When it comes to cancer patients, conversations about treating pain can be complex. Options abound and one size does not fit all.
Discussions about opioids add yet another layer of complexity to the issue.
"The U.S. opioid epidemic has stigmatized opioid use and undermined pain management in individuals with advanced cancer," one interview-based study concludes. "Negative media coverage and personal experiences with the epidemic promoted stigma, fear, and guilt surrounding opioid use. As a result, many patients delayed initiating opioids and often viewed their decision to take opioids as a moral failure — as 'caving in.' ”
Here’s a clear message about cancer patients: They are not 'caving' when they use opioid medications for pain relief. We want our patients to be and feel comfortable, and not to allow external factors to stifle them from discussing their pain.
The opioid epidemic is real and we don't want our patients to normalize pain that we can help them manage. The issue is front-of-mind for many patients and their doctors: About 120,000 New Yorkers are diagnosed with cancer each year. It’s the second-most common chronic disease in the state (second to heart disease).
Opioids can and should be part of a treatment plan for some patients with cancer, as well as sickle cell disease and patients receiving palliative or end-of-life care.
And let’s understand that, just as suffering doesn't have to be inevitable for cancer patients, addiction doesn't have to be inevitable in opioid use. Pain specialists have tools to assess addiction risk. These include validated risk assessments like the Opioid Risk Tool, urine toxicology testing and state prescription drug monitoring programs to evaluate a patient's prescription history.
We don’t want cancer patients to turn the “new normal” of their diagnosis into an acceptance of pain. Between 20 and 50% of cancer patients experience cancer pain; and this is moderate to severe pain in about 80% of people with advanced cancer.
The sources of cancer-related pain are multi-factorial: the emotional and existential pain of receiving a cancer diagnosis, the physical pain inflicted by the tumor(s), not to mention pain caused by the surgery, radiation and chemotherapy used to treat the cancer.
We know that pain can directly impact our patients' quality of life and become debilitating. Perhaps the phrase "quality of life” doesn’t fully convey how cancer pain can erode what our patients want to do, experience and enjoy.
Cancer pain can be disruptive even when a cancer diagnosis seems straightforward. It can keep our patients from working or from taking care of themselves or loved ones. Sometimes patients have experienced their pain for so long, that they feel it’s simply not worth mentioning.
And that’s just the physical pain. Cancer can also affect psychological health.
Depression affects 15 to 20% of cancer patients. It can include a range of symptoms, from normal sadness to major depression.
Those feelings can make patients and their loved ones hurt our patients' ability to face and manage the cancer journey and cause a difficult depression-pain dynamic: Patients with pain have more symptoms of depression and those symptoms can worsen pain, a vicious cycle.
To help our patients regain control over their health, we should encourage them to discuss their pain without embarrassment or hesitation, describe their physical limits and mental health, and share what they want and need to accomplish. We can recommend lifestyle changes (diet or exercise) or refer patients to a psychologist or nutritionist who can address other aspects of pain or depression.
Cancer rehabilitation is an effective way to address pain, restore certain losses of function, ease fatigue and manage nerve dysfunction after treatment. Prehabilitation also is designed to prevent those challenges by improving strength and endurance to prepare for surgery and recovery.
Medication like opioids can be part of that conversation. Without frank discussions, we might have patients waiting for pain, depression or a loss of function and then rationalizing and normalizing it as part of their experience.
We have so many resources to maximize daily function and minimize short- and long-term pain. With expertise and knowledge, we can talk about what works best for our patients and guide them through their cancer experience. As cancer treatments and approaches evolve, so can our dialogues about the multiple options for managing the pain that can come with it.
This guest essay reflects the views of Dr. Catherine Alfano, vice president of Cancer Care Management & Research at the Northwell Health Cancer Institute; Dr. Susan Maltser, chair of rehabilitation medicine at Glen Cove Hospital; and Dr. Diana Martins-Welch, director of supportive oncology at Northwell Health’s R.J. Zuckerberg Cancer Center.