Fears of opioid abuse and addiction might be keeping patients with advanced cancer from getting enough pain medicine, researchers say.
"At the end of life, we should feel comfortable providing whatever necessary to control pain," said Joel Hyatt, assistant regional director at Kaiser Permanente. Concerns about overdose and addiction, he told Reuters Health, should not prevent terminally ill patients from obtaining relief.
Pain undertreatment is estimated to affect half of cancer patients, according to a recent report in the Journal of Clinical Oncology.
Opioids, a type of narcotic, work in the spinal cord and brain to reduce the intensity of pain signals reaching the brain. The opioids hydrocodone (Vicodin), hydromorphone (Dilaudid) and oxycodone (Oxycontin, Percocet) are commonly prescribed painkillers. Hydrocodone is the most prescribed medication in the U.S., according to the International Narcotics Control Board.
Opioid overuse and abuse are a widespread problem that gets lots of attention in the news media – and that may keep cancer patients and doctors from using them appropriately.
"On one hand, we're told we overuse opioids," Hyatt said. "On the other, we're told we underuse them."
Underuse worries Judith Paice, a pain specialist at Northwestern University Feinberg School of Medicine in Chicago. Part of the problem, she said, is that it's sometimes hard for patients to convey to doctors how severe the pain is.
Most pain is controllable, she maintains; patients must describe symptoms, and physicians must seriously consider them.
"All pain is real to the person experiencing it," Paice told Reuters Health. "But unlike infections we measure with blood samples, it doesn't have an objective marker."
Doctors often ask patients to rate their pain on a 0 to 10 scale. But severity, experts say, should be described in more detail than that.
"The zero to ten scale was a good beginning when introduced to quantify pain," said Paice. "Unfortunately, it's now a check in the box. It's another thing physicians ask, and patients feel frustrated because they don't feel doctors take it to the next step and work on their pain."
She advises patients to elaborate. Diaries may help detail sites of pain, severity and factors prompting pain to worsen. "Whether it's when walking, coughing, sitting or lying flat, those give clues where pain comes from," she said. "What words describe it?" Adjectives could include aching, throbbing, tingling, burning, electrical or shooting.
Narcotics are not the only option for treating pain. Patrick Fehling, a University of Colorado Hospital addiction psychiatrist, says anxiety often makes pain worse. In some cases, he told Reuters Health, pain should be treated with interdisciplinary counseling from social workers, clergy or psychologists. Research suggests complementary treatments such as massage and acupuncture may also be beneficial.
"Patients might say, 'I have pain and would like it taken away,'" said Fehling. "But their experience might be they felt pain on a three out of ten level, and they wanted zero. That's not always realistic."
Some populations are at particularly high risk for inadequate pain control. For example, research has shown that patients in minority care settings are three times more likely to receive undertreatment than those in non-minority settings. Sixty percent of African-American and 74 percent of Hispanic outpatients with cancer-related pain reported inadequate prescriptions.
"This is a most vulnerable population," said Egidio Del Fabbro, a Virginia Commonwealth University palliative specialist. "To undertreat them is something we should avoid at all costs." Research cites unrelieved pain as the greatest fear among the terminally ill.
While stigmas may be keeping doctors from prescribing adequate pain medication in certain patient populations, similar misconceptions may keep patients from seeking relief.
"There is a stigma surrounding opioids, with morphine more than others," Paice said. Many people, she added, associate morphine with dying; they think it's only used in the final hours. In fact, she said, can be used anytime during cancer treatment to maintain mobility, appetite and quality of life.
"Pain keeps patients from being able to enjoy whatever time they have left," Paice said.
When time is precious, however, balancing relief and alertness is essential, Del Fabbro maintains. The sedative effects of opioids may be troubling.
"Families want to recognize the loved one they know," he told Reuters Health. "What you get with excessive opioids is sedation, delirium, cognitive changes, and that's not the person they love. You want the best of both worlds. You want patients to be themselves and their pain controlled."