In today’s podcast, Dr. Judith Paice discusses options for managing cancer-related pain, including opioid medications, and medication-free alternatives. She also discusses the use of cannabinoids, which are derived from marijuana, including recent clinical research and associated risks and barriers.
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This podcast is part of a series featuring articles from the 2017 ASCO Educational Book. Published annually, the Educational Book is a collection of articles written by ASCO Annual Meeting speakers and oncology experts. Each volume highlights the most compelling research and developments across the multidisciplinary fields of oncology.
In today’s podcast, Dr. Judith Paice discusses options for managing cancer-related pain, including opioid medications, and medication-free alternatives. She also discusses the use of cannabinoids, which are derived from marijuana, including recent clinical research and associated risks and barriers. Dr. Paice is a research professor of medicine at Northwestern University’s Feinberg School of Medicine.
ASCO would like to thank Dr. Paice for discussing this topic.
Dr. Paice: Hello, I’m Dr. Judith Paice from Northwestern University. In this podcast, I will be sharing some key points from my 2017 ASCO Educational Book article titled, “Pain and Opioids in Cancer Care: Benefits, Risks, and Alternatives,” and talking about its implications for patients and especially cancer survivors.
Pain is a common side effect of cancer and its treatment. In fact, about 53% of people with all stages of cancer experience pain. Optimal management of cancer pain incorporates pharmacologic therapies, including a variety of medicines, and nonpharmacologic therapies, such as massage, stretching, and mindfulness. Opioids--the category for medications like morphine, oxycodone, hydrocodone, and fentanyl--are the mainstay of pain management medications and are essential for patients with pain from advanced disease. However, our evolving understanding of the risks of long-term side effects, including the potential for misuse or abuse, raises concerns about the long-term use of opioids for cancer survivors. The challenges surrounding the use of opioids, and the need for safe and effective alternative pain relievers, are leading to intense interest in the potential benefits of cannabis for cancer-related pain.
Currently, there are approximately 15.5 million cancer survivors in the United States, and this number is expected to grow to 26.1 million by 2040. The impressive increase in survivorship is because of extraordinary advances in cancer therapies. Unfortunately, however, many of these highly effective treatments also lead to persistent pain syndromes. Among cancer survivors, maybe 40% or more experience pain as a result of the cancer or its treatment.
Although opioids have a clear and primary role in the care of pain associated with advanced disease, their role in relieving pain in cancer survivors is less apparent. Although clinical experience suggests that some patients may obtain safe and effective pain control with opioids, there are no studies that guide clinicians as they consider using opioids in cancer survivors. There is also a growing list of side effects associated with long-term use of opioids, including mental clouding, effects on sexual desire and fertility, and sleep disorders. Of particular concern in the face of the current opioid abuse epidemic is that cancer survivors treated with opioids may also develop opioid or other substance abuse disorders.
Before prescribing opioids, physicians will determine a patient’s risk level for opioid misuse or abuse. Asking patients about their family history of mental health disorders and alcohol or drug abuse can help determine an individual’s risk. If a physician determines a patient’s risk is low and the pain warrants use of an opioid, the oncologist may decide to prescribe opioids. If the risk of abuse is moderate or high, the oncologist must decide if the severity of the pain is seriously affecting the patient’s physical or mental well-being and whether there are any reasonable alternatives to opioids. If the effect of pain is severe and there are no other reasonable alternatives, and the risk of abuse is manageable, a trial of opioids may be considered.
If opioids are prescribed, the physician will put in place something called an adherence-monitoring plan. Adherence monitoring can be done in different ways depending on a person’s risk level and history. For example, someone with a high-risk of misuse may have to receive periodic drug testing or submit pill counts. This is not done to punish the patient; it is done in the best interest of the patient to ensure that the opioids are taken safely.
If opioids are ineffective or serious side effects occur, treatment must be carefully reconsidered, including alternative pain relief methods, if they aren’t already part of the treatment plan. Physical therapy, such as massage, and psychologic techniques, like mindfulness, can help relieve pain and other negative side effects caused by cancer and its treatment. One study showed that therapeutic massage reduced the severity of symptoms, including pain, fatigue, stress and anxiety, nausea, and depression, in patients with cancer by 50%. These results are promising, but the symptom relief was shown to be short-term.
Mindfulness teaches purposeful, nonjudgmental, moment-to-moment awareness. Patients with cancer who have incorporated mindfulness as part of their treatment have commonly reported reductions in psychological distress, sleep disturbance, and fatigue. Some patients have reported pain relief, but more studies are needed to validate these responses.
Cannabinoids are also emerging as an alternative pain relief treatment when other options fail. Cannabinoids refer to the chemical compounds secreted or extracted from marijuana. It is important to state right away that even though over half of the U.S. states have legalized the medicinal use of marijuana, with a handful legalizing recreational use, it is illegal at the federal level.
Stimulated by the burden of chronic pain globally and the need to find safer, nonopioid treatments for pain, the number of medical studies on cannabinoids has been rising. The limited studies have shown intriguing results that need further investigation. As with any potential therapy, cannabinoids carry risks and side effects. The most common include sedation, dizziness, and dry mouth. Other significant side effects include cognitive impairment, anxiety, and psychosis. The abuse potential of cannabis is controversial and more research is needed.
The best way to treat chronic and long-term pain should be an open discussion between people with cancer and their doctors. Risks and benefits, as well as regulatory and legal issues, must be carefully considered when choosing treatment options.
To learn more, please view my article online at ASCO.org/edbook for an in-depth discussion of this topic. Thank you.
ASCO: Thank you Dr. Paice. Please visit ASCO.org/edbook to read the full article, or visit www.cancer.net/pain to learn more about options for managing cancer-related pain. And for more expert interviews and stories from people living with cancer, visit the Cancer.Net Blog at www.cancer.net/blog.
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