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.
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.”