Taking Action to Ease Suffering: Advancing Cancer Pain Control as a Health Care Priority
Authors: O. W. Brawley, D. E. Smith, R. A. Kirch
Journal: CA A Cancer Journal for Clinicians (2009)

“We don’t beat the Reaper by living longer. We beat the Reaper by living well.” Professor Randy Pausch made this declaration in his May 2008 address to graduates at Carnegie Mellon University just months before his death last September. His cancer battle and his personal priorities, as he described in his Carnegie “Last Lecture,” resonated with the public in a remarkable way and captured the heart and soul of what most patients believe and want. There is no doubt that persons diagnosed with cancer want to be cured or, at least, achieve a long remission from disease. But setting aside prognosis, most patients and their loved ones also want to be able to live well with their cancer—whether that life lasts weeks, months, or years. They also want to have comfort, dignity, and relief from pain as they face the end of life. Pain remains one of the most feared and burdensome symptoms for cancer patients and survivors. Nearly all cancer pain can be relieved, yet the prevalence of pain and its undertreatment has remained consistently high and largely unchanged for more than 4 decades.1 Still more troubling, significant pain treatment and access disparities in medically underserved and socioeconomically disadvantaged populations continue to be documented.2–5 Many effective pain medicines and nondrug therapies are available to bring pain relief to cancer patients so that they can complete scheduled treatments, continue to work, and enjoy the company of family and friends.6,7 But significant pain assessment and management deficiencies are consistently reported in the clinical settings where cancer patients are seen.8–10 Open communication with health-care professionals about pain, the medications for it, and other methods available to treat it is essential to relieve symptoms and improve quality of life. Opioid analgesics, generally recognized as a mainstay of treatment for moderate to severe cancer pain, pose particular policy challenges for practitioners. These controlled substances tend to trigger a dueling policy debate among physicians, who must consider the interface between providing pain relief and curbing diversion and misuse.11,12 Health care professionals are increasingly being recruited to fight on both fronts, but they are armed with very little clear and practical prescribing guidance from the Drug Enforcement Administration (DEA) or state medical boards.13 Adding to the challenge, the growing misuse of prescription pain medications appears to be receiving more frequent attention, including in the popular press. USA Today, and several other media outlets, covered the White House Director of National Drug Control Policy’s release of the DEA’s National Prescription Drug Threat Assessment this May and reported that unintentional deaths involving prescription opioids increased 114% from 2001 to 2005 (8,500 deaths nationwide), with pain relievers identified as the most widely abused and diverted, particularly among teens. According to this DEA report, 1 in 5 new drug abusers indicated that they began their illicit drug use with potent opioids such as oxycodone, hydrocodone, and methadone.14 The Food and Drug Administration (FDA) also has had its scope expanded and chose to carve out a role in drug control through its ongoing Risk Evaluation and Mitigation Strategy deliberations for cer-