Ask the Expert

On Cancer: Will I become addicted to the pain medications I may need during my cancer treatment?

By Jim Stallard, MA, Writer/Editor  |  Wednesday, December 18, 2013
Pictured: Natalie Moryl (Khojainova), MD Pain specialist Natalie Moryl

Although many cancer patients never have pain from their disease or its treatment, the possibility of experiencing this symptom is often a cause of great anxiety for those who are newly diagnosed.

What’s more, patients who do have pain are often reluctant to ask for pain medications or even admit they need them because they worry they will become addicted. In particular, they fear addiction to opioids such as morphine and oxycodone, which are frequently prescribed by cancer doctors.

Memorial Sloan Kettering physician Natalie Moryl specializes in treating pain and other cancer-related symptoms. She says concern over opioid addiction has been a longstanding barrier to controlling pain effectively in cancer patients. In almost all cases, this fear is groundless.

“Cancer patients rarely become addicted to medications prescribed for cancer-related pain,” she says. “If the patient takes the medication exactly as prescribed and follows the directions of the physician, we see very little reason to be concerned.”

Dr. Moryl explains that cancer patients with a history of substance abuse receive additional counseling and may require more frequent clinic visits. Their pain treatment may have to be adjusted to minimize the risk of substance-abuse relapse. They also may need a few additional layers of support such as social workers, psychiatrists, and drug rehabilitation centers.

Opioid Misconceptions

The widespread misgivings about opioid use may rest on a failure to understand the difference between physical dependence on a drug — which is temporary and usually no cause for worry — and actual addiction. Patients usually become physically dependent after taking opioids for more than a few days or weeks, but this dependence is a normal part of proper pain treatment.

“Most of our patients have no problem stopping opioids as long as we taper the amount slowly, usually over a few weeks,” says Dr. Moryl, who serves on the Adult Cancer Pain Panel for the National Comprehensive Cancer Network, an alliance of 23 of the world's leading cancer centers that develops evidence-based treatment guidelines for most cancers and cancer-related symptoms including pain.

“Even if opioid withdrawal symptoms do occur, they are usually short lived,” she adds. “Although opiates are more publicly scrutinized than some other pain medications, they do not cause any permanent or irreversible organ toxicity, and any side effects will stop after the patient discontinues the drug. With long-term use, they are often much safer than pain medications you could get over the counter.”

Dr. Moryl says that increased media coverage of opioid abuse in society over the last few years, especially prescription painkillers outside the hospital setting, may have heightened worries about addiction among cancer patients.

“The government has become concerned about side effects and death associated with opioids — it’s been called a new epidemic,” she says. “But most emergency room visits and deaths related to opioids are seen in the non-cancer community. In a majority of cases, the person abusing the drug is not even the person for whom the medication was prescribed. This type of abuse is more of a societal problem than a medical one. It’s not really an issue in the cancer population.”

Another emerging barrier is a backlash from pharmacies and insurance companies working to control the increase in abuse and overdose. “When patients with severe cancer pain pick up pain medication prescribed by their oncologist or pain physician, the local pharmacy or insurance company may at times ask questions that make some patients feel they are taking or wanting ‘too much’ medication,” Dr. Moryl explains.

She says that while more patients seem to be asking about the possibility of addiction, she is usually able to put their fears to rest, explaining that the likelihood for most people is very low.

Pain Relief Is Essential to Good Care

Apart from fears of addiction, Dr. Moryl says cancer patients, especially elderly people, are sometimes afraid to report pain because they fear decline of cognitive function and loss of independence that may result from taking any sedating medications, including opioids. They also are concerned that their cancer treatment may be withheld if they report too much pain.

“I’m still surprised at how much stigma cancer patients may carry and how much shame they associate with taking opioids,” she says. “Recently, I had a patient with advanced kidney cancer who was very reluctant to increase her medications despite being in so much pain she couldn’t sit down to be examined. Even though we were discussing hospice care, she did not feel comfortable increasing her dose because someone outside our hospital had told her the dose she was taking was high.”

Dr. Moryl emphasizes that cancer patients should understand that pain relief is not a sign of weakness but an essential part of their care. Uncontrolled pain decreases a patient’s quality of life, mobility, ability to go to medical appointments, and in some cases ability to continue essential treatment that may cause pain as a side effect.

“I’ve seen patients decide to stop life-prolonging or life-preserving treatment because of pain that could be controlled,” she says. “It’s a shame people think they have to live with pain when we have medications that could help.”

Comments

This article was very timely for me. I am trying to wean myself off of my pain meds. I definitely feel that uncontrolled pain does more harm than good when recovering from cancer surgery. The pain med goes to the pain receptors. Thank you for clarifying this and discussing the fear of addiction for those of us who are not abusers of these meds. This was much appreciated.

I have had Lymphoma for just under a year now and have gone through CHOP, ICE and Rituximab - I have had the same type of worries about taking opioids due to the fact I know I have an additive personality. I made this clear to my doctors and they said that I should not worry about it. I took probably 6 or 7 rounds of Oxycodone - it basically made me sick every time I took it - I would just feel completely out of it and couldn't focus on anything. So it was safe to say that I didn't grow any type of addiction to them. I think it would be interesting to hear the doctors view on Lorazapane - this was an extremely effect drug for me during the hard times - especially when the side effects where strongest. I watched my behavior and released I was taking too much of this drug - kind of put me in La La land when I wanted to get away. I am happy to say I realized I was over doing it with this drug. It was just something that was giving me an escape instead of dealing with the disease. I now only take it when the times get really bad – Great article!!

Dr. Moryl has been treating my husband for chronic pain for many years. Her extensive knowledge,is matched by her compassion. Don't know what we would without her.

Thankful for reading this! I have stage 4 breast cancer w mets to the bone. I have a TON of pain on a daily constant basis. One if the things I struggle with is the stigma of being on opioids. I know I shouldn't because I actually need to have round the clock pain management, but I often feel ashamed if I have to go up in dosing on my pain meds. It's something the Dr's at Sloan have helped me deal with by explaining to me and reassuring me. They are right. I've tried to taper down and the pain is so unbearable that I can't. I've learned there's no shame in it. It's ok to take these meds! I deserve a quality of life! This article means a lot to me. I almost became a patient of Dr. Moryl! But I have Dr. Cubert instead, he's been wonderful. Sloan Kettering really cares about their patients quality of life. I've had the office team work very hard getting my insurance to cover my expensive pain meds! It saddens me that there is such an epidemic and stigma that the insurance companies can deny a cancer patient pain meds. It's unreal. I am thankful that my team at Sloan cares about patients comfort and fights hard for us to have access to a "normal" way of life.
Thank you Dr. Moryl for this article! :)

Dr. Moryl shouldn't be defending the use of suboptimal and dangerous treatments like opioids- he should be calling for better medications. We all know that doctors are addicted to using opioids for they lack education in pain care-and refuse to have education in pain care. And so regretfully doctors like Dr Moryl dont know how to use treatments like electrotherapy, scs, scrambler therapy, ultrasound patches, etc. Moreover Dr. Moryl fails to recognize that opioids dont work for neuropathic pain that is not uncommon in cancer.

Dear Dave, We reached out to Dr. Moryl. She writes: "Fortunately, at MSKCC we have access to most of the FDA-approved pain treatment modalities. Every modality has its advantages as well as side effects that MSKCC doctors are experienced with. Each patient’s treatment strategy is decided individually. If needed, consultation is done with Rehabilitation and Anesthesia Pain groups that help with nerve blocks and implanted devices such as spinal cord stimulators (SCS) or other devices. Fortunately, most cancer pain management doesn’t require such surgically implanted devices. Opioids, along with other medications often used for cancer pain (including neuropathic pain), are effective in the majority of cases."

Dr. Moryl, if you could offer me some advice God bless you, I have breast cancer and was prescribed pain meds when it was found in the bone. I am finished treatment except for maintainence but i am still taking about 30 mg of oxycodone a day, I am so depressed and feel no good because i cant seem to stop although i rarely go over that amount i am afraid to be black listed if i ask for help will my dr. abandon me will insurance do the same if I need meds in the future will i be able to get them i am 61 and did not ask for this i nned help i feel alone and ashamed. God be with you i feel like i am nothing,

Michele, we consulted with Dr. Moryl about your question and she provided this response:

“Thank you for your question. I recommend that you discuss your concerns with your oncologist who may address this with you or refer you to a pain specialist. A pain specialist will interview and examine you to help you decide if you should continue your pain medication or should try to taper it down and even stop. If you have withdrawal symptoms when you are trying to stop I would definitely recommend a consultation with a pain specialist who would guide you through the process and help address your symptoms as you are tapering down your medications. This is just another part of your treatment. Your doctor’s team may help you work with the insurance company as well.”

In addition to this input from Dr. Moryl, you also might contact Memorial Sloan-Kettering’s Counseling Center to learn about the services they offer. The center can be reached at 646-888-0100 or go to:

http://www.mskcc.org/cancer-care/outpatient/msk-counseling

Pain medication has become part of my life. A small price to pay for surviving two cancers. Making the decision to use a medication that may be seen as addictive was not easy. I began to look at as If I was diabetic. I would take daily injections. I could have a heart issues which required that I take medications daily also. The conclusion I came to was that if I had a different medical issue other than pain, that required daily medication for the rest of my life, of course, I would take it. Why should pain be different? My pain is a medical condition with a name, radiation fibrosis. The medication prescribed helps me live with less pain. I applaud the physicians that are knowledgable enough and brave enough to write my monthly scripts.

Opioids are not effective for neuropathic pain as Dr Moryl suggests. In addition, to say Sloan Kettering will make available alternative treatments when needed is indication that Sloan Kettering is just promoting the opioid economy for opioids should not be the first line of treatment for cancer pain- as opioids can lower immunity and spread cancer. I regret that dr. Moryl has failed to indicate knowledge of such- but I am not surprised. If Dr Moryl would like to openly discuss proper pain care of people with cancer or painful conditions- let her know this pain care advocates dorsolateral prefrontal cortex is well methylated for such discussion.

Thus, would it say pain killers also the danger of heart attack, or the underlying pain/disease/inflammation that leads people to chronic use of pain medication? Better avoid pain killers if you want than first consult your doctor than take it.

I am thankful for insightful pain doctors. I survived advanced metastic breast cancer stage 3c a very aggressive form. I had to endure high doses of chemo which included Taxol. I was left with CIPN: chemically induced peripheral neuropathy that has severely affected my life. Traditional nerve pills such as neurotin and lyrics actually made my nerves more sensitive. I tried all of the other non drug therapies which "Dave" above recommended and to no avail. At only 43, a single mother, I needed to be able to work. I was recommended to a wonderful pain management Dr in my area. He also has a psychologist in his office. Both convinced me to try the Morphine treatment and I am able to work without too many days missed due to horrible pain. Dave some neurologic pain does respond to narcotics. Trust me my quality of life was horrible due to my uncontrolled pain from chemo damaged nerves. My pain is like my lower leg bones and feet have been beaten by a baseball bat. I do not believe in doctors throwing medications at people, but just like insulin for diabetics, some of us whose bodies were permanently damaged by the treatments to save our lives, need narcotic medications to be able to be productive members of society and enjoy our lives. Being treated like we are criminals is frustrating and also cancer related pain is nothing like any pain I have ever experienced and I would not wish CIPN on my worst enemy. Thank you for an insightful article from a knowledgeable doctor who cares.

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