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 a 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. Certain anti-depressants and anti-seizure drugs can modify how the brain perceives pain and help 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 cases 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 is sometimes possible to switch to a different narcotic, which reduces tolerance and allows a lower dose. Sometimes a decreased total narcotic dose is possible by using adjuvant analgesics, steroids or neuro-modifying drugs. However, despite all efforts, there remain situations in which very high doses are required. 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%), but several instruments can reduce it even further: the CAGE questionnaire, Cyr-Wartman Screen, Skinner Trauma Screen and Opioid Assessment for Patients. It is important to understand the distinction between addiction (a psychological syndrome) and habituation, where the body gets used to narcotics and requires 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 suit, or it can play a role in increasing recovery time. 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 damn a physician who has 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 that involve standards of pain management.