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Safe and effective chronic opioid therapy for chronic cancer related pain requires clinical skills and knowledge in both the principles of opioid prescribing and on the assessment and management of risks associated with opioid abuse, addiction, and diversion.

Although evidence is limited in many areas related to use of opioids for chronic cancer pain, several guidelines provide recommendations developed by multidisciplinary expert panel after a systematic review of the evidence.

Generally, narcotics are not the only modality that can be used to treat pain. Adjuvant therapies together with narcotics can be very helpful. For example, steroids and non-steroidal anti-inflammatory drugs, such as ibuprofen(Advil) can reduce the inflammation associated with tumors pressing on tissues, and certain anti-depressants and anti-seizure drugs can modify how the brain perceived pain and lessen it. There are also procedures, such as nerve blocks, that can be helpful when pain is localized.

Cancer pain can require very high doses of narcotics. Guidelines provide guidance and in some case, recommend a specialty pain management consultation. A diagnostic re-evaluation is often indicated to exclude cancer progression. If there is progression, the best pain management is successful treatment of the underlying disease. It may sometimes be possible to switch to a different narcotic, which reduces tolerance and allows a lower dose, or decrease total narcotic dose by using adjuvant analgesics, steroids or neuro-modifiyng drugs discussed above, but there remain situations in which very high doses are required despite all efforts. Intravenous patient controlled analgesia(PCA) with outpatient medication via a pump, or intrathecal catheters present other options.

Risk of addiction in cancer patients is very low, around 2% (Friedman et al), but several instruments can reduce it even farther: CAGE questionnaire, Cyr-Wartman Screen, Skinner Trauma Screen, Screener and Opioid Assessment for Patients. It is important to understand the distinction between addiction, a psychological syndrome, and habituation, which is the body getting used to narotics and requring higher doses. Habituation can be easily treated; addiction is much more difficult to treat. Unfortunately, overrated fear of addiction or unwarranted anxiety about attracting the attention of the DEA, sometimes leaves patients with inadequate pain control.

Failure to provide adequate pain control to cancer patients is a deviation from the standard of care and can be grounds for a malpractice suite, or it can play a role in increasing recovery. The use of national guidelines or local state policies can be helpful to both plaintiff and defense. State pain policies can shield practitioners who have complied with the state policy, or a damn physician who have not. Some state policies are so restrictive that they automatically put the defendant at a disadvantage. An expert who is familiar with the use of guidelines and local policies can prove invaluable in the litigation of cases the involve standards of pain management.

REFERENCES:

Davis MP, Weissman DE, Arnold RM, Opioid dose titration for severe cancer pain: a systematic evidence-based review.J Palliat Med. 2004 Jun;7(3):462-8.

Washington State Agency Medical Directors' Group. Interagency guideline on opioid dosing for chronic non-cancer pain: an educational aid to improve care and safety with opioid treatment. Olympia (WA): Washington State Department of Labor and Industries; 2010. 55 p. [123 references].

Friedman DP. Perspectives on the medical use of drugs of abuse. J Pain Symptom Manage 1990; 5: S2-S5.

Joranson DE, Gilson AM, Dahl JL, Haddox JD. Pain management, controlled substances, and state medical board policy: A decade of change. J Pain Symptom Manage. 2002;23:138-147.

Furrow BR. Pain management and provider liability: No more excuses. J Law Med Ethics. 2001;29:28-51.

Ziegler SJ, Lovrich NP Jr. Pain relief, prescription drugs, and prosecution: A four-state survey of chief prosecutors. J Law Med Ethics. 2003;31:75-100.

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Dr. Mark Levin is an Academic Physician with a wide range of experience in various practice settings, including academia, teaching hospital and private practice settings. He has a consulting practice in clinical standards and utilization review in Oncology and runs a blog devoted to Standards of Care. He is in active medical practice.

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