A 42-year-old female with ovarian cancer, receiving adjuvant treatment, was referred to me for pain assessment and management. Following assessment, my impression was that she was suffering from bilateral leg pain, likely neuropathic in origin. She related to this pain as a paclitaxel-related side effect, which is unusual but not impossible.
This lady tried a range of different opioids from which she developed unacceptable side effects. Anti-convulsants were also tried in managing her pain with no desired pain relief as result. She found it increasing difficult to care for her three young children, and her husband was becoming increasingly more frustrated about her pain issues.
Amongst all the difficulties in gaining appropriate pain control, her GP prescribed Pethidine IM, which she now requires on a daily basis. Pethidine is her drug of choice as it provides her with good pain relief for a short time with few side effects. I educated this lady on the long-term effects of chronic Pethidine use and coordinated with her GP to consider the use of methadone in addition to psychotherapy in managing her pain.
In managing cancer pain, do we need to reframe our thinking around chronic opioid therapy, particularly when a patient is not dying? Do we recognize that there are both benefits and risks to long-term opioid therapy? What is our role in assessing and screening for psychosocial distress and opioid dependency? In approaching a patient and her problems, what is actually guiding our practice?
Attitudes toward opioid use has changed over the last two decades. Twenty years ago, pain relief was delivered to the dying, and then the process changed to pain relief delivery to cancer patients. Nowadays, pain relief is also administered to patients suffering from chronic, non-malignant diseases. Emerging evidence tells us the picture is getting more complicated. Today we consider denial of pain relief as unethical. Fifty out of 206 countries have legalized opioids for cancer pain.
Evidence is telling us that opioid treatment of acute and progressive cancer pain is appropriate and effective. So is the delivery of pain management for someone who is dying. For chronic, short-term use, opioids are effective and have little risk of adverse outcomes. Emerging evidence tells us that long-term opioid use can worsen pain over time, the recipient will utilize healthcare more, she is less likely to return to work, and chronic opioid use can be an independent mortality risk factor.
The use of strong opioids is associated with poor health-related quality of life. There is a significant association between mental health issues and chronic opioid use. Therefore continuous, persistent pain should be seen as a disease of the CNS, not just a symptom of illness or injury. Chronic pain is a centrally sustained process and often develops without even a nociceptive pathology. Emotional states can become the generator of pain. Opioids may even be the cause of pain.
It is of importance that the drivers for a patients’ pain are resolved rather than just palliated with opioids. We often see the implementation of opioids in the absence of optimal treatment services and support. It is important to treat anxiety and muscle tension, and set functional goals. We need to work towards opioid minimization and containment from the beginning. We need to look at interdisciplinary models of care, better screening for psychosocial/psychiatric dependency comorbidities, and looking at current opioid misuse measures. And how about increasing self-empowerment of the patients to manage their pain?
- Savage S. Role and management of opioids in chronic pain. Pain Refresher Course IASP Press, Seattle 2012
- Sullivan M, Ballantyne. What are we treating with chronic opioid therapy? Arch Intern Med 2012;172:433-434
- Woolf CJ. Central sensitisation: implication for diagnosis and treatment of pain. Pain 2011:152;S2-15