Social workers play vital role in cancer pain management
Social workers play a critical role in cancer care, helping patients — as well as their families and caregivers — successfully navigate many of the challenges they face.
The care team relies on these skilled professionals — educated and trained in multiple disciplines — to help patients cope with the psychological, social, emotional and spiritual issues that commonly arise after diagnosis.
However, when it comes to cancer pain management, master’s-prepared social workers (MSWs) often are undervalued and underutilized.
Although they are highly qualified to offer a wide range of evidence-based, nonpharmacologic interventions for pain management, MSWs seldom are called upon to function in this role.
Many clinicians lack understanding about how MSWs can contribute to pain management, and others are skeptical about the efficacy of these interventions.
Many factors influence pain
Many factors other than the primary malignancy affect the severity and duration of pain that patients with cancer experience.
Evidence shows psychological distress and anxiety can intensify cancer pain.
Patients with cancer often deal with many complex issues — such as depression, financial worries, family dynamics, and spiritual or existential concerns — that can amplify distress during treatment.
For many patients, a vicious cycle emerges. Increased distress leads to heightened anxiety. This increases pain, which creates more anxiety and leads to even more pain.
The relationship between cancer pain and anxiety is complex and bidirectional, occurring on both physiologic and psychologic levels.
Consequently, interventions other than pharmaceutical agents may be required to attain the level of pain control needed to help a patient achieve optimal outcomes and quality of life.
In these situations, MSWs can help patients confront and resolve underlying issues that may be contributing to their pain. They also can provide nonpharmacologic interventions that interrupt the pain cycle, reducing pain while helping patients learn valuable skills that empower them to have more control over their situation.
This approach can be especially beneficial not only for relieving cancer pain, but also in combating the opioid epidemic that has overtaken our country. Providing nonpharmacologic interventions to patients battling drug addiction can offer a lifeline to many patients with no associated harm.
Role of MSWs
MSWs who graduate from programs accredited by the Council on Social Work Education have knowledge of evidence-based clinical interventions designed to diminish pain.
Examples of these interventions include cognitive behavioral therapy; acceptance and commitment therapy; and guided imagery, mindfulness and meditation.
Although each of these techniques is unique, they all are designed to reframe how a patient thinks about and responds to pain. By calming the mind, the thought pattern that drives the pain cycle can be interrupted, reducing pain.
Most of these techniques are easy to learn, and many software applications are available to guide patients through the process. Family members and caregivers often are included in training sessions so they can help patients use these strategies at home.
To develop expertise in specific evidence-based interventions for patients with cancer, some MSWs complete many additional hours of continuing education and spend thousands of hours gaining supervised experience with patients to obtain their clinical social work license.
A substantial part of this training can focus on pain management, including how pain is observed and assessed, which treatment options work well as part of a multidisciplinary care team, and intervention strategies to employ for the lifespan of the patient.
This comprehensive training allows licensed clinical social workers to provide pain management to patients across a wide variety of settings, populations and care team models.
Licensed clinical social workers are credentialed to deliver psychosocial assessments, diagnosis and nonpharmacologic treatment to patients with behavioral health needs, without physician oversight.
Unlike other providers, these highly skilled specialists take a holistic approach to care, identifying and helping patients resolve mental, emotional, social or spiritual issues that may be affecting them during treatment and survivorship. They use results of these assessments to identify nonpharmacologic approaches that can complement prescribed medications to relieve pain and alleviate symptoms that may be causing distress.
Lack of physician understanding
Many oncologists lack the time to familiarize themselves with nonpharmacologic interventions for pain management. Others are unaware about which modalities have been effective for cancer pain management and which ones have scientific evidence to support their use.
Consequently, they often dismiss the interventions MSWs offer, viewing their techniques with skepticism.
A study conducted by social workers from The US Oncology Network showed that only 32% of medical oncologists surveyed would include an MSW to help manage a patient in a pain crisis. In addition, Ralli and colleagues determined only 45% would include an MSW in managing chronic pain.
However, a growing body of credible evidence supports the use of complementary interventions for cancer pain management.
Gorin and colleagues performed a meta-analysis of 37 randomized controlled studies over a 40-year period that included nearly 4,200 adults with cancer.
Researchers aimed to estimate the effect of psychosocial interventions on pain.
Results, published in 2012 in Journal of Clinical Oncology, showed psychosocial interventions significantly reduced cancer pain severity (P < .001) and pain interference (P < .001).
“These robust findings support the systematic implementation of quality-controlled psychosocial interventions as part of a multimodal approach to the management of pain [among] patients with cancer,” Gorin and colleagues wrote.
Lee and colleagues examined systematic reviews and meta-analyses of studies on complementary therapies for patients with cancer. The results, published in 2019 in Integrative Cancer Therapies, provided more promising evidence of the effectiveness of complementary therapies for pain control.
Of 62 randomized controlled trials or controlled clinical trials analyzed in 11 systematic reviews, 53 (85%) reported pain relief benefits from complementary therapies. Of 20 meta-analyses, 16 (80%) reported significant positive effects on pain relief among people with cancer.
Reframing pain management
Physicians and other members of the care team need to reframe their thinking about pain management.
In cases when medications are not sufficiently effective, they should not simply reach for another pharmaceutical agent; rather, they should consult an MSW to see if he or she can identify and treat underlying issues that may be exacerbating the patient’s pain. Calming interventions may help the patient break the pain cycle.
An MSW should be involved in developing a patient’s pain management plan. This should be a routine part of patient care rather than the exception.
MSWs also must be more proactive in promoting their role in pain management, as well as educating their colleagues and other providers about the effectiveness of the interventions they offer.
If MSWs regularly attend team huddles and multidisciplinary meetings, their presence and input will be more readily accepted and expected. MSWs also can build credibility for the interventions they provide by sharing articles and research that demonstrate these techniques are evidence-based and effective.
The study by Ralli and colleagues mentioned above is an example of research shared with medical providers. This has increased awareness of and discussions about social workers’ role in pain management and interventions they can offer patients in the outpatient oncology setting.
Every time a highly qualified MSW is excluded from participating in pain management, the chance to ensure optimal outcomes and improved quality of life for a patient is lost.
Oncology practices must embrace the valuable contributions these knowledgeable professionals can make, particularly now that opioid use has come to the forefront of the health care landscape.
References:
Gorin SS, et al. J Clin Oncol. 2012;doi:10.1200/JCO.2011.37.0437.
Lee SM, et al. Integr Cancer Ther. 2019; doi:10.1177/1534735419890029.
Pujol LAM and Monti DA. J Am Osteopath Assoc. 2007;107:ES15-21.
Ralli C, et al. J Clin Oncol. 2019;doi:10.1200/JCO.2019.37.27_suppl.214.
Thielking PD. Curr Pain Headache Rep. 2003;doi:10.1007/s11916-003-0045-x.
For more information:
Lydia Mills, MSW, LCSW, LICSW, can be reached at lydia.mills@mckesson.com.
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