From diagnosis through survivorship, pain is one of the most frequent, and most feared, consequences of cancer. Approximately 55% of patients with cancer report pain during treatment, with 66% of patients experiencing pain in the advanced stages; after curative cancer treatment, 39% of patients still describe pain.1 Moreover, it is not uncommon for practitioners to undertreat cancer pain,2 with socioeconomically disadvantaged minority patients with cancer at particular risk for undertreatment.3
Every health care provider plays a significant role in pain management. Comprehensive cancer pain management must be an interprofessional, collaborative effort that includes screening for pain at each encounter, as well as ongoing assessment, evaluation, intervention, and pain relief. However, with their specialized knowledge of medications, pharmacists should take a leadership role in ensuring patients with cancer receive sufficient pain relief while keeping abreast of the signs of opioid tolerance, physical dependence, and addiction.
The Pharmacist’s Role
Pain is defined by the International Association for the Study of Pain as: An unpleasant sensory or emotional experience associated with actual or potential tissue damage.4 Understanding the significance of this definition is critical: The patient need not have overt major lesions to experience severe pain. In some situations, a patient without obvious injuries may still suffer severe pain. Pain is multifactorial (see SIDEBAR5) and causes significant physical and psychosocial burdens, impacts quality of life, increases vulnerability in an already vulnerable population, and requires dependence on health care providers for access to adequate pain management.
Pharmacists can impact pain management by educating patients and caregivers in pain assessment and management, including explaining the risks and benefits of long-term opioid therapy and the safe storage, use, and disposal of controlled substances. Pharmacists should discuss the use of both pharmacologic and non-pharmacologic treatment options for cancer-related pain. Non-pharmacologic approaches include stretching, acupuncture, massage, and cognitive behavioral therapy. To better facilitate pain management in cancer patients, pharmacists should engage patients in the treatment selection process and provide education on the agreed-upon pain regimen in order to enhance a patient’s knowledge, attitudes, and beliefs. Pharmacists can also have a significant influence on practitioners’ attitudes toward opioid prescribing.
Although cancer pain can be well managed, it remains a consistently undertreated problem. To properly manage cancer pain, identifying and addressing barriers to treatment are imperative. These barriers are typically characterized in three main categories: patient-related barriers, professional-related barriers, and health care system-related barriers.6 Pharmacists can ensure patients receive adequate pain relief by helping decrease patient- and professional-related barriers to effective pain management.
Patient-Related Barriers to Pain Management
Challenge Patient Beliefs
Because patients with cancer may have misconceptions about cancer pain that may prevent them from accessing appropriate pain treatment, challenging these assumptions is often necessary. For example, patients may believe that pain is simply intrinsic to the experience of having cancer, and that cancer pain is uncontrollable. It is imperative that pharmacists communicate to patients that most cancer pain can be alleviated, while also setting realistic expectations and goals for treatment. Pharmacists should emphasize improvement in function as the primary goal for pain management, and reinforce that functional improvement can improve their quality of life even when pain is present.
Patients may also harbor a belief that pain indicates disease progression, and thus may be hesitant to discuss pain with their practitioner.7 The pharmacist should explain to the patient that pain can result from multiple causes and does not necessarily indicate disease progression. Patients must take an active role in notifying practitioners about their pain to ensure they receive adequate pain relief. If pain is due to disease progression, then it is critical that the practitioner discover the progression as soon as possible. The patient can assist in this determination by providing the practitioner with an honest evaluation of their pain level. Pharmacists can deliver significant value by facilitating communication between patients and the provider care team.
It is not uncommon for patients to fear becoming tolerant to, dependent on, or addicted to opioid medications8; a patient with such concerns about pain medications may be reluctant to report pain and seek pain management.6 Moreover, patients may fear that others will perceive them to be an addict for taking pain medications.3
Pharmacists must understand the differences among opioid tolerance, dependence, and addiction, and provide this information to patients in order to improve their comfort in accepting opioid medications.8
- Tolerance occurs when the patient is no longer responding to the medication. The risk of tolerance can result in the requirement of higher doses of opioids to achieve equal pain relief.
- Physical dependence arises when a patient will experience withdrawal syndromes if the medication is abruptly discontinued.
- Addiction occurs when a patient experiences impaired control over drug use, compulsive use, continued use despite harm, or craving for the medication.
By understanding these definitions and differences, pharmacists can assist in identifying and monitoring for behaviors of medication misuse, abuse, and/or addiction. Pharmacists should also assess the patient’s adherence to pain medications; this evaluation can provide valuable information regarding the patient’s underuse or overuse of medications. In cases of nonadherence, pharmacists can provide behavior modification techniques and follow-up services. In addition, if addiction is of concern, a patient can undergo pharmacokinetic and drug screening medication monitoring.
Educate Patients About Side Effects
Patients may fear that they will experience unmanageable side effects to pain medications, and such worry can result in poor adherence to pain regimens.9 To prevent side effects while attaining adequate control of cancer pain, analgesic combinations often are required. In addition, around-the-clock dosing schedules may be utilized, rather than on-demand schedules, to minimize the frequent use of medications for breakthrough pain when pain is constant. Patient adherence to opioids is reported to be 63% to 91% for scheduled pain management; the adherence rate for as-needed medications is reported to be 22% to 27%.6 This lower adherence rate for as-needed medications may be due to a patient’s negative beliefs concerning opioid use, fear that opioids will affect the patient’s normal behavior, and opioid cost issues.
It is imperative that patients are aware of the adverse effects associated with analgesic use, including those beyond the immediate adverse effects, such as respiratory depression or constipation.5 Pharmacists should ensure that patients receiving pain medication are initiated on appropriate bowel regimens. Pharmacists can monitor adverse effects through laboratory data, vital sign assessment, and patient interviews. When a pharmacist provides a patient with education about their pain management, they experience decreased incidence of adverse effects and report an overall improvement in their satisfaction with care.10
Patients who are adherent to their pain medication regimen report less severe pain.11 Thus, providing patients and family members with education on the appropriate use of pain medications can increase adherence. Pharmacists can help improve adherence by performing regular follow-ups with patients in-person or via telephone. In addition, pharmacists can advise patients to use medication diaries, which have been shown to improve patient empowerment, to track intake of pain medications and their pain scores throughout the day.12 Tracking patient pain scores throughout the day in conjunction with medication administration can help identify triggers for breakthrough pain and aid in titrating pain regimens.
Lack of Effective Prescribing
Pain treatment should address the cause of pain and be titrated to meet patient goals and expectations. It is critical to note that by utilizing the available pain management therapies, approximately 80% of cancer pain can be controlled with simple means, while 20% may require a multidimensional approach, with ongoing reassessment of pain and use of second‐line agents and/or non-pharmacologic interventions.13
To ensure appropriate prescribing, pharmacists should educate physicians about the requirements of safely prescribing opioids.6 According to the Drug Enforcement Administration (DEA), a controlled substance prescription must contain the following: patient’s full name and address, provider’s full name and address, DEA registration number, drug name, strength, dosage form, quantity prescribed, directions for use, number of refills (if any) authorized, and must be dated and signed on the date when issued. For a Schedule II controlled substance, refills are not allowed.14
It is interesting to note that according to surveys, physicians desire additional guidance on how to assess and properly treat pain with opioids, as well as how to counsel patients about opioid safety, which creates an unique opportunity for pharmacists.15 Pharmacists should provide additional educational resources and training to providers in the management of cancer-related pain. For example, pharmacists may discuss pharmacokinetic and pharmacodynamic properties of pain regimens, as well as patient-specific factors that influence treatment selection and assessment of pain management in this population.
Physicians may be reluctant to prescribe opioids due to the risk of addiction. Approximately 25% to 40% of physicians report concern over patients becoming addicted.5 In addition, prescribers and pharmacists should be aware of possible legal or regulatory sanctions for overuse of opioids. Global opioid consumption increased from 28 mg to 42 mg morphine equivalents per capita from 2005 to 2012.1 It is interesting to note that primary care physicians are more likely to delay the use of strong opioids compared to oncologists.5
The Centers for Disease Control and Prevention recommends providers review the patient’s history of controlled substance prescriptions using state prescription drug-monitoring program data prior to writing a prescription for opioids, as well as monitor use periodically during opioid therapy.16
Patients receiving opioid medications for cancer-related pain must be closely monitored. Based on extensive clinical experience, four domains have been proposed as most relevant for ongoing monitoring of patients with chronic pain receiving opioids: pain relief, physical and psychosocial functioning, side effects, and the occurrence of any potentially non-adherent drug-related behaviors. These domains have been summarized as the “4 As”17:
- Activities of daily living
- Adverse side effects
- Aberrant drug-taking behaviors
Monitoring these outcomes throughout treatment is critical to inform therapeutic decisions and provide a framework for documenting the clinical use of these controlled drugs.
Because pain is a common symptom in patients with all stages of cancer, providing proper pain management for these patients is a crucial goal for pharmacists. Comprehensive pain assessments are integral to achieving adequate pain control. In addition, developing extensive experience managing opioid treatment will facilitate pharmacists’ ability to introduce adjuvant analgesics appropriately and refer to palliative care colleagues when pain or related symptoms in their patients are not well controlled.
Practitioners with a strong opioid management plan ensure patient safety, inspire confidence in the capability of the pain management team, and can help assuage patients’ fear of cancer-related pain. Pharmacists should be instrumental in educating patients and in proactively managing pain with the same intensity applied to treating the cancer itself.
Megan May, PharmD, BCOP, is a clinical oncology pharmacy specialist at Baptist Health’s Lexington Cancer Center in Lexington, Kentucky. She received her Doctor of Pharmacy from Samford University’s McWhorter School of Pharmacy in Birmingham, Alabama, and completed a pharmacy practice residency at Shands Jacksonville Medical Center and a hematology/oncology pharmacy residency at the Medical University of South Carolina.
Jeannie Patrick, PharmD, BCOP, is a clinical oncology pharmacy specialist at Baptist Health’s Lexington Cancer Center. She serves as the primary pharmacist within the pharmacy-led oral chemotherapy clinic, where she provides patient education counseling, adherence checks, assistance with medication acquisition, and patient navigation. Jeannie received her Doctor of Pharmacy from the University of Kentucky College of Pharmacy in Lexington, Kentucky, and completed a pharmacy practice residency at the Lexington VA Medical Center and a hematology/oncology pharmacy residency at the University of Kentucky Medical Center.
- van den Beuken-van Everdingen MH, Hochstenbach LM, Joosten EA, et al. Update on prevalence of pain in patients with cancer: systematic review and meta-analysis. J Pain and Symptom Manage. 2016;51(6):1070-1090.
- Greco MT, Roberto A, Corli O, et al. Quality of cancer pain management: an update of a systematic review of undertreatment of patients with cancer. J Clin Oncol. 2014;32(36):4149-4154.
- Anderson KO, Richman SP, Hurley J, et al. Cancer pain management among underserved minority outpatients: perceived needs and barriers to optimal control. Cancer. 2002;94(8):2295-2304.
- International Association for the Study of Pain. IASP Terminology. www.iasp-pain.org/Education/Content.aspx?ItemNumber=1698. Accessed on February 20, 2019.
- Paice JA, Portenoy R, Lacchetti C, et al. Management of chronic pain in survivors of adult cancers: American Society of Clinical Oncology clinical practice guideline. J Clin Oncol. 2016;34(27):3325-3345.
- Kwon JH. Overcoming barriers in cancer pain management. J Clin Oncol. 2014;32:1727-1733.
- Hodes R. Cancer patients’ needs and concerns when using narcotic analgesics. In: Hill CS, Fields WS, editors. Drug treatment of cancer pain in a drug-oriented society. Advances in pain research and therapy. Vol 11. New York: Raven Press; 1989:91-99.
- American Society of Addiction Medicine. Definitions related to the use of opioids for the treatment of pain: consensus statement of the American Academy of Pain Medicine, the American Pain Society, and the American Society of addiction medicine. www.asam.org/docs/default-source/public-policy-statements/1opioid-definitions-consensus-2-011.pdf. Accessed February 21, 2019.
- Miaskowski C, Dodd MJ, West C, et al. Lack of adherence with the analgesic regimen: a significant barrier to effective cancer pain management. J Clin Oncol. 2001;19(23):4275-4279.
- Bennett MI, Bagnall AM, Raine G, et al. Educational interventions by pharmacists to patients with chronic pain: systematic review and meta-analysis. Clin J Pain. 2011;27(7):623-630.
- Jerant A, Frank P, Tancredi DJ, et al. Tendency to adhere to provider-recommended treatments and subsequent pain severity among individuals with cancer. Patient Prefer Adherence. 2011;5:23-31.
- Lovell MR, Luckett T, Boyle FM, et al. Patient education, coaching, and self-management for cancer pain. J Clin Oncol. 2014;32(16):1712-1720.
- World Health Organization. Cancer pain relief: Second edition, with a guide to opioid availability. Geneva: World Health Organization; 1996. http://apps.who.int/medicinedocs/documents/s22085en/s22085en.pdf. Accessed February 21, 2019.
- US Department of Justice. Drug Enforcement Agency Diversion Control Division. Practitioner’s Manual—Section V. Valid Prescription Requirements. www.deadiversion.usdoj.gov/pubs/manuals/pract/section5.htm. Accessed March 8, 2019.
- Cushman PA, Liebschutz JM, Hodgkin JG, et al. What do providers want to know about opioid prescribing? A qualitative analysis of their questions. Subst Abus. 2017;38(2):222-229.
- Centers for Disease Control and Prevention. Guideline for Prescribing Opioids for Chronic Pain. www.cdc.gov/drugoverdose/pdf/guidelines_at-a-glance-a.pdf. Accessed March 8, 2019.
- Passik SD, Kirsh KL, Whitcomb L, et al. A new tool to assess and document pain outcomes in chronic pain patients receiving opioid therapy. Clin Ther. 2004;26(4):552-561.
The Causes of Pain5
Pain may arise directly as a result of the underlying oncologic condition, from the therapy intended to modify the disease, and from adverse drug effects.
- Pain Resulting from the Underlying Oncologic Condition. For example: Bone pain can present from metastatic disease spreading into the bone; muscle pain may result from skeletal muscle tumors; headaches may be due to brain metastasis; and peripheral nerve pain may be secondary to tumor infiltration.
- Pain Arising from the Therapy Intended to Modify the Disease. Chronic post-surgery pain syndrome can include postmastectomy pain syndrome, post-radical neck dissection pain, chronic post-radiation pain syndrome, and phantom pain syndromes.
- Adverse Drug Effects Can Cause Pain. Adverse drug effects, such as peripheral neuropathy, may also contribute to cancer-related pain post-chemotherapy.
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