Cancer pain wasn’t on my mind when I carved out time this week to attend Cottage Health System’s psychiatric grand rounds entitled, “Dueling Diagnosis: Complicated Pain and Substance Use Disorders,” in Santa Barbara. But the lecture by Dr. Jerry Lerner, chief of pain medicine at Arizona’s Sierra Tucson residential treatment center, soon had me thinking about the many levels of pain suffered by patients diagnosed with cancer and other organic diseases.
Ironically, the oncology community has struggled for years against the erroneous belief among patients and family members that effectively managing cancer pain will make addicts of patients once they’re cured. It’s simply not true, of course, but the barriers to effective cancer pain management are vast, multifactorial, and deeply held, as documented by the International Association for the Study of Pain.
As they say in the pain medicine world, it’s complicated.
Dr. Jerry Lerner
And becoming even more so, it would seem.
A growing epidemic of prescription painkiller abuse, especially among young adults, will mean that a growing number of cancer patients arrive at our doorsteps already grappling with pre-existing addictions to opioids. The past decade has seen a 400% increase in substance disorders arising from prescription painkiller use, resulting in an overdose rate that today outpaces deaths from heroin and cocaine combined, according to the Centers for Disease Control and Prevention.
Dr. Lerner outlined a delicate strategy for treating moderate to severe pain in patients with preexisting addiction or dependency problems. Any pain at a 6 or above on a 0-10 pain scale must be treated medically, he said, or attempts at treating the substance problem will be undermined by a diminishment of therapeutic trust and a lack of “attendance, attention, and intention.”
On the other hand, pain is more than the mere presence of nerve signals to the brain because of compromised tissue.
Long-term opioid use can create hyperalgesia, a condition where the body is actually more sensitized to pain, Dr. Lerner explained. “Things that didn’t hurt before, hurt,” he said.
With 1 in 20 Americans over the age of 12 years – an estimated 12 million people – diverting and using prescription painkillers “nonmedically,” chances are that many present and future cancer patients will present to oncologists already resistant to the relief such medications might offer for cancer-related pain.
Dr. Lerner emphasized as well that pain of all kinds is influenced not only by physical biological events (tumor growth, for example), but by other factors as well: inflammation (sometimes activated or exacerbated by stress and fear), hypersensitivity from overactivity of the sympathetic nervous system, unresolved emotional trauma, and dysfunctional relationships.
He views each of these as “tumblers” in the combination lock that must be cracked to adequately treat pain, be it the result of a broken bone, a tumor, or a body-wide pain syndrome of unknown origin.
With most cancer patients, the physical source of pain is clear, and no preexisting painkiller addiction will interfere with the action of appropriately prescribed analgesics. Still, the evidence is growing that pain is a multisystemic, multifactorial challenge, felt more acutely in the face of fear or stress, so the wise guidance of those who treat “Dueling Diagnoses” will add value to the treatment of cancer pain, even in the most straightforward of cases.
Dr. Freed is a psychologist in Santa Barbara, Calif., and a medical journalist.