Behind the Science

Where Opioids Fit in Cancer Pain Management

While opioids can provide necessary pain relief, there are cases when other non-opioid options may be a better choice.

By Rachael Bieschke

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It seems like today, you can’t turn on the news without hearing a negative story about opioids and the epidemic of addiction associated with these powerful painkillers. For cancer patients, hearing these stories day in and out can cause fear that something that helps them cope with their daily pain may cause bigger problems in the long run.

Pain management is a critical aspect of cancer care. When patients experience pain from cancer or cancer treatment, it can negatively impact how they function on a daily basis. Pain decreases quality of life and can make it physically and mentally difficult to persevere through treatment.

Physicians increasingly recognize the importance of managing pain associated with a number of conditions, which may be one of the many reasons for the increase in the number of prescribed opioids, which has nearly quadrupled since 1999, as well as the increase in deaths from opioid overdoses.

These startling statistics have led to calls for more careful prescribing and use. Part of the problem, according to Vivek Iyer, MD, Medical Director of Pain Management, interventional pain management specialist at Cancer Treatment Centers of America® (CTCA) at Western Regional Medical Center in Goodyear, Arizona, is that opioids numb the pain but don’t treat the underlying problem.

“Patients may start by taking one pill a day, but the pill only lasts a few hours. So they start taking two a day, then maybe three or four,” he says. “If you’re taking an opioid or Percocet [a combination of acetaminophen and the opioid oxycodone] and it’s not helping the pain, the instinct will be to continue upping the dosage, but it won’t make a difference.”

Even when taken as directed, it’s possible to develop a tolerance to prescription opioids, meaning you have to take more to get the same amount of pain relief.

Understanding the difference between dependence, addiction and abuse

Opioids can have significant effects on the body, leading to dependence, abuse, and potentially addiction, but understanding the difference between these terms may help ease fears:

  • Opioid dependence (i.e., physical dependence), can occur if a patient abruptly stops using their pain medication and notices physiological withdrawal effects of the opioid pain medications. These symptoms can include anxiety, diarrhea, irritability, insomnia, among others.
  • Opioid abuse is an improper use of an opioid. For example, taking more pain medications in a daily period than prescribed.
  • Opioid addiction is the inability to control drug use, compulsive drug use, and/or continued use despite doing harm to oneself or others.

Are certain people at increased risk of becoming addicted?

People from all across the U.S., of all ages and all walks of life, have been affected by the opioid epidemic, so no one is immune. However, if you have a history of addiction or anxiety, you may be at an increased risk of opioid misuse. “Everyone deserves the opportunity to treat their pain, but someone with high anxiety may panic when things aren’t going well and may take higher doses without calling their doctor,” Dr. Iyer says, stressing the importance of keeping open lines of communication with your physician.

“If I don’t know that Plan A isn’t working, we can’t go to Plan B,” he says. Studies have also found that chronic pain patients who suffer from anxiety are more likely to misuse opioids. A study published in the journal General Hospital Psychiatry found that among patients with anxiety, 50 percent also screened positive for opioid misuse, compared to 10 percent among those without anxiety.

It’s important to understand that opioid dependency can occur after just days of therapy, and the likelihood of chronic opioid use increases with each additional day the drugs are used, beginning with the third day and spiking after the fifth and 31st day using the drugs.

Receiving a second prescription or one for an initial 10- or 30-day supply also increases the risk. Dr. Iyer explains, “Some people don’t realize these medications are different than, say, blood pressure meds and are a controlled substance monitored by the DEA [Drug Enforcement Agency].”

When are opioids appropriate — and inappropriate — for managing pain?

Opioids, which include drugs such as hydrocodone, oxycodone, methadone and fentanyl, can be useful for relieving severe pain in the short term , or when incapacitating pain exists but nothing can be done about the underlying medical problem, Dr. Iyer says. This includes short-term use for patients with active cancer and those in hospice or certain palliative care cases. Dr. Iyer explains:

They may be appropriate for cancer patients immediately after surgery for a short period — a couple of weeks at most. They may help with quality of life when you can’t do anything about the medical problem. Additionally, if you’re just diagnosed with cancer and getting chemotherapy, you can use opioids to buy time until the treatments catch up. Beyond that, treat the problem — don’t just use a Band-Aid.

Opioids should not be used for mild pain or chronic pain such as that from arthritis or back pain. They also shouldn’t be used if other options, be it a different drug with less risk of addiction or a non-drug option, could effectively relieve the pain or make it more manageable. For cancer patients, the risks of opioids may come in when they find taking one pill is no longer enough to relieve their pain.

“Some patients think, ‘If one pill isn’t enough, take two. If two aren’t enough, take three,’” Dr. Iyer says, leading to a dangerous scenario that can quickly snowball towards dependence, abuse and potentially addiction. He continues:

Addiction can also result if the prescribing doctor continues to prescribe higher doses. There is a fear among some health care practitioners of not addressing pain; it’s easier to give narcotics. But they just numb the pain signals in your brain and don’t address the problem. You need to understand why you have pain and you need to address the problem.

If a cancer patient has chronic pain but nothing can be done about the underlying problem, it is important to communicate with your physician about your pain levels. There are many options for managing pain with medication, including extended release opioids that are formulated to be released slowly throughout the day. Adding other non-opioid methods for managing pain can help, as well.

Seeking non-opioid options to control pain

If you have pain, talk to your health care team to better understand all your options. Ask about non-opioid alternatives, some of which may work as well as or better than opioids, while posing fewer risks. Dr. Iyer recommends exploring injections and other procedures, physical therapy and exercise for back pain, along with attention to diet. “Being active is still the best way to get pain control,” he says, pointing out that you should get up and moving as soon as possible following surgery to help manage pain. In addition, “treating conditions with appropriate medicines is important,” Dr. Iyer explains.

Rather than prescribing an opioid to treat pain in general, more individualized treatments may include interventional therapies such as injections, cognitive behavioral therapy or less potent medications, such as acetaminophen or ibuprofen. Dr. Iyer also stresses the importance of a healthy mind in addition to a healthy body as crucial for pain relief and management:

Having the right mindset and trying to reduce stress in your daily life, along with living a healthy lifestyle, will help pain, but we’re so busy we don’t have time to work on our mental fitness. Being open-minded to chiropractic, acupuncture and other tools for overall well-being can also help.

If you are prescribed opioids, take them according to the prescription and don’t take more of them, or take them more often, than prescribed. Plan to take them for as short a period as possible and work with your health care team to create a plan to manage your pain once you stop taking the opioids. Finally, be sure to store the prescription in a safe, preferably locked, location, as many people who misuse opioids get the drugs by taking them from family members.