Cancer pain management

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Published: 1 Feb 2023
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Prof Ebtesam Ahmed - St John's University New York, New York City, USA

Prof Ebtesam Ahmed speaks to ecancer at BGICC 2023 about cancer pain management in the adult patient population.

She discusses the European Society for Medical Oncology pain guidelines with the aim to educate oncologists about the importance of screening patients and assessing their pain.

Prof Ahmed also highlights how pain can be viewed as biopsychosocial as it can often lead patients to self-isolation, anxiety and depression.

Today in our palliative care session, or our palliative care workshop, my talk was in particular talking about cancer pain management in the adult patient population. I briefly discussed the ESMO guidelines, the European Society of Medical Oncology pain guidelines, to try to educate oncologists about the importance of screening patients and assessing their pain.

As we know, cancer, for many reasons, patients could experience pain. It could be as a result from the surgery – think of a woman who had breast cancer and she had a mastectomy, she will have post-op pain. It could be also from the treatment – some chemotherapies are debilitating and they can cause neuropathy, they can cause myalgia, they can cause arthralgia and so on. It could be also from the radiation therapy, especially, as an example, for head and neck cancer patients who develop mucositis and that could be very debilitating because it affects their ability to eat, ability to drink, they can lose more weight and so on. So we talked first, in the first part of the talk, talked about the cancer, some of the reasons why patients who have cancer develop pain. Again, it’s either the treatment or the cancer itself or comorbidities and so on.

We went on to educate oncologists who attended the session about assessing pain and understanding that pain is not just an open-ended question. When you talk to patients you need to do more of a proper comprehensive assessment, by asking patients about the quality of their pain to gather more information to determine the right, correct regimen. So, we need to do a better job when you see a patient, asking them how does it feel like, where is it, how long has it been, what treatment options they tried. Also to understand that pain, and we think about it in the pain world, is a biopsychosocial – it not only affects your physical symptoms but it also affects your mood, it can cause depression, it can cause anxiety, it can cause distress. Patients who have uncontrolled pain tend to isolate themselves, not interact with their family, not eat, not drink, not properly sleep, so it affects their overall quality of life. So part of the assessment is also to assess the functional status, not just the fact that you have pain or not.

Also we talked about the treatment options. So, the ESMO guidelines, just like the WHO guidelines, they mirror each other in the way that the starting pain after the proper assessment is to start depending on the type of pain. Is it going to be somatic pain, visceral pain, neuropathic pain? If a patient presents with mild pain, like the pain is not significant to the point it’s interfering or impairing their quality of life, is to start what we call non-adjuvant analgesic. So to stay away from the opioids at this point because you don’t really need them. So you could try simple things like try certain antidepressants, steroids and also there are the anti-inflammatories – paracetamol and so on. 

If the patient comes in with moderate pain, which is the next step, or if the pain progresses from mild to moderate pain then you can start to introduce what we call the weak opioids. So opioids that do not have strong affinity, so something like Tramadol or codeine and so on. But if the pain continues to persist or if patients are presenting with what we call severe pain, at this point you really need the strong opioids, so you need the gold standard, morphine, or you need fentanyl, hydromorphone, depending on the availability. 

Also in the talk today I made a very strong point about emphasising what are some of the barriers of pain management, especially in the region here, in the Middle Eastern region. So some of the barriers, in my own opinion, my own experience, is lack of training. Oncologists are very well trained into curing cancer; they are very familiar with the guidelines, the treatment options when it comes to chemotherapy, radiation, but not much emphasis is placed on symptom management, pain being a very common symptom that happens in cancer care. So the lack of training of oncologists in pain management. Also the lack of palliative care specialists in the region. We don’t have that many palliative care specialists. Thank God – I look back a few years ago, we only had maybe two people attending the meetings where we were practising palliative care; today we had a room full of six or seven or eight people, so it was great. 

Also the availability and affordability and accessibility. Opioids, and particularly in the region, there are very strict regulations that they are prescribed in a specific prescription, that patients had to go and get the prescription stamped. There is limited quantity which, if you look at the standard clinical guidelines, opioids do not have a maximum daily dose, however, some countries took it upon themselves to restrict the amount a patient can get. Accessibility is a very big barrier – you find only opioids in major cancer centres or major pharmacies. When you go to rural areas or you go outside the city it becomes extremely problematic for patients to commute or to be able to come. Culture in general – there’s this notion also, especially when it comes to men, they tend not to complain about pain a lot. And the fear of opioids – there is this opiophobia in general because, unfortunately, the Middle East looks at the United States and looks at the opioid crisis that is going on right now in the United States. I hate to say, people hate to say, that it’s an opioid crisis of opioids, it’s more of a heroin crisis right now in the United States; so, people need to understand that also. So there’s this opiophobia notion here and people don’t want to prescribe opioids, patients are very reluctant to take them because of this notion that they are very highly addictive. Even when they refer to them, one of the points I was trying to emphasise today, here in Egypt and in many Arab countries when we refer to opioids we don’t say opioids as a pain analgesic, we refer to them as narcotics. When we use this language to talk to patients, narcotic is a very legal term so patients associate that term that this is a bad substance, I shouldn’t be taking it, it’s going to affect me, it’s going to affect my family, I’m going to be addicted, I’m going to go to jail and so on. So we should use better terms to explain to patients that these are analgesics, it’s going to help cure your pain, it’s going to alleviate your symptoms and so on.

Also the availability, unfortunately, in the region. Not that many opioids are available. Here in Egypt we don’t have morphine in liquid form so it becomes problematic for people who cannot swallow. Children you don’t have that many options. We have importation issues because we only have one supplier that we have here in Egypt, we have to get the opioids from the outside. So now with inflation worldwide it becomes problematic. So discussing about availability, maybe we should have more local pharmaceuticals who are interested in developing these substances.

Then we talked also about managing the side effects of the opioids, to understand that it’s not just giving patients a tablet. Part of it is to make sure that if side effects are rising how to manage them. We talked about also how it’s important to include the family members because they are the caregivers. Let’s not forget the caregivers, they are a very big element, important element, of taking care of patients, that you have to involve them, you have to educate them, you have to explain to them what’s going on with the patients, the importance of taking the medicines, not telling the patient, ‘Oh, it’s okay, it’s okay. It’s fine, it’s fine. Tolerate the pain, it’s not that severe,’ or whatnot. Or not being fearful of the medication and giving it to their loved ones. So it’s very important to invite all key members to the table. 

So the talk today, in summary, sorry if I talked a lot, it’s more about cancer pain management and how to properly assess it and the importance of educating oncologists. Increasing our awareness in general among regulators, among pharmacy schools, medical schools, obviously nursing schools. Inviting all people to be around the table and putting the patient and the caregiver in the centre to try to improve the quality of life of patients who are undergoing cancer treatment.