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by Richard Payne, MD, Medical Director, PAINS Project

Richard Payne, MD, Medical Director John B. Francis Chair, Center for Bioethics Esther Colliflower Professor Medicine and Divinity, Duke University

As a young doctor I attended a conference at MD Anderson Cancer Center titled “Treating Pain in a Drug Oriented Society.” One of the conference keynote speakers, Dr. Kathleen Foley, called for the “decriminalization” of cancer pain, noting that (even back then) the American Medical Association, the American Pain Society, the American College of Physicians and the World Health Organization recognized that opioid pharmacotherapy was the mainstay of treatment for patients with cancer experiencing moderate to severe pain.1 Citing surveys that she and colleagues had conducted at Memorial Sloan-Kettering Cancer Center, she noted that fear of addiction and risk of substance abuse were over riding concerns of physicians, patients and families and called for prospective studies of abuse liability and educational programs for clinicians to improve cancer pain management. Such was the world in 1989. Sadly, after innumerable clinical research trials, the development and FDA approval of several long-acting opioids for cancer-related pain, countless educational efforts (industry and non-industry funded) and the dissemination of numerous clinical practice guidelines over the past 36 years, it seems that the proverbial pendulum has swung back to a gloomier time in which cancer patients are once again being denied opioid therapy as are many others who live with persistent disabling chronic pain.

Clearly the tragedy of the current opioid epidemic has negatively influenced clinician, patient and family attitudes about opioid therapy for pain management, even for those with cancer pain.  As Susan Glod described in her recent NEJM article, “The Other Victims of the Opioid Epidemic,” she is accused of “making monsters” when she advocates for more aggressive opioid analgesia for her dying patient Jerry.2 Not only is Jerry called a “monster,” but Dr. Glod is complicit in “making the monster.”  Although it is true that Jerry also suffers from the disease of addiction, even the recent guidelines on opioid prescribing released by the Centers for Disease Control would not deny opioids to Jerry—and in fact, state explicitly that the guidelines restricting opioid prescribing are not to be applied to persons with cancer pain and those who are in hospice/palliative care.3 Dr. Glod makes a very important point that the “opioid epidemic” has so seized the attention of us all that, “We have placed the blame for the tragic losses of so many lives in so many communities on the drugs themselves rather than on the complex interplay of factors that has led to the current crises.” This distorted thinking is the basis for challenging the credentials and integrity of many advocates for persons in chronic pain who have worked in good faith with the pharmaceutical industry on joint efforts to bring improved opioids to clinical practice, or to create and disseminate educational programs to improve pain management.

The Pain Action Alliance to Implement a National Strategy (PAINS), through its No Longer Silent (NLS) campaign, was created to speak for Jerry and many millions of persons with chronic pain who require more effective treatment for chronic pain. The mantra of the NLS Campaign is that “Better chronic pain treatment will improve the lives of millions of Americans, save billions of dollars, and reduce opioid misuse.” We must advocate for the continued use of opioid analgesics when indicated in cancer pain management and hospice care, and the judicious use of opioid analgesics as part of a process of comprehensive assessment and management of chronic pain. As Dr. Glod’s essay so poignantly reminds us, we cannot allow the tragedy of the “opioid epidemic” to induce us to accept as collateral victims those with cancer pain responsive to opioids or to silence us in this important advocacy work to speak for those with chronic pain.

1 Foley K. The “Decriminalization” of Cancer Pain. In Advances in Pain Research and Therapy, Vol. 11, Drug Treatment of Cancer Pain in a Drug-Oriented Society.  edited by C.S.Hill, Jr and W. S. Fields. Raven Press, New York, 1989, p. 5-18

2 Glod S.  The Other Victims of the Opioid Epidemic. N Engl J Med 2017;376:22:2101-2102.

3 Dowell D, Haegerich T, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. Morbidity and Mortality Weekly Report. Recommendations and Reports / Vol. 65 / No. 1 March 18, 2016