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 “At the end of life, we should feel comfortable providing whatever
necessary to control pain,” said Joel Hyatt, assistant regional
director at Kaiser Permanente. Concerns about overdose and
addiction, he told Reuters Health, should not prevent terminally ill
patients from obtaining relief.
Pain undertreatment is estimated to affect half of cancer patients,
according to a recent report in the Journal of Clinical Oncology.
Opioids, a type of narcotic, work in the spinal cord and brain to
reduce the intensity of pain signals reaching the brain. The opioids
hydrocodone (Vicodin), hydromorphone (Dilaudid) and oxycodone (Oxycontin,
Percocet) are commonly prescribed painkillers. Hydrocodone is the
most prescribed medication in the U.S., according to the
International Narcotics Control Board.
Opioid overuse and abuse are a widespread problem that gets lots of
attention in the news media – and that may keep cancer patients and
doctors from using them appropriately.
“On one hand, we’re told we overuse opioids,” Hyatt said. “On the
other, we’re told we underuse them.”
Underuse worries Judith Paice, a pain specialist at Northwestern
University Feinberg School of Medicine in Chicago. Part of the
problem, she said, is that it’s sometimes hard for patients to
convey to doctors how severe the pain is.
Most pain is controllable, she maintains; patients must describe
symptoms, and physicians must seriously consider them.
“All pain is real to the person experiencing it,” Paice told Reuters
Health. “But unlike infections we measure with blood samples, it
doesn’t have an objective marker.”
Doctors often ask patients to rate their pain on a 0 to 10 scale.
But severity, experts say, should be described in more detail than
that.
“The zero to ten scale was a good beginning when introduced to
quantify pain,” said Paice. “Unfortunately, it’s now a check in the
box. It’s another thing physicians ask, and patients feel frustrated
because they don’t feel doctors take it to the next step and work on
their pain.”
She advises patients to elaborate. Diaries may help detail sites of
pain, severity and factors prompting pain to worsen. “Whether it’s
when walking, coughing, sitting or lying flat, those give clues
where pain comes from,” she said. “What words describe it?”
Adjectives could include aching, throbbing, tingling, burning,
electrical or shooting.
Narcotics are not the only option for treating pain. Patrick
Fehling, a University of Colorado Hospital addiction psychiatrist,
says anxiety often makes pain worse. In some cases, he told Reuters
Health, pain should be treated with interdisciplinary counseling
from social workers, clergy or psychologists. Research suggests
complementary treatments such as massage and acupuncture may also be
beneficial.
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“Patients might say, ‘I have pain and would like it taken away,’”
said Fehling. “But their experience might be they felt pain on a
three out of ten level, and they wanted zero. That’s not always
realistic.”
Some populations are at particularly high risk for inadequate pain
control. For example, research has shown that patients in minority
care settings are three times more likely to receive undertreatment
than those in non-minority settings. Sixty percent of
African-American and 74 percent of Hispanic outpatients with
cancer-related pain reported inadequate prescriptions.
“This is a most vulnerable population,” said Egidio Del Fabbro, a
Virginia Commonwealth University palliative specialist. “To
undertreat them is something we should avoid at all costs.” Research
cites unrelieved pain as the greatest fear among the terminally ill.
While stigmas may be keeping doctors from prescribing adequate pain
medication in certain patient populations, similar misconceptions
may keep patients from seeking relief.
“There is a stigma surrounding opioids, with morphine more than
others,” Paice said. Many people, she added, associate morphine with
dying; they think it’s only used in the final hours. In fact, she
said, can be used anytime during cancer treatment to maintain
mobility, appetite and quality of life.
“Pain keeps patients from being able to enjoy whatever time they
have left,” Paice said.
When time is precious, however, balancing relief and alertness is
essential, Del Fabbro maintains. The sedative effects of opioids may
be troubling.
“Families want to recognize the loved one they know,” he told
Reuters Health. “What you get with excessive opioids is sedation,
delirium, cognitive changes, and that’s not the person they love.
You want the best of both worlds. You want patients to be themselves
and their pain controlled.”
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