Chronic pain is a common, lasting result of cancer and its treatment, occurring in about 35-45% of cancer survivors. Prescription opioids are considered the standard of care to treat moderate-to-severe cancer pain during active treatment, but guidance in the survivorship phase is much less clear.
Many clinicians in the current era are reluctant or even unwilling to prescribe opioids for chronic pain of any origin, viewing pain management to be outside of their skill set or not feeling well equipped to handle the complexities of chronic opioid therapy. Additionally, when it comes to research on chronic pain therapies, cancer survivors have often been intentionally excluded from studies, leaving providers in the dark about the best ways to help this unique population.
The purpose of this study, part of NIDA Clinical Trials Network protocol CTN-0115, was to talk to different types of clinicians about their thoughts and feelings about opioid pain management in cancer survivorship and collect some of their ideas for ways to improve chronic cancer pain care.
Because cancer survivors may visit several different settings when seeking care after cancer treatment, participants were recruited from multiple specialties. Twenty clinicians were ultimately recruited from a range of specialties, providing a variety of perspectives: oncology (5 participants), palliative care (8), pain management (2) or primary care (5). On average, participants had spent 16.4 years in practice (range was 3-44 years). Each participating provider was interviewed by a trained interviewer over the phone
Several themes emerged from the analysis:
There is no consistent medical “home” for chronic pain management in cancer survivors.
Oncologists, primary care physicians, and palliative care physicians all reported being approached by cancer survivors for help with post-cancer-treatment pain, but none felt they were the appropriate choice for ongoing care. Pain management clinicians, in contrast, were willing to take on these patients, but wanted to be referred to them earlier, even included during active cancer treatment, so that patients wouldn’t wind up on unnecessarily high doses of opioids early on in their care.
Clinicians are influenced by their peers’ perceptions of their opioid prescribing decisions, sparking self-doubt and tension when disagreement occurs.
Many of the clinicians cited overthinking, self-doubt, and second-guessing themselves as a significant barrier to opioid prescribing. Clinicians who knew other providers had declined to prescribe opioids second-guessed their own decisions to prescribe, even when they felt it was the appropriate decision. They also described feeling shame and stigma from peers when they chose to use opioids to treat chronic cancer pain.
Clinicians fear consequences of their prescribing decisions, including patient and family anger, the potential for aggression and violence, and disciplinary action.
Clinicians described situations in which refusing to prescribe opioids led patients and/or family members to become argumentative and aggressive, calling them “uncaring” and even threatening to get opioids on the streets, something that could be very dangerous given the hazards of the unregulated drug supply. At the same time, clinicians were afraid of disciplinary actions that could result from prescribing or overprescribing, including being sued or losing their license.
Clinicians had suggestions for ways to improve care
Clinicians also made some suggestions for improvements, such as the development and implementation of systematic approaches to opioid prescribing for cancer survivors, increased education for clinicians who treat chronic pain in cancer survivors, increased and earlier communication with other clinicians, and enhanced use of multidisciplinary teams to comprehensively manage chronic cancer pain. They also expressed a clear desire for the development and use of non-pharmacologic interventions for their patients.
Providers who treat cancer survivors with chronic pain may be in an extra-challenging situation, as very little research on this specific population exists. Patients with chronic cancer pain do not have a clear “home” – there isn’t a coordinated system in place to transition survivors to chronic pain care, making individual clinicians have to decide on a treatment approach within the context of their own training and practice preferences. Many providers do not feel comfortable or confident treating chronic pain with opioids, leaving patients feeling frustrated or uncared for. Given the impact of undertreated pain, however, it is essential to establish a clear process for chronic cancer pain management and to develop innovative models of care for this population.
Behavioral health and substance use disorder treatment professionals should also be aware of the unique needs of this population, who may be seeking support related to both their pain and their opioid use.