Rethinking the Hierarchy
August 3, 2012 11:25 am Dr. Webster Leave a Comment (Edit)
For a riveting read, see “The Emperor of all Maladies: A Biography of Cancer,” by Siddhartha Mukherjee. The book chronicles the history of humankind’s most feared disease, including a multitude of treatment failures. The word cancer conjures a picture of death to many people. Not only was cancer nearly always terminal, but dying in pain was expected, the norm.
Today, many cancers are curable. The Centers for Disease Control and Prevention estimates that 66% of people diagnosed with cancer are still alive five years after their diagnosis. Early detection and treatment have made these encouraging statistics possible.
The idea that people with cancer will necessarily suffer severe pain is also something our society no longer accepts. Use of opioids, the strongest medications we have to treat pain, is not questioned for cancer pain, even for patients expected to survive. This represents progress in our state of compassion and our standard of medical care.
However, the national dialogue on appropriate opioid prescribing is less compassionate when it comes to other types of moderate-to-severe pain. A petition is on its way to Food And Drug Administration (FDA) urging that opioids not be used past 90 days for chronic pain – chronic,noncancer pain, that is. This well-meant policy intended to reduce the availability of opioids for abuse and overdose is likely to backfire, because it is not based on sound science or compassionate care.
Cancer or cancer therapy can cause tissue injury. But is the tissue or injured nervous system caused by cancer different than that caused by trauma, diabetes, shingles, or arthritis? No. There is no valid scientific explanation for the separation. Pain is pain.
The majority of chronic noncancer pain patients will not need or tolerate opioids long term, but some suffer severe pain that is unrelenting. This pain is just as intense as pain from cancer and doesn’t stop when the clock has run out on the opioid prescription. Evidence suggeststhat this subset of patients who are able to remain on opioids past six months do benefit from them. Physicians must retain the flexibility to treat these patients whose pain is not relieved by other currently available methods.
Because, historically, we expected a person with cancer to die, it was permissible to treat their pain with opioids, an inherently short-term use, we reasoned. Now that many patients with cancer survive long term, there is a lingering sense that their pain is more noble, more deserving of treatment than patients whose pain does not involve a malignancy. This is not fair. It is based on prejudice. It may, indeed, be open to legal challenge.
As one of my patients recently said: “Why is it that cancer patients’ pain is somehow worse than mine?”
We all want to stop prescription drug abuse, but public policy cannot be built on selectively targeting a group of patients to prevent others from selling or diverting their drugs for nonmedical use. For that matter, patients who now survive cancer should also be screened and followed clinically to make sure they do not develop problems with abuse or addiction to medication.
The artificial distinction of cancer vs. noncancer pain is more about attitudes, emotions and politics than science. Our sense of compassion should not stop at the word non.
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Filed Under: Drug Overdose, Opioids, Pain Medication Abuse, Substance Abuse