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Treating cancer pain: Barriers and fears to overcome
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Patients and clinicians alike fear the overuse of opioid medications for cancer pain, but the underuse of opioids is much more common.
HemOnc Today recently reported in its July 10 edition on the occurrence of abuse and misuse of opioids and discussed “opioidphobia,” particularly from the viewpoint of providers, and Biren Saraiya, MD, provided an update on pain research in last month’s issue. In this column, I’d like to discuss the underuse of opioids, the barriers to pain control and fears that patients face, and strategies to help patients get the relief they so desperately need.
A 2010 study by Lewis and colleagues in Pain Medicine found that among a group of veterans who were prescribed opioids for pain — both cancer pain and noncancer pain — underuse was more common than overuse; 20% vs. 9%. Problems in doctor-patient communication were cited frequently as to why under-users did not utilize their prescribed opioids for their pain. Other reasons cited for underuse included fear of adverse effects and a general desire to decrease pill burden.
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Even the terminology used to describe pain medications causes confusion among patients. A 2008 study surveying outpatients showed that most are unfamiliar with the term “opioid” and instead are more familiar with the term “narcotic.” Patients associated narcotics with pain management, as well as addiction and abuse; they also expressed fear of adverse outcomes with the use of a narcotic.
Separate from the misperceptions of opioids, patients also have concerns about treating cancer pain specifically. In the journal Nursing Clinics of North America, Gunnarsdottir and colleagues described the common patient-related barriers to adequate pain management. The researchers said patients perceive that treatment of pain masks how the cancer is behaving. Patients also may believe that pain medications should not be utilized early in cancer treatment, even if a patient is having severe pain, because there will not be effective medications if the pain worsens later on in the course of the disease. This is a common misunderstanding of the concept of medication tolerance. Patients do not want their oncologists to be “distracted” from treating the cancer and may minimize their pain levels to convey this.
Although there has been a recent emphasis on provider education for Risk Evaluation and Mitigation Strategies (REMS) in the prescribing of opioids, there continues to be a need to improve upon the assessment of pain and the underuse of pain medications. In light of the myths and misperceptions surrounding cancer pain and opioids, it is important to assess patients for their concerns and barriers before initiating opioid therapy. This includes addressing major fears of addiction and side effects by preparing patients and educating them on what to expect when taking certain medications. It is helpful to ask, “What have you heard about morphine or oxycodone?” or “What do you know about this medication?”
Dealing with misinformation and debunking myths by asking regular follow-up questions on pain and side effects can help mitigate underuse as well.
Stephanie M. Harman, MD, FACP, is a palliative care physician at Stanford University Medical Center and director of its inpatient palliative care service. Disclosure: Dr. Harman reports no relevant financial disclosures.
For more information:
- Arnold R. Why patients do not take their opioids, 2nd edition. Fast facts and concepts. October 2007;83. Available at: www.eperc.mcw.edu/fastfact/ff_083.htm.
- Gunnarsdottir S. Nurs Clin North Am. 2003;38:419-434.
- Lewis ET. Pain Medicine. 2010;11:861-871.
- Mangione MP. J Gen Intern Med. 2008;23:1336-1338.