Palliative specialists like Dr D’Olimpio are getting pushback for the opioids they do prescribe, even when indicated for cancer pain. Insurers and pharmacists frequently refuse to dispense as written — arbitrarily limiting coverage before receiving a letter of necessity, insisting other, less-effective therapies be tried first, or limiting quantities or refills.
“We have been facing a sort of a backlash, a pendulum swinging in the wrong direction regarding availability or accessibility of these drugs,” Dr D’Olimpio said. He wants guidelines, such as a 7-day limits on pain prescriptions, be better codified to separate the problems that cancer patients have from the general population.
The US Department of Health and Human Services’ Pain Management Best Practices Inter-Agency Task Force report noted there is no one-size-fits-all approach to pain management, but instead, recommends a multipronged approach, including other medications, nerve blocks, physical therapy, and other modalities.4
But there aren’t a lot of good options to manage pain currently available, many experts say.
As people live longer with more chronic and serious conditions, including cancer, the need for palliative care specialists is growing. There are an estimated 15 million cancer survivors in the US, and the number of those living with chronic pain is increasing — including many who live with the effects of pain from cancer or its treatment.5
Yet, there are only about 2000 board-certified palliative specialists in the US, according to Dr DelFabbro. And even among this small cohort, there is a need for increased training, specifically in cancer pain management. “Pain expression is a multidimensional issue in cancer, including psychological and spiritual distress.”
Sometimes the pain complications after treatment can be as significant or worse than the disease itself. Dr D’Olimipo’s team has seen an uptick in fibromyalgia among women treated for breast cancer — and fibromyalgia is often permanent. “We’re having a lot of trouble treating it. It is opiate resistant; we’re trying to understand it, neurologically.”6
For others, cancer treatment will result in chronic neuropathic pain. It’s something palliative specialists like Dr D’Olimpio see almost daily, and can be quite debilitating. However, there are few good ways to treat this. “Opioids for that type of neuropathic pain is very dicey,” he said. “Those patients have to be monitored very carefully.” He generally uses specific types of highly individualized “cocktails” he finds have worked over the years.