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Is pain management an overlooked factor in suicide ideation?
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Probably.
If patients understand that we can help to minimize suffering at the end of life — and that is what supportive and palliative care is supposed to do — then patients may be less inclined to consider suicide. It is important to understand that pain comes in many flavors — physical, emotional and spiritual. If that was the case, patients would understand that they can have support around them and have someone to address their symptoms, psychosocial and existential concerns. With a good support system in place, physicians have the potential to minimize the incidence of these kinds of tragedies.
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We have made great progress over time in managing pain, but there is still room for improvement. There are some misconceptions about how to use pain management drugs. More education is needed for physicians, in general, as well as for patients. We can control pain effectively. Fifty years ago, we may not have had the knowledge. Now we do, and it is time to apply what we know to educate physicians and the public.
Education in medical school is improving. More and more medical students are getting training in pain management and palliation, although I would say it is still inadequate. We can do a better job. We see a lot of patients in pain and we have to do a better job managing that. It is something that is very fixable.
David Hui, MD, is a Research Fellow with The University of Texas M.D. Anderson Cancer Center Department of Palliative Care and Symptom Management.
Pain is not the whole story.
Yes, with a qualification. Untreated or undertreated cancer pain is a significant problem for patients living with cancer. In a variety of studies going back 20 years or more, patients with cancer who have undertreated pain have been found to have an increased risk of suicidal ideation.
Cancer pain is a very prevalent symptom. If you look at the public at large, the vast majority expect a lot of pain with cancer. Cancer pain is so prevalent and so expected, one would think it really should not be so undertreated.
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The problem is that — and the data seem to support this — when a patient is suffering from cancer, the physical pain is a part of it, but there is also an additional component of distress with cancer pain that I will call “suffering.” There are patients with severe cancer pain who, because of their social network or the quality of their medical care or just who they are intrinsically, even in the context of undertreated cancer pain, do not progress to experiencing suicidal ideation.
When I think about cancer pain correlating with suicidality, I think about some combination of physical pain and emotional distress or a sense of hopelessness. Although it is true and documented that uncontrolled or undertreated cancer pain is a risk factor for suicide ideation, there is also an important component of emotional or existential distress or mental health issues, most notably depression, that plays a crucial role.
Hunter Groninger, MD, is the Medical Director of Palliative Care at the Washington Cancer Institute at Washington Hospital Center.