Pain Management: How the Opioid Epidemic Has Left Cancer Patients Exploring Other Options

By David Haas,Community Outreach Coordinator at Mesothelioma Cancer Alliance

The National Cancer Institute estimated 1,735,350 new diagnoses of cancer in 2018. While finding new treatment options has become a top priority for medical practitioners, cancer patients continue to struggle with pain caused by invasive surgeries and intensive treatments such as chemotherapy. To help them cope, addictive prescription opioids are often necessary for patients to feel relief.

Unfortunately, prescription painkillers also have a tendency to make patients physically dependent, which can lead to a cycle of overprescribing, misuse, and even death. Doctors have thus begun exploring alternative options for pain management in hopes that patients can find relief without risking addiction. These include both medical marijuana and new, nonaddictive opioids.


Prescribing Practices: The Patient Comes Second

Many patients who undergo invasive surgeries are given painkillers to alleviate their symptoms during recovery. However, unlike long-term cancer treatments such as chemotherapy and radiation, the body’s ability to heal from a surgical procedure happens relatively quickly. As a result, patients may not use the opioid prescription to its full extent, leaving an excess of painkillers behind. Without proper knowledge of prescription disposal, pills may be kept in medicine cabinets for later use or handed out to others.

Sadly, doctors are partly to blame for the problem. While many people believe their health is a top priority during a doctor’s visit, that may not always be the case. An abundance of information is beginning to surface regarding corruption in the medical field.

In March 2018, an article published by CNN revealed that doctors have been receiving kickbacks from pharmaceutical companies to prescribe certain drugs. Between 2014 and 2015, over 200,000 doctors received incentives from pharmaceutical companies that manufacture opioids. Among them, nearly 4,000 doctors received more than $15,000 to prescribe certain painkillers. Dr. Aathirayen Thiyagarajah, for example, a doctor who specializes in pain management, received upwards of $200,000 a year for prescribing a synthetic pain reliever known as Subsys. Subsys, a form of fentanyl prescribed as an oral spray, leaves users in a “zombie-like” state, often losing memories and decision-making ability for multiple days with no recollection of what occurred.


With prescription opioid use often leading to synthetic opioid abuse, the problem must be resolved while it is still in the doctor’s office.


It is disheartening to think that trusted medical professionals may not always be as concerned with patients’ health as one would assume. Yet overprescribing and misuse have created an illegal market for prescription opioids, and previous attempts to reduce their availability, such as I-STOP, have failed to curb their misuse. Due to their highly addictive nature, serious patient evaluations need to be made before patients are prescribed opioids and the reasons why patients would be given painkillers must be analyzed carefully. With prescription opioid use often leading to synthetic opioid abuse, the problem must be resolved while it is still in the doctor’s office.


The Challenges of Managing Cancer Pain during the Height of the Opioid Epidemic

With the opioid epidemic affecting so many lives, doctors must now weigh the risks and benefits that come with prescribing such medications. There are a variety of factors that play into a patient’s vulnerability of becoming dependent, and the ability for doctors to understand these factors is crucial to how a patient is able to manage their pain.

Some of the key risk factors associated with developing a dependency on opioids are the dosage of medicine needed to relieve pain, prior usage of opioids by the patient, overall mental health of the patient, and the severity of the patient’s pain per its root cause.

These factors have made doctors think twice about what they prescribe and how often they prescribe it, which has led to cancer patients not only receiving fewer prescriptions, but some not wanting to take painkillers at all.

For patients with forms of cancer that have progressed beyond the possibility of remission, such as late-stage mesothelioma, the primary focus is to make the patient as comfortable as possible. This means that although pain relief is a top priority, someone who has terminal cancer should not have to fight a dependency while trying to create lasting memories with friends and family. This leaves doctors and patients in a tough position, as they must seek nonaddictive alternatives in order for relief to be provided.


The Evolving Use of Cannabis

Medical cannabis is perhaps one of the most widely debated substances in terms of its medicinal purposes and legality. While regulations are slowly being lifted, there is still a stigma attached to cannabis, in large part because it is illegal at the federal level. Nonetheless, doctors and patients are exploring medical marijuana as a viable option to relieve pain.

Cannabis contains an array of compounds, with the two that are best understood being tetrahydrocannabinol (THC) and cannabidiol (CBD). CBD is nonpsychoactive and does not produce the same euphoric effects as THC, making CBD ideal for patients who are solely seeking pain relief.

Unlike opioids, CBD does not create an excess of dopamine, the substance that tricks our neurotransmitters into feelings of pleasure. Instead, cannabinoids work with the CB1 and CB2 receptors throughout this system to suppress the absorption of our body’s naturally produced pain relievers, such as anandamide. This slow absorption allows for prolonged relief, and because building a tolerance to CBD is highly unlikely, a patient can take the same dosage over a longer period of time without having to increase the amount needed to reap the benefits.


While regulations are slowly being lifted, there is still a stigma attached to cannabis, in large part because it is illegal at the federal level. Nonetheless, doctors and patients are exploring medical marijuana as a viable option to relieve pain.


Another encouraging advance in cannabis for medical use is the research being conducted to better understand how it can be an effective form of pain relief. A study published by the National Center for Biotechnology Information of 177 patients with cancer pain found that THC:CBD extract was an effective way to relieve cancer pain that is not fully relieved using opioids.

While this study was on a small scale, there is an active community of scientists and doctors who are conducting research and trial studies to further understand CBD and its pain relief usages. However, because cannabis is still classified as a Schedule I drug (the same category under which heroin is classified), the ability for researchers to understand it is limited.

The lack of existing research has prevented the medical field from considering marijuana as an alternative form of pain relief. In an article published by Targeted Oncology, just over 70 percent of oncologists said they do not feel informed enough to make clinical recommendations to patients seeking CBD as treatment. However, 34.3 percent consider medical cannabis to be equal or even more beneficial than current forms of pain relief.

The classification of cannabis as a Schedule I drug needs to be reevaluated before it can become widely used for pain management. And entities such as the Drug Enforcement Administration (DEA) need to understand that imposing strict guidelines on how cannabis is studied only leads to further damage by letting opioids be the pain reliever of choice.


Other Promising Alternative Forms of Nonaddictive Pain Management

As of late 2018, research on nonaddictive opioids was conducted by the Wake Forest Baptist Medical Center. The scientific team led by Professor Mei-Chuan Ko tested their new nonaddictive painkiller, AT-121, in a species of primates known as rhesus monkeys.

AT-121 was designed to block pain signals while also preventing the addictive behaviors that result from traditional opioids. This is achieved through the way AT-121 targets certain receptors in the body. Our “mu” opioid receptor is what allows us to feel relief, while our “nociceptin” receptor is what prohibits the addictive action of opioids. Traditional opioids only target the “mu” receptor, which is why AT-121 may be successful, as it simultaneously targets both. As the researchers observed:

The fact that this data was in nonhuman primates, a closely related species to humans, was also significant because it showed that compounds such as AT-121, have the translational potential to be a viable opioid alternative or replacement for prescription opioids.

The development of nonaddictive opioids such as AT-121 is another crucial component of ending the worldwide opioid epidemic. Once approved by the FDA, clinical trials for humans may begin.


Ending the Epidemic

Whether it be natural medicine such as cannabis that will aid in relieving the epidemic, or new nonaddictive opioids, the changing tides against addictive pain relief are positive. As research continues, more medical breakthroughs are expected to occur, and the market for traditional pain relievers will shrink. For its part, the government should also tighten up regulations in this market and start to limit the damaging effects pharmaceutical giants have on the overall medical industry.