Chronic pain after cancer

A recent letter published in JAMA Oncology reported data from a survey of 4,526 people in the 2016-2017 National Health Interview Survey. Approximately 1 in 3 cancer survivors, and that means about 5 million Americans, reported that they are still in pain three years after completing treatment. Even more distressing, more than 16 years after diagnosis, that statistic held.

Any conversation about pain and pain management now necessarily includes discussion of pain meds, specifically of opioids, and worries about addiction. There is a competing view that cancer pain may be under-diagnosed and that some cancer doctors, both oncologists and palliative care specialists, may be more cautious about using narcotics than is necessary.

I am not a pain specialist so quickly can feel that I am over my head in this conversation. It does not seem wise for someone to be dependent on opioids for 16 or more years, and it certainly seems appropriate for strong pain meds to be available after surgery, during episodes of acute pain, and during the end of life. Especially during the last weeks or months, there is no defensible reason to be concerned about addiction; all attention should be focused then on QOL and comfort.

Why would someone still be in pain so many years after cancer treatment? The answers are often vague and unclear, but include nerve and tissue damage from surgery or radiation and possible small fractures. Surprisingly, the researchers also found that, among survivors younger than 65, people with private health insurance were slightly more than 1/3 less likely to report chronic pain than those who received Medicaid. They also found that reports of chronic pain were more common among Americans who had a less than high school education and a low household income. These last facts scream out for attention.

Unfortunately, it does not surprise me that chronic pain, often inadequately managed, is more common among people who are struggling with other life problems. This is one more indication of the disparities of income and opportunity and resources and support in our country. We all know that pain sometimes has a psychological component. If someone is already very worried about other issues, it makes sense that less emotional energy is available to contend with pain.

Someone who has pain, but who also has access to excellent medical care and is generally well resourced is likely to be better able to manage and control the problem. I am thinking of several women with whom I am now working who do live with chronic pain years after cancer surgery. For all of them, the reasons seem to be related to nerve damage from surgery and subsequent build up of scar tissue that has exacerbated the problem. Not to minimize their pain, but they all are making active and good use of resources and treatment. In addition to counseling with me, they are working with physical therapists, receiving acupuncture or other complementary treatments, staying well informed and trying to focus on the positive parts of their health and lives.

If you are having chronic pain several or more years after cancer treatment, please be sure that you are exploring all possible avenues of help. In addition to speaking with your cancer doctors and your PCP, you might benefit from a consultation with a pain specialist and/or a palliative care physician. Biofeedback and hypnosis and acupuncture and talk therapy may all help. Please try.

Read more about the Pain Center at BIDMC here.