ONI: What about patients' fear of addiction to pain medication? What is the best way for a healthcare professional to address that?
Dr. Craig: The addiction issue is always a concern for all of our patients; unfortunately, even the ones who are actively dying from cancer. Our society has a way of punishing "the weak," those who take opioids (narcotics) and holding up the "strong" who resist opioids. The short answer is yes, patients, providers, caretakers, spouses, employers, physicians, nurses, pharmacists, etc, are all concerned about addiction. I have never heard anyone say to me "I don't care about addiction to pain medication."
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Dr. Kronenberg: Why are we so afraid of addiction? It's our misunderstanding of what addiction is. An addict wants that drug all the time. When you picture an addict, you picture someone who is maybe homeless, or who has done a lot of illegal things in order to get drugs; we think of people whose lives are down the tubes. But with cancer patients, you are talking about a population of people whose lives are being ruined by pain. Most people will talk about the side effects of pain medication. Yes, the medication gives some pain relief, but they are not happy about the adverse effects. Can they be addicts? You've got to love the drug to be an addict. What we typically see is confusion between addiction and dependence. Dependence is a physical need; if you stop a substance abruptly, there will be withdrawal symptoms.
ONI: In the current healthcare climate, there is an emphasis on cost-effectiveness and cost cutting. How do you think pain and pain management will fare under healthcare reform?
Dr. Craig: I don't think cost-cutting efforts are initially the reason breakthrough pain gets overlooked; it may happen later if a particular drug (see Table 2) is not covered by a medical insurance plan. We encounter this problem because of the cost associated with [pain management] products on a regular basis with our cancer patients with breakthrough pain episodes.
I think physicians want to do what is best for the patient and worry about possible cost considerations later.
"Guidelines for the assessment and management of chronic pain"
American Cancer Society
"Taking action to ease suffering: Advancing cancer pain control as a healthcare priority"
American Pain Foundation
"Online guide to breakthrough cancer pain"
International Association for the Study of Pain
"Assessment of cancer pain"
National Pain Foundation
"Understanding breakthrough pain"
Dr. Kronenberg: The FDA has been looking at short-acting pain medications as something that can be very dangerous to society. They are trying to develop risk evaluation mitigation strategies (REMS) that require education of the prescriber and the patients. It limits access to a lot of potential pain therapies that may start to work very quickly.
Ms. Bennett: My hope is that healthcare reform actually does change the landscape. If we are managing pain well and palliative care is provided to patients, it will cost less and they will do better (see Table 3).
I also hope that looking at comparative effectiveness and cost-effectiveness will change the way we educate our healthcare professionals. Until that occurs, there is a danger that care decisions will be made solely on the basis of cost, rather than on what is most effective in terms of an individualized treatment regimen.