New guidelines help doctors and patients with chronic pain management
Pain is one of the most common symptoms of cancer and its treatment, and if left unmanaged, experts say it may have serious impacts on patients’ quality of life and may even slow recovery from cancer treatment. About 50 to 70 percent of cancer patients experience uncontrolled pain at some point during their illness, according to the American Cancer Society. Cancer pain shows up in various ways and ranges widely from patient to patient, depending on the stage of the disease, the treatments used to fight it, where the cancer has spread and other factors.
As tumors grow, for example, they may put pressure on bones, nerves or organs, or treatments— such as chemotherapy, surgery or radiation—may leave incisions, burns or other damages that cause pain. Whatever the reason, experts say it is critical that cancer patients get help managing their pain. “Pain, the way that our bodies are designed, is a trigger to alert us of something going on,” says Dr. Nathan Neufeld, Medical Director of Pain Services and Supportive Therapies & Interventional Pain Management Specialist at our hospital near Atlanta. “Patients often find out they have cancer because of pain. They’ll go to an emergency room or a doctor to find out what’s going on. All of the sudden, that pain is now associated with the diagnosis of cancer.”
More than just narcotics
Despite its ubiquitous nature, cancer pain is often undertreated, studies show—for many reasons. The National Cancer Institute says some patients don’t discuss pain symptoms out of fear it will impact their cancer treatment. Others aren’t candid about how much pain they are experiencing, and so their pain isn’t addressed adequately. “Cancer patients are some of the most complex pain patients you can find,” says Dr. Neufeld.
Many people hear “pain management” and think of one thing: prescription narcotics like opioids. While pain medicines play an important role for some patients, the field of pain management has many more tools available in improving patients’ quality of life, including over-the-counter medicines like acetaminophen and nonsteroidal anti-inflammatories (such as ibuprofen), interventional therapies and nerve block therapies. “As an interventionalist, I like to highlight interventions. Injections and minor procedures can often get a lot of pain relief from very little risk, especially compared to narcotics,” says Dr. Neufeld. “These therapies have the potential to make a big difference for some cancer patients.”
Still, opioids and other narcotics have their place in managing pain, and because they can be addictive, so does the responsibility for reducing the risk of abuse. That’s true for some patients even after treatment has ended. As many as 40 percent of the 14 million-plus cancer survivors in the United States continue to experience pain after treatment, according to The American Society of Clinical Oncology (ASCO). Survivors are defined as someone who has been free of any sign of disease for five years after the initial diagnosis.
ASCO released new guidelines on how to manage chronic pain in adult cancer survivors, and they were published online in the July 25 Journal of Clinical Oncology. The guidelines are the first of their kind specifically directed at cancer survivors. “This is an important topic,” says Dr. Neufeld. “Cancer survivors are a growing community with specific needs.”
Among its key findings, ASCO recommends that cancer patients’ doctors:
- Screen for pain at every patient encounter
- Assess for the risk of adverse effects from opioids to reduce the likelihood for abuse
- Assess the risk of opioids used in pain management and incorporate universal precautions to reduce abuse, addiction and adverse consequences
- Use interventions other than opioids, such as physical therapy and rehabilitation, acupuncture, massage and psychological approaches like meditation
- Use non-opioid analgesics (over-the-counter pain relievers like acetaminophen) to relieve chronic pain and improve physical function
- Prescribe a trial of opioids in carefully selected cancer patients who do not respond to more conservative pain management and who continue to experience pain-related distress
Managing the risk of abuse
With the opioid epidemic mounting across the United States, potentially addictive opioids are now under growing scrutiny. “The ASCO guidelines address this issue head on,” says Dr. Neufeld. “So much has been written lately belittling the use of opioids, which is decreasing patients’ acceptance of something that could be extraordinarily valuable to them.”
Dr. Neufeld says most of his patients fall into two groups. “There are patients who struggle with liking the medicine too much and probably need to be reined in, and there are others who don't want to take the medicine at all because they are scared they will become addicted,” he says. “So I have to go through and define what addiction is and what dependence is. Most people who take narcotics do become dependent on them, meaning if they didn't take their dose that day, they would hurt and life would not be as good. Therefore, they are dependent on taking that medicine.”
But dependence and addiction are not the same. “When medicine is taken beyond a doctor’s prescription, usually with intention to get high, that is addiction,” Dr. Neufeld explains. “Addiction is intense drug craving with an inability to control use.”
For some cancer survivors, pain management is a long-term consideration, and their care plans should be developed accordingly. “We must think differently about their long-term outlook,” says Dr. Neufeld. “We need to think about these treatments, not as a short burst, but as the long haul. As a pain management specialist, I strive to reduce patients’ pain and reduce the reminder that cancer is present. I think restoration of hope by removal of pain improves psychological health and quality of life more than anything else.”
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