Although the guidelines make an exception for chronic pain from cancer as well as palliative and end-of-life care, they are unintentionally contributing to the undertreatment of chronic pain in patients with cancer, according to Daniel B. Hinshaw, MD, Professor Emeritus of Surgery at the University of Michigan and Founding Director of the Palliative Care Consultation Service at the Veterans Administration Medical Center in Ann Arbor, Michigan.
Complex Pain Syndromes
Uncontrolled pain can have devastating consequences on the quality of life of cancer survivors, hindering their ability to perform routine daily functions such as working and maintaining relationships. To address the complex pain syndromes of cancer survivors, this past September, ASCO published “Management of Chronic Pain in Survivors of Adult Cancers: American Society of Clinical Oncology Clinical Practice Guideline” in the Journal of Clinical Oncology.5
ASCO’s recommendations include:
The ASCO Post talked with Dr. Hinshaw about the challenges of managing cancer-related pain, how state and federal laws restricting opioid prescribing are deterring adequate pain control in patients with cancer, and how oncologists can adequately assess and manage chronic pain in their patients.
Pain Management Challenges
Most patients with cancer experience pain from their disease and/or its treatment, and many receive inadequate treatment to control that pain. Why is managing cancer pain so difficult?
There are many contributing factors. Opioid medications have been the standard for controlling moderate to severe cancer pain for decades, but the increased abuse of these medicines, including prescription opioids and heroin—which have led to more than 33,000 deaths in 20156—has resulted in restrictive state and federal prescribing policies. Even though the recent opioid prescribing guidelines from the CDC are geared primarily to primary care physicians, they have sent a chill throughout the oncology community.
One of the most useful medications for treating chronic cancer pain in my armamentarium is methadone. But the drug gets a bad rap largely due to data from the CDC showing that one in three prescription painkiller deaths in 2009 was attributed to methadone.7 Patients with cancer, not infrequently, need medication for complex mixed nociceptive and neuropathic pain, and methadone is often a good choice for them, but there is increasing anxiety over its use because of the CDC guidelines. The fallout is creating problems for oncologists—and their patients.
Some patients are cured of their cancer but left with long-lasting residual pain. Such patients may require a drug like methadone or a combination of a conventional opioid and adjuvant medications like anticonvulsants (eg, gabapentin) or antidepressants (eg, duloxetine) to find relief. It’s unfortunate that increased restrictions on opioid prescribing, prescription-monitoring programs, and laws implicating physicians whose patients develop substance abuse have led to some physicians saying, “I don’t want to get involved in this problem. Somebody is going to be watching my every move, and if I make a mistake or don’t follow someone’s ideal protocol correctly, I’ll be in trouble.”
The tragedy of opioid abuse and overdosing isn’t going to go away with the current laws. There need to be fixes to the problem, but you can’t just force patients off opioids without providing them with other effective options. The fallout from these restrictions is making it more difficult to provide cancer pain relief that is quick, effective, and safe.
Other factors contributing to pain undertreatment include professional-related barriers, such as limited education in pain management during medical training, unavailability of analgesics from pharmacies, inadequate pain assessment, and patient-related barriers such as nonadherence to analgesic regimens and cultural differences in response to pain.
Which types of cancer are likely to cause the greatest amount of pain for patients?
The highest prevalence of cancer pain has been associated with cancers of the head and neck and prostate. Any cancer that has a proclivity to metastasize to bone, including non–small cell lung cancer, renal cell carcinoma, and, of course, multiple myeloma, is likely to cause pain. We know that because of structural and chronic inflammatory changes that take place in the tissue around a tumor, there may be residual pain that lingers after the tumor is gone. There is even recent evidence showing that serine proteases on the surface of some types of cancer cells cause pain as they invade the tissue.8
Other Treatment Options
If oncologists are reluctant to use opiates, what are some other pain treatment options?
The general principle in palliative care is that if you know the underlying cause of a symptom you should try to address it. Palliative chemotherapy or radiotherapy can be successful in treating the underlying symptoms of cancer pain, although the relief may be temporary. Bisphosphonates can also help relieve cancer-related bone pain. And in the acute pain setting, anti-inflammatory drugs, such as dexamethasone, are effective.
For less severe pain, nonsteroidal anti-inflammatory drugs (NSAIDs) are useful, although they should be used with caution, especially in the elderly, because they can cause significant toxicities, such as gastrointestinal bleeding and impaired renal function.
What’s important to remember is that most pain remedies—even common ones like NSAIDs—have troubling side effects, so although they don’t have the awful reputation of opiates, they carry their own negative baggage.
Assessing Risk vs Benefit
How can oncologists ensure a safe and effective treatment plan to reduce pain in the palliative care setting without risking opioid addiction in patients, especially survivors whose cancer is cured or in remission but with lingering pain?
ASCO’s guideline on the optimal management of chronic pain in cancer survivors provides us with an important starting point. And ASCO’s recent updated guideline9 on the early integration of palliative care into standard oncology care for patients with advanced cancer also provides clinicians with a framework for addressing chronic symptoms such as pain through interdisciplinary palliative care teams.
Bringing this type of collaborative approach to pain symptom management earlier in the course of cancer treatment will result in safer, more effective strategies and curb inappropriate opioid prescribing. ■
Disclosure: Dr. Hinshaw reported no potential conflicts of interest.
1. American Cancer Society: Addressing state policy barriers to cancer pain management, June 2007. Available at http://action.acscan.org/site/DocServer/Policy_-_Addressing_State_Policy_Barriers_to_Cancer_Pain.pdf?docID=6824. Accessed January 26, 2017.
2. Stein KD, Alcaraz KI, Kamson C, et al: Sociodemographic inequalities in barriers to cancer pain management: A report from the American Cancer Society’s Study of Cancer Survivors-II (SCS-II). Psychooncology 25:1212-1221, 2016.
3. Department of Health and Human Services: The opioid epidemic: By the numbers. Available at www.hhs.gov/sites/default/files/Factsheet-opioids-061516.pdf. Accessed January 26, 2017.
4. Dowell D, Haegerich TM, Chou R: CDC Guideline for Prescribing Opioids for Chronic Pain—United States, 2016. MMWR Recomm Rep 65:1-49, 2016.
5. Paice JA, Portenoy R, Lacchetti C, et al: Management of chronic pain in survivors of adult cancers: American Society of Clinical Oncology clinical practice guideline. J Clin Oncol 34:3325-3345, 2016.
6. Centers for Disease Control and Prevention: Injury prevention & control: Opioid overdose. Available at https://www.cdc.gov/drugoverdose. Accessed January 26, 2017.
7. Centers for Disease Control and Prevention: Prescription painkiller overdoses. Available at www.cdc.gov/vitalsigns/methadoneoverdoses. Accessed January 26, 2017.
8. Lam DK, Dang D, Flynn AN, et al: TMPRSS2, a novel membrane-anchored mediator in cancer pain. Pain 156:923-930, 2015.
9. Ferrell BR, Temel JS, Temin S, et al: Integration of palliative care into standard oncology care: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol 35:96-112, 2017.