A Q&A with Kevin Sevarino, MD, PhD, President-elect of the American Academy of Addiction Psychiatry and Consulting Psychiatrist at Gaylord Hospital in Wallingford, CT
Q: Opioid abuse, addiction, and overdose are huge American problems right now. Many cancer patients experience chronic pain. What is the best way to use opioids to manage chronic pain?
[Note: The views expressed below represent the opinion of the author, and do not necessarily reflect the views of the American Academy of Addiction Psychiatry nor those of Gaylord Hospital.]
A. We live in amazing times. Targeted immunotherapies, stem cell transplants of transfected cells, identification of unique molecular targets in cancer cells through differential gene expression profiling—all promise to expand survival rates (or cures!) with diminished adverse effects compared to the “blunt hammer” approach of chemotherapy, radiation treatments, and more.
But for cancer survivors today, of which it is estimated there are over 14 million in the United States, some 40% live with chronic pain. The pain may be the result of residual effects of the cancer or its treatment, recurrence of the cancer, or development of a new cancer, as well as the many other causes of chronic pain that also afflict those without cancer, such as degenerative joint disease. This pain often goes untreated, since reporting the pain may represent cancer recurrence to the patient, and providers may take a nihilistic view of the pain. Some 25% of patients dying of cancer are in pain.
The opioid epidemic that exploded on the American consciousness has brought to light the role inappropriate opioid prescribing played in triggering the crisis. To reverse harm by the medical profession, organizations like the American Pain Society and the American Academy of Pain Medicine have released guidelines since the late 2000s that emphasize four key points for use of opioids in the treatment of chronic pain in “non-cancer” patients: 1) aim for both adequate pain control and functional improvement; 2) preferentially use non-pharmacologic treatments via multidisciplinary teams and non-opioid pharmacological management, and then if needed, the judicious use of opioids when alternative therapies prove inadequate; 3) maintain high vigilance for the development of opioid use disorders, including use of “universal precautions”; and 4) discontinue opioids in the face of severe adverse reactions. It was not until these were represented as Centers for Disease Control and Prevention (CDC) guidelines in 2016 that widespread attention was paid, as before then the guidelines had little effect on opioid prescribing practices.
So what happens to the cancer patient or survivor who has chronic pain—do the guidelines not apply? Among the few guidelines addressing chronic pain management in cancer patients and survivors, those released by the American Society of Clinical Oncology in 2016 reaffirmed most of the points raised for “non-cancer” chronic pain. Cancer patients face unique pain conditions, including bony metastases, post-chemotherapy pain syndromes, functional loss, and severe psychosocial stresses that have led medical professionals to feel opioids may be better indicated for them than others. But can we say these differ significantly from the stressors faced by those with severe chronic obstructive pulmonary disease, debilitating cardiovascular disease, post-stroke para- or quadraplegia and neuropathy, and more? Yet, the medical field tends not to treat them the same.
I believe there are unique aspects of chronic pain in cancer survivors, but our ability to extend life in the face of terminal illness makes such distinctions increasingly artificial. Our goal should be to extend quality life for as long as possible, and that includes maximizing function, in all people. If one applies the first principal of aiming for adequate pain control balanced with improved function, we should be able to apply the CDC guidelines to cancer patients and survivors not in palliative care or in active cancer treatment.
I am struck by leading cancer treatment center guidances and literature reviews published as recently as 2017 that continue to say opioid use in the treatment of cancer pain rarely results in addiction. This is frighteningly close to what was asserted for opioid use in the treatment of chronic non-cancer pain only 15 years earlier, a bombshell misperception whose splash partially caused the opioid tsunami.
Is the risk of an opioid use disorder lower in the cancer patient with chronic pain, or do we choose to not recognize it or just accept it in the face of a diagnosis so loaded with emotional reaction? Working in a hospital specializing in the care of those with traumatic brain injury and spinal cord injury, I know of the devastating effects lowered expectations can have on treatment outcomes and conversely, the power of positive thinking. If opioids are provided with minimal restriction, and assessment of adverse consequences is not performed, how would a developing addiction be recognized?
If one’s days are numbered by a terminal illness such as cancer we should aim to make those years as meaningful as possible, and the human condition demands those years have meaning; without functioning, without being needed, almost no one feels fulfilled. So, personally, I throw out the contention that the cancer survivor has a lower threshold than those without cancer for the use of opioids when they cannot be shown to be effective for pain control or that they do not cause harm, such as a reduced level of function (interaction with family, continuing to work, etc.). Harm does include ignoring or undertreating pain, but that does not equate to turning to opioids for pain management when so many other modalities may be of benefit. Harm in this population includes the development of an opioid use disorder as well as the indirect provision of opioids to others, either through patient agreement or theft.
Pain management is complicated, it is multimodal, it is time consuming, it is emotionally draining at times, and it is not done well today. What has been learned in oncology, addiction psychiatry and medicine, and other specialties can inform as well as be informed by what we have learned in the rest of medicine.
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