About 1 in 6 deaths around the world is caused by cancer. A large portion of these deaths occur in countries with low to middle incomes, and weaker healthcare. While the mortality of cancer was once much higher, its prevalence has risen dramatically as well. And with it, cancer pain.
Lifestyle issues, like obesity and lower rates of activity, coupled with existing issues such as tobacco and alcohol use, and poor nutrition, play a major role. These factors account for roughly a third of all cancer deaths, with tobacco alone accounting for 22 percent.
But a more significant factor is the fact that human life expectancy is on the rise throughout the world. Cancer is a very old disease, and one that has plagued us since time immemorial. The longer we live, the more likely it is for us to develop cancer. And the better our medical care, the more likely it is for us to survive a cancer. As well as living with its aftermath, including cancer pain.
The discussion surrounding cancer pain and its management is particularly important in these times. We continue to face the looming shadow of an opioid crisis that had been brewing since the 1990s. Despite the crisis, opioids continue to play an important role in the management of cancer pain, due to their as-of-yet unrivaled ability to shut down pain, especially in terminal cases.
However, a troubling history of over prescription, unethical business practices, and story after story of industrial manipulation in medicine has left public faith in pharmaceutical companies and particularly opioid manufacturers quite eroded, while opioid deaths continue to break records. Alternatives are critical.
The Prevalence of Cancer Pain
Cancer pain refers to any pain related to the condition of cancer. Which includes acute pain (pain that can directly trace to an ongoing cause), chronic pain (pain lasting longer than 12 weeks), pain caused by the growth of the tumor itself. Or the cancer treatments can cause pain.
In general, the prevalence of pain in cancer is roughly 50 percent in its early stages, rising to 75 percent in late stages. Pain caused by the tumor itself is, according to a large aggregation of data, most prevalent in: head and neck cancer (67 to 91 percent), prostate cancer (56 to 94 percent), uterine cancer (30 to 90 percent), genitourinary cancer (58 to 90 percent), breast cancer (40 to 89 percent), and pancreatic cancer (72 to 85 percent).
Treatment-related pain can be caused by any number of treatments. Which includes a variety of surgeries (including mastectomies, thoracotomies, amputations, etc.), neuropathy caused by chemotherapy, and radiation-induced nerve damage. A significant amount of pain during and after cancer is nociceptive. Which is tissue damage, bone fractures, pressure and pain caused by growths. Most is neuropathic (damage done to the nerves, including those that grow within the tumor).
Some pain felt during cancer may not be related to the condition but can make it worse. Chronic conditions like diabetes can cause peripheral neuropathy and excruciating pain. Psychological conditions like depression can greatly increase pain sensitivity. Although these conditions aren’t related to the cancer, their treatment needs to be incorporated in cancer pain management.
Addressing Cancer Pain
When it comes to addressing pain, the first medication that springs to mind for most patients is opioids. Opioids present an effective way to manage extreme pain. Once in the bloodstream, they attach to opioid receptors in our cells, and reduce the transmission of pain signals to the brain.
A common myth is that the treatment of opioids for pain cannot cause addiction. This, sadly, is not true. While it is exceedingly rare and most cases of addiction are in people who weren’t even prescribed opioids to begin with, it can happen. However, opioid dependence can be a common occurrence.
Different from addiction, dependence is a phenomenon that occurs in many forms of medication, especially those with a systematic effect on the body. Just as the body needs to adjust to a new drug, it also needs to adjust to its removal. Both dependence and withdrawal are carefully monitored and managed to avoid addiction.
But opioids are not the end-all-be-all of pain management. When we attempt to simplify both pain and its treatment, we run the risk of forgetting that pain is a complex problem with biopsychosocial factors.
The management of pain needs to be holistic. It addresses contributing issues that aggravate a patient’s pain and improving their quality of life. In addition to, helping them manage symptoms of pain in perpetuity, especially if the result of their cancer leaves them with chronic pain.
Opioids are not always effective in treating neuropathic pain, which constitutes a large percentage of cancer pain. And in rare cases, opioids can actually cause hyperalgesia, increasing a patient’s pain sensitivity. Other rare issues include opioid immunity and allergy/pseudo-allergy.
Alternatives are necessary. More than just a matter of comfort, the treatment of cancer pain is not just optional. It’s an essential part of the overall treatment of cancer.
A Holistic Approach
A holistic approach to pain, including cancer pain, explores a multimodal treatment program tailored to each individual case. It tackles physical, social, and mental factors that need to be addressed during the treatment of cancer pain.
Alternatives to opioids for milder forms of cancer pain include over-the-counter analgesics and anti-inflammatories, as well as changes made to the patient’s diet to improve the body’s own ability to combat pain. These alternatives cannot replace opioids in severe cases of cancer pain, but they are not the only potential alternatives.
Other medications for cancer pain are being explored, and some medications see off-label usage for pain, including antidepressants and anticonvulsants. Experimental drugs for cancer pain include THC-free cannabidiol drugs (CBD), although cannabidiol is currently only approved in the US for epilepsy, and sees use in other countries for cancer pain (nabiximols) and as a complementary drug in chemotherapy to reduce nausea and vomiting.
Medication is only one part of treatment. Patients with cancer pain can get therapeutic help if they experience mental health issues. A patient with major depressive disorder and cancer will most likely experience more severe pain problems as a result of their increased sensitivity to pain.
Changes at Home
Medicinal and professional help is an important part of pain management. But healing has to continue outside of the purview of a doctor’s supervision. Even with excellent medication adherence and a consistent schedule of follow-ups and continued care, there are many lifestyle changes that can considerably help patients combat cancer pain.
These include ceasing previous activities that greatly contributed to the cancer risk (including smoking and excessive drinking. Also, cutting down on certain foods that are carcinogenic, while increasing intake of foods with a large amount of micronutrients, meaning, vitamins and minerals. Daily exercise – from short evening strolls to more intense daily activity – can help manage pain and improve other markers of health and overall quality of life.
These changes, if implemented one at a time and in a sustainable fashion (i.e. no crash diets, no sudden challenges, no ‘cleansing’), can better equip the body with the means to reduce inflammation, reduce pain sensitivity, and even increase endorphins. However, they work best in combination with treatment and management.