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12 Articles in Volume 16, Issue #10
2016 Practical Clinical Advances: Ketamine and Metformin
Case Challenge: Amniotic Allograft Reduces Joint and Soft Tissue Pain
Challenges of Treating Young Patients With a Terminal Prognosis
Defining Palliative Care
Discussing Benefits of Palliative Care
Evaluation of Antiemetic Pharmacotherapy in the Setting of Opioid Withdrawal
Fibromyalgia, Chronic Fatigue, and Chronic Fatigue Syndrome
Gabapentin Dosing for Neuropathic Pain
IV Acetaminophen Reduces Need for Opioids in Burn Patients
Opioid-Induced Constipation: New and Emerging Therapies—Update 2016
Osteopathic Treatment Considerations For Head, Neck, and Facial Pain
Tips From the Field: Deconstructing the Art of Headache Medicine

Defining Palliative Care

Palliative care focuses on maximizing the quality of life of seriously ill patients and their families.
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Indeed, many patients now seeing pain specialists are survivors of serious illnesses. These patients may have received palliative care during the course of their illness but now have transitioned into pain management for chronic pain. Cancer survivors comprise a predominant portion of these patients. Approximately 14 million people with a history of cancer are currently living in the United States,4 and two-thirds of these people are living more than 5 years after diagnosis.5 Dr. Brennan, who worked for a period of time at Memorial Sloan-Kettering Cancer Center (MSKCC) in New York City, currently sees many patients who are cancer survivors suffering from chronic pain conditions as a result of the treatments that were used to cure them, such as chemotherapy and mastectomy procedures.

“Back then, there was never a clinic for cancer survivors. There are some popping up now,” but only recently have doctors been developing more experience about treating chronic pain conditions found in patients who survive cancer, Dr. Brennan noted.

In July, the ASCO published one of the first guidelines addressing the management of chronic pain in survivors of adult cancers.6 As the cancer survivor population continues to grow, practitioners have to contend with a variety of chronic pain conditions, such as chemotherapy-induced peripheral neuropathy and persistent postsurgical mastectomy pain.

“A specific concern regarding the CDC guideline is the recommended dose limit of 90 morphine milligram equivalents [MME] per day,” said Judith A. Paice, PhD, RN, who is the director of the cancer pain program at the Feinberg School of Medicine at Northwestern University in Chicago, Illinois.

“This recommendation is untested in this population and may produce harm. We should strive to use the lowest effective dose to limit adverse effects, yet we have no data about an optimal dose effective for all individuals with pain related to cancer or its treatment,” said Dr. Paice, who helped coauthor the ASCO’s guidelines on pain management in adult cancer survivors.

Dr. Brennan agrees that the dose limit set by the CDC guidelines was ill-conceived, especially for cancer survivors. “The CDC guidelines were a necessary step to bring the attention of over-prescribing pain medications, but at the same time we can’t throw the baby out with the bathwater,” said Dr. Brennan. “There are people who do require [opioid] treatment, and there are people who may require doses that go above and beyond the recommended CDC dose limit.”

Following the release of the CDC guidelines, many doctors have moved completely away from prescribing any opioids. This has led to a sudden wave of patients being referred to pain specialists like Dr. Brennan, who finds the migration of patients to pain specialist practices is creating significant problems.

“What’s happening is there aren’t nearly enough pain specialists to handle the number of patients who need to be treated. It’s a phenomenon across the country where pain specialists are having to take on more and more people that don’t need to be in their offices,” he noted. According to the American Medical Association, there are approximately 4,800 physicians who identify as pain medicine specialists, and there are an estimated 100 million Americans in chronic pain. If only 20% of these patients were to see a pain specialist, this would mean that each doctor would have to see 4,167 new patients.8

Understandably, pain practices have become overloaded with patients, resulting in longer wait times for patients to receive the pain management they need. For Dr. Brennan, patients may have to wait, on average, 8 weeks. “Can you imagine if you had a family member in horrible pain and you are told it was going to take 8 weeks to get them to see a pain doctor and no one else will do anything until the pain doctor sees the patient?”

Furthermore, patients who had been prescribed pain medications for years are now having their prescriptions threatened by insurance companies who are citing the CDC guidelines as justification for cutting off their access to care. “This has been taken by insurance companies and they are running with it to try and restrict access to care for those who use these medicines,” Dr. Brennan explained. “Will doctors somehow or another be held accountable by insurance companies if we’re prescribing above the threshold?”

While Drs. Brennan, McPherson, and Paice all expressed their concerns over the possible deficiencies of the CDC guidelines, they still agree with the CDC’s primary focus on promoting safe, appropriate use of opioid medications for the management of chronic pain, especially as it relates to noncancer-related conditions. Indeed, the CDC guidelines share similar recommendations on opioid safety compared to the ASCO’s guideline.7

“The pathophysiology and contributors to chronic pain in cancer survivors are different from those of patients with advanced cancer and those on active treatment. There is much more overlapping with chronic non-cancer-related pain patients, and many of the precautions proposed in the CDC guidelines might be useful for the care of these patients,” Eduardo Bruera, MD, chair of the department of palliative, rehabilitation, and integrative medicine at the UT MD Anderson Cancer Center in Houston, Texas, told Practical Pain Management.

The hope is that the CDC will revise specific aspects of the guidelines to ensure health care providers and lawmakers are in congruence with one another, especially as palliative care and pain management therapies continue to evolve and improve in efficacy and safety.


Last updated on: December 12, 2016
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Challenges of Treating Young Patients With a Terminal Prognosis

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