Cancer pain in the opioid-addicted patient: Can we treat it right?

Vania Modesto-Lowe, MD, MPH; Lisa Girard, BS, MHS, PA-C; Margaret Chaplin, MD

doi:10.5055/jom.2012.0113

Authors

Vania Modesto-Lowe, MD, MPH
Lisa Girard, BS, MHS, PA-C
Margaret Chaplin, MD

DOI:

https://doi.org/10.5055/jom.2012.0113

Keywords:

opioid, addiction, cancer pain

Abstract

Although cancer elicits an array of physical and emotional symptoms, pain is often identified as the most distressing. Cancer pain may result from the primary tumor, metastasis, surgery, radiation, chemotherapy, or medical comorbidities. Although treatment with opioid analgesics is accepted as appropriate therapy for cancer-related pain, under treatment may persist among certain patients. Opioidaddicted individuals represent a challenging and heterogeneous population to treat. Addiction is linked to psychopathology and antisocial behaviors (eg, lying) which often complicate evaluation. Chronic exposure to opioids may lead to physiologic dependence and its correlates, tolerance and hyperalgesia. Given the variability and subjectivity of the cancer pain experience, there are no objective measures which capture the adequacy of pain control. Thus, when faced with complaints of uncontrolled pain, clinicians must consider a differential diagnosis of tolerance, disease progression, addiction, pseudoaddiction, chemical coping, or even criminal behavior. This article explores the cognitive, behavioral, and physiological correlates of opioid addiction that may impact cancer pain management. It also discusses risk reduction strategies for opioid misuse and research directions that may lead to improved clinical outcomes in these patients.

Author Biographies

Vania Modesto-Lowe, MD, MPH

Addiction Services Division, Connecticut Valley Hospital, Middletown, Connecticut; Health Sciences, Quinnipiac University, Hamden, Connecticut.

Lisa Girard, BS, MHS, PA-C

Health Sciences, Quinnipiac University, Hamden, Connecticut

Margaret Chaplin, MD

Community Mental Health Affiliates, New Britain, Connecticut

References

Green CR, Hart-Johnson T, Loeffler DR: Cancer-related chronic pain: Examining quality of life in diverse cancer survivors. Cancer. 2011; 117(9): 1994-2003.

Marcus DA: Epidemiology of cancer pain. Curr Pain Headache Rep. 2011; 15(4): 231-234.

World Health Organization: Cancer pain relief and palliative care. Report of a WHO Expert Committee. WHO Tech Rep Ser. 1990; 804: 7-21.

Starr TD, Rogak LJ, Passik SD: Substance abuse in cancer pain. Curr Pain Headache Rep. 2010; 14(4): 268-275.

Sng BL, Schug SA: The role of opioids in managing chronic non-cancer pain. Ann Acad Med Singapore. 2009; 38(11): 960-966.

Modesto-Lowe V, Brooks D, Petry N: Methadone deaths: Risk factors in pain and addiction populations. J Gen Intern Med. 2010; 25(4):305-309.

Raffa RB, Pergolizzi JV Jr: Opioid formulations designed to resist/deter abuse. Drugs. 2010; 70(13): 1657-1675.

Berg KM, Arnsten JH, Sacajiu G, et al.: Providers’ experiences treating chronic pain among opioid-dependent drug users. J Gen Intern Med. 2009; 24(4): 482-488.

Green E, Zwaal C, Beals C, et al.: Cancer-related pain management: A report of evidence-based recommendations to guide practice. Clin J Pain. 2010; 26(6): 449-462.

Dy SM: Evidence-based approaches to pain in advanced cancer. Cancer J. 2010; 16(5): 500-506.

Højsted J, Sjøgren P: An update on the role of opioids in the management of chronic pain of nonmalignant origin. Curr Opin Anaesthesiol. 2007; 20(5): 451-455.

Bohnert AS, Valenstein M, Bair MJ, et al.: Association between opioid prescribing patterns and opioid overdose-related deaths. JAMA. 2011; 305(13): 1315-1321.

Kroenke K, Zhong X, Theobald D, et al.: Somatic symptoms in patients with cancer experiencing pain or depression: Prevalence, disability, and health care use. Arch Intern Med. 2010; 170(18): 1686-1694.

Paulozzi LJ, Xi Y: Recent changes in drug poisoning mortality in the United States by urban-rural status and by drug type. Pharmacoepidemiol Drug Saf. 2008; 17(10): 997-1005.

Goudas LC, Bloch R, Gialeli-Goudas M, et al.: The epidemiology of cancer pain. Cancer Invest. 2005; 23(2): 182-190.

Tofthagen CS, McMillan SC: Pain, neuropathic symptoms, and physical and mental well-being in persons with cancer. Cancer Nurs. 2010; 33(6): 436-444.

Epstein JB, Wilkie DJ, Fischer DJ, et al.: Neuropathic and nociceptive pain in head and neck cancer patients receiving radiation therapy. Head Neck Oncol. 2009; 1: 26.

Ngamkham S, Holden JE, Wilkie DJ: Differences in pain location, intensity, and quality by pain pattern in outpatients with cancer. Cancer Nurs. 2011; 34(3): 228-237.

Knopp KL, Nisenbaum ES, Arneric SP: Evolving cancer pain treatments: Rational approaches to improve the quality of life for cancer patients. Curr Pharm Biotechnol. 2011; 12(10): 1627-1643.

Dickman A: Integrated strategies for the successful management of breakthrough cancer pain. Curr Opin Support Palliat Care. 2011; 5(1): 8-14.

Fine PG, Narayana A, Passik SD: Treatment of breakthrough pain with fentanyl buccal tablet in opioid-tolerant patients with chronic pain: Appropriate patient selection and management. Pain Med. 2010; 11(7): 1024-1036.

Jost L, Roila F; ESMO Guidelines Working Group: Management of cancer pain: ESMO clinical practice guidelines. Ann Oncol. 2010; 21(suppl 5): v257-v260.

Apolone G, Corli O, Caraceni A, et al.: Pattern and quality of care of cancer pain management. Results from the cancer pain outcome research study group. Br J Cancer. 2009; 100(10): 1566-1574.

Modesto-Lowe V, Johnson K, Petry NM: Pain management in patients with substance abuse: Treatment challenges for pain and addiction specialists. Am J Addict. 2007; 16(5): 424-425.

Jacobsen R, Møldrup C, Christrup L, et al.: Patient-related barriers to cancer pain management: A systematic exploratory review. Scand J Caring Sci. 2009; 23(1): 190-208.

Jacobsen R, Møldrup C, Christrup L, et al.: Psychological and behavioural predictors of pain management outcomes in patients with cancer. Scand J Caring Sci. 2010; 24(4): 781-790.

Cleeland CS, Ryan KM: Pain assessment: Global use of the brief pain inventory. Ann Acad Med Singapore. 1994; 23(2): 129-138.

Koyyalagunta D, Burton A, Perez M, et al.: Opioid abuse in cancer pain: Report of two cases and presentation of an algorithm of multidisciplinary care. Pain Physician. 2011; 14(4): E361-E371.

Porter LS, Keefe FJ: Psychosocial issues in cancer pain. Curr Pain Headache Rep. 2011; 15(4): 3-18.

Dalton JA, Keefe FJ, Carlson J, et al.: Tailoring cognitive-behavioral treatment for cancer pain. Pain Manag Nurs. 2004; 5(1): 3-18.

Fishman B: The cognitive behavioral perspective on pain management in terminal illness. Hosp J. 1992; 8(1-2): 73-88.

Greer JA, Park ER, Prigerson HG, et al.: Tailoring cognitive-behavioral therapy to treat anxiety comorbid with advanced cancer. J Cogn Psychother. 2010; 24(4): 294-313.

Garnet B, Beitel M, Cutter CJ, et al.: Pain catastrophizing and pain coping among methadone-maintained patients. Pain Med. 2011; 12(1): 79-86.

Schieffer BM, Pham Q, Labus J, et al.: Pain medication beliefs and medication misuse in chronic pain. J Pain. 2005; 6(9): 620-629.

Brothers BM, Yang HC, Strunk DR, et al.: Cancer patients with major depressive disorder: Testing a biobehavioral/cognitive behavior intervention. J Consult Clin Psychol. 2011; 79(2): 253-260.

Bean HK, Gannon R: Treatment of acute pain in opioid tolerant patients. Conn Med. 2010; 74(3): 143-148.

Rowley D, McLean S, O’Gorman A, et al.: Review of cancer pain management in patients receiving maintenance methadone therapy. Am J Hosp Palliat Care. 2011; 28(3): 183-187.

Ling W, Mooney L, Hillhouse M: Prescription opioid abuse, pain and addiction: Clinical issues and implications. Drug Alcohol Rev. 2011; 30(3): 300-305.

Barry DT, Irwin KS, Jones ES, et al.: Opioids, chronic pain, and addiction in primary care. J Pain. 2010; 11(12): 1442-1450.

Larance B, Degenhardt L, Lintzers N, et al.: Definitions related to the use of pharmaceutical opioids: Extramedical use, diversion, nonadherence and aberrant medication-related behaviors. Drug Alcohol Rev. 2011; 30(3): 236-245.

Haller D: Adherence therapy for opioid abusing pain patients “PROJECT PAIN”. NIDA (Grant #R01DA1369) presented at 2006 CPDD Conference, Scottsdale, AZ, April 17, 2006.

Passik SD, Kirsh KL: Addictions in pain clinics and pain treatment. Ann N Y Acad Sci. 2011; 1216: 138-143.

Gourlay DL, Heit HA, Almahrezi A: Universal precautions in pain medicine: A rational approach to the treatment of chronic pain. Pain Med. 2005; 6(2): 107-112.

Craike MJ, Livingston PM, Warne C: Sensitivity and specificity of the distress impact thermometer for the detection of psychological distress among CRS survivors. J Psychosoc Oncol. 2011; 29(3): 231-241.

Webster LR, Webster RM: Predicting aberrant behaviors in opioid-treated patients: Preliminary validation of the opioid risk tool. Pain Med. 2005; 6(6): 432-442.

Savage SR: Management of opioid medications in patients with chronic pain and risk of substance misuse. Curr Psychiatry Rep. 2009; 11(5): 377-384.

Slevin KA, Ashburn MA: Primary care physician opinion survey on FDA opioid risk evaluation and mitigation strategies. Opioid Manag. 2011; 7(2): 109-115.

Brennan MJ, Stanos S: Strategies to optimize pain management with opioids while minimizing risk of abuse. PM R. 2010; 2(6): 544-558.

Wiedemer NL, Harden PS, Arndt IO, et al.: The opioid renewal clinic: A primary care, managed approach to opioid therapy in chronic pain patients at risk for substance abuse. Pain Med. 2007; 8(7): 573-584.

Schroeder JR, Epstein DH, Umbricht A, et al.: Changes in HIV risk behaviors among patients receiving combined pharmacological and behavioral interventions for heroin and cocaine dependence. Addict Behav. 2006; 31(5): 868-879.