Types of treatments
Clinicians try to optimize use of non-opioid medications for chronic pain, Paice says. That can include nonsteroidal anti-inflammatory drugs. Steroid injections and nerve blocks are useful, especially for abdominal pain related to pancreatic cancer, says David Craig, PharmD, clinical pharmacist in pain management/palliative care at H. Lee Moffit Cancer Center in Tampa, Florida. “Drugs are not very good at managing abdominal or neuropathic pain,” he says.
But 30% to 50% of those getting antineoplastic therapy, and 75% to 90% of those with advanced disease, have pain best treated by opioids, according to UpToDate, topic updated June 2019. Opioids have received a lot of negative press lately. “Our first goal as physicians is to do no harm,” Strand says. And that means being thoughtful about how medications are used and how patients are monitored, to minimize even unintentional harm.
Not only are some clinicians reticent to prescribe opioids when indicated, but patients are afraid to take them. “We need to be really direct and ask them if they’re worried about becoming addicted,” Paice says. Patients may not take prescribed opioids out of fear, or because they receive negative messages from family members. That contributes to undertreatment of pain.
Part of Strand’s risk screening process includes checking the state prescription monitoring database, to see if the patient may be at risk for substance abuse. Closely monitoring outcomes and patient function, as opposed to pain level, helps with safer prescribing. “We can provide it safely and still manage pain effectively,” Strand says. He tells patients that part of his job is to make sure they’re safe, and that can help overcome some fear of addiction. The number of patients in his practice who benefit from opioid treatment far outweigh the number of patients harmed from it, he says. Monitoring patients with opioid prescriptions is labor intensive, requiring close communication with oncology and PCP colleagues. “Opioids for all” is not an appropriate strategy, but they’re helpful for some patients.
Clinicians disagree about the utility of cannabis in pain management. Craig does not recommend it to his patients, as he says there’s not enough data to support it, and patients think they can buy it from someone off the street, smoke it, and it will work. “We don’t disallow it, but we don’t recommend it,” he says.
A 2018 study, “Medical Oncologists’ Beliefs, Practices, and Knowledge Regarding Marijuana Used Therapeutically: A Nationally Representative Survey Study,” in the Journal of Clinical Oncology reported that up to 80% of oncologists have discussed medical cannabis use with patients, though only 30% felt informed enough to recommend it. The study, which surveyed 400 medical oncologists in 2016, showed that 67% of oncologists thought it was a helpful addition to standard pain management options. The American Cancer Society noted that some studies found that inhaled marijuana was helpful for neuropathic pain, and that those using marijuana extracts in clinical trials needed less pain medication.
Strand has comprehensive discussions with his patients about medical cannabis, as he knows patients will ask about it. He says the data on effectiveness in pain management for cancer pain is mixed. In his practice he’s seen patients benefit from it, and those who don’t. Like many treatments, clinicians need to determine how cannabis fits into treatment, and monitor it closely for side effects. “They’re not the savior to our problems with pain, but they should also not be discarded,” he says. Before a patient uses cannabis for pain management, he asks them to track it in a pain diary, just as they would with any other pain medication.