Mitigación del dolor del cáncer en personas con antecedentes de adicción

Welcome to The Breastcancer.org Podcast, the podcast that brings you the latest information on breast cancer research, treatments, side effects, and survivorship issues through expert interviews, as well as personal stories from people affected by breast cancer. Here’s your host, Breastcancer.org senior editor Jamie DePolo .

Jamie DePolo: Hello. As always, thanks for listening.

Pain is a common side effect of breast cancer. The cancer itself may cause pain and nearly all breast cancer treatments, including surgery, radiation, hormonal therapy, chemotherapy, and targeted therapy, may cause some type of pain. If the breast cancer is metastatic, meaning it’s spread to parts of the body away from the breast such as the bones or liver, it may cause pain in those areas.

There are many medicines that can ease cancer pain. Opioids are narcotic drugs that are commonly used to treat moderate to severe pain caused by breast cancer or its treatments. While effective, opioids can be habit forming, which can be a problem for people with a history of addiction.

Our guest today is Dr. Natalie Moryl, a supportive care physician at Memorial Sloan Kettering Cancer Center. Dr. Moryl specializes in treating pain and other symptoms related to cancer and is board-certified in addiction. We’re going to discuss how people with a history of addiction or people who are worried about addiction can successfully control pain. Dr. Moryl, welcome to the podcast.

Dr. Natalie Moryl: Thank you so much for inviting me. I’m very happy to be here and appreciate the opportunity to speak with women and men with breast cancer.

Jamie DePolo: Yes. We’re very delighted to have you because this is an important topic, especially in today’s climate of people are very concerned about addiction, opioids, misuse, fentanyl, all those kinds of things. But to start, I kind of want to back up. Doctors talk about acute pain and chronic pain and I’m not sure everybody understands the differences. So, could you explain the differences between those two for us?

Dr. Natalie Moryl: Sure. In terms of textbook classification it’s very simple. Less than three months is acute pain and more than three months or longer is a chronic pain. However, philosophically, acute pain is the helpful pain. If you touch the stove and it’s hot and it hurts, you’re not ever going to touch it again. So, it helps us. Chronic pain makes us want to decrease activity and nurse our wounds. So, it is not helpful pain, usually, and that is the pain that is most concerning for people living with cancer. 

Jamie DePolo: So, is chronic pain more common with cancer? Is that what you’re saying? I just want to make sure I understand.

Dr. Natalie Moryl: Fortunately, acute pain is more common, and it’s related to either cancer, initial presentation of cancer, radiation, surgery, and we can control that pain easier, usually, and that pain is more common. People who end up with chronic pain, up to 40% of cancer survivors have some degree of pain related to cancer treatment and especially people with advanced cancer with bone metastases may have chronic pain as well. So, these patients that we establish relationship with and continue to treat their pain throughout the lifespan or until pain resolves. 

Jamie DePolo: Okay. That makes sense. You must have read my mind. That was going to be my next question. I was assuming that somebody who had metastatic disease -- especially as you said bone metastases -- that would be more likely to cause chronic pain. So, that makes sense.

Dr. Natalie Moryl: Yes, but some people do have more pain and some people have less pain for the same amount of disease on imaging scans and we don’t exactly understand why that happens, but the gold standard is the patient’s report. If the patient reports pain and we understand where this pain is coming from, this is diagnosed as cancer-related pain and treated very aggressively. Cancer pain treatment is not add-on. It’s not something additional, but it’s essential for cancer care.

Jamie DePolo: Absolutely. Now I’m curious, do oncologists usually treat cancer pain or would an oncologist refer a patient to somebody like you who specializes in pain management?

Dr. Natalie Moryl: Most oncologists are very comfortable treating cancer pain because as I said, that this part of the cancer treatment. Patients who are referred to us, usually, either the oncologist may need additional help with pain diagnosis, or doses become outside the comfort zone for oncologists, or medications that are needed are not something that oncologist is prescribing every day. So, if they feel they need to escalate pain management to a specialist, and usually this is again outside the comfort zone of the oncologist, then we come in.

The other group that is being referred to us sometimes earlier patients either with history of substance use disorder, especially opioid use disorder, or patients who are complaining of severe pain but refuse to take opioid medications because of concern about addiction.

Jamie DePolo: Okay. Yes. That’s exactly what I want to talk about. As you said, opioids are commonly used to treat pain. Huge potential for addiction. There’s also kind of a stigma nowadays I would say around opioids, just because of, I don’t know if we would call it a crisis, but it seems it is a crisis in some areas, of addiction problems, and you know substance abuse is a really sensitive topic. It can be potentially embarrassing for somebody. How do you talk about it? How do you screen for it? How do you help these people?

Dr. Natalie Moryl: That’s a very important question. While we are fighting a war on drug overdoses, cancer patients are supposed to be exempt from limitations on the prescribers’ and CDC guidelines that govern use of opioids for non-cancer pain but, unfortunately, outpatients also are dealing with either lack of access or decreased access to pain management to opioid prescriptions or societal concern about addiction, including families that are worried about addiction, and patients themselves reporting nine or 10 out of 10, which is the most severe cancer pain, and terrified of taking opioids because of what they saw on TV or read on the newspapers online. 

So, it’s very important to educate the patient not only about safe use, storage, and disposal of opioids but also about the risk factors for opioid use disorder, and this is the correct term right now for addiction opioid use disorder, but a lot of people still use the word addiction as well. I personally, when I see a patient in clinic who’s terrified of addiction or stigma of addiction or overdose, I administer a risk tool that is called opioid risk tool and the questions are, do you have personal family history of substance use such as alcohol, illegal drugs, prescription drugs?

Younger patients are at higher risk between the ages of 16 to 45, history of preadolescent sexual abuse, and severe psychological or psychiatric diseases. Depression, obsessive compulsive disorder, bipolar disorder, schizophrenia. So, those can signify maladaptive coping and that also can increase their risk of substance use disorder.

Having said that, the prevalence of substance use disorder is 10 times lower in cancer patients than in general population with pain. So, having cancer in a way is a protective factor. Our patients don’t want to be altered. They want to live every day. Every day counts. They don’t want to be sleepy, high, or altered in any way. So, the goal is very different from patients who cope using opioid medications.

Jamie DePolo: I see. I see. That’s very interesting. When you’re administering this tool is it difficult for patients to be honest about it? Or is it as you said, because the people with cancer that you see they want to control their pain, but they want to live their life? They’re not using medications to cope, so I guess they’re less likely to not admit things. Am I sort of generalizing correctly or not?

Dr. Natalie Moryl: Actually, women in particular tend to get less opioid doses or less opioid prescriptions and I would like to study that more and understand if women tend to underreport their symptoms or they attempt to decline opioid medications because they are so busy managing the family or other work. So, we’re not sure where this is coming from, whether it’s clinician-driven or women-driven issue. To answer your question about sensitivity of patients during these discussions, I’ve never heard…I’ve been working with the cancer pain patients for over 25 years and have never heard people push back because when patients come in this is already on their mind. 

So, when I use this tool, and often I use to explain to the patient look you have very few risk factors for addiction and I will be watching you, and if I see any concerns, any aberrant drug use, if I have any doubts, I will directly address this with you and if you have any craving, any withdrawal between the doses, please be very direct with me. I’m here to help you. I’m on your side. I’m here to help you through this treatment and we’ll do it together. So, I think it’s usually very well-received, provided both parties -- the clinician and the patient -- are open and very direct. That’s very helpful.

Jamie DePolo: Okay. That was very helpful. That’s good information to know. 

Dr. Natalie Moryl: I would like to add one more thing. There is a big difference between opioid withdrawal and addiction. If somebody takes chronic opioids for, let’s say, post mastectomy pain syndrome, and this happens after mastectomy and sometimes women have chronic pain related to the nerve cutting during the surgery, and that person decides to stop opioids abruptly, there will be withdrawal, which is dysphoria, bad mood, increasing abdominal pain, diarrhea, nausea, runny nose, joint pain. That is not addiction. That is physiological withdrawal. That also happens with other medications if you take them for a long time and then suddenly stop. 

Addiction is something different. Addiction is aberrant use of a substance characterized by loss of control, craving, compulsive use. It’s not the person’s choice. If it’s there, he’s going to take it. Preoccupation with getting it and continued use despite harm. As one of my patients with comorbid…the person who has cancer, cancer pain, and substance use disorder, he explained it this way. First you take it and then it takes you. So, it’s basically loss of control. That’s addiction and those two are very different and it’s very important not to over-diagnose addiction and not to self-diagnose addiction when there is none.

In fact, recently we published a study when we looked at one of the screening tools that was recommended by one of the national organizations to screen for aberrant or inappropriate drug use in patients with cancer and we clearly showed that using that tool was associated with dramatic overdosing of addiction. So, this is relatively new field and it’s growing and hopefully we will be more equipped to discuss addiction, prevent addiction, and help people with active addiction or history of addiction to get through cancer treatment and not to be stuck back on controlled substances or medications of addiction.

Jamie DePolo: Thank you for explaining that difference. You specialize, you have special training in addiction or substance abuse disorder, whatever the correct terminology is. Do you think most oncologists understand the difference as you said between addiction and withdrawal symptoms? I’m assuming most patients don’t really understand because they’re probably thinking if they start having the effects of withdrawal they’re thinking, “Oh my gosh, I’m addicted.” But do you think most oncologists understand that difference?

Dr. Natalie Moryl: I want to say yes but I can’t really say for sure, and I will give you some information. So, there was a study that was published in 2021. There was a survey of 1,144 American cancer centers. Of them, less than half offered any chemical dependency services, any addiction services, with some of them limited to alcohol alone. So, cancer centers do not have specialists who are trained to do addiction. And another survey asked clinicians who are working with cancer patients how comfortable they are treating addiction, treating patients with addiction, and 69% expressed concerns about addiction in patients with cancer. 

Sixty-three percent felt that they worried about risk of under-treatment of cancer pain because of this concern, and only a third reported adequate knowledge and confidence in caring for patients with cancer and opioid use disorder. So, we have a lot of work to do. We need to support our staff, educate clinicians, and establish national and institutional guidelines for cancer pain management. It’s very important to reduce stigma in patients. We really need to advocate and destigmatize substance use disorder it is another medical condition like diabetes. 

We don’t marginalize patients with diabetes and cancer pain. So, we really need to advocate, include patients with addiction, and provide additional support and services to make sure we’re not only treating cancer, cancer pain, but also treat addiction or substance use disorder at the same time.

Jamie DePolo: Yes. And just information, I’m going to thank you at the end of the podcast but I’m going to thank you right now because I think this is so important just talking about it and educating people can  help remove some of the stigma. Obviously, it’s not going to happen overnight, but people need to know that, you know, they shouldn’t be stigmatized. It’s a treatable condition.

Dr. Natalie Moryl: Yes, and if anybody has history or anybody is in any structured substance abuse program, such as methadone maintenance program, on Suboxone for prior history of substance abuse, in Alcoholics Anonymous, in Narcotics Anonymous, I would recommend that they, again, have a direct conversation with the oncologist or pain medicine specialist and ask their substance use disorder provider to advocate for them, to work together with the pain management, whoever is managing the pain of this patient, so that to make it very transparent that there are two medical conditions and both are being addressed.

Jamie DePolo: Okay. What in your practice, what are the pain control options for somebody who has a history of substance abuse or is currently in treatment for substance abuse? I don’t know if they have the ability to take opioids, if there’s something else that can be used. How do you treat that?

Dr. Natalie Moryl: There are a lot of different modalities, including physical therapy, exercises, massage, acupuncture, psychotherapy, or supportive counseling.

As I said, this chronic pain, especially nerve pain, neuropathic pain, really affects the whole person and kind of separates you from your community or your family. Acetaminophen, non-steroidals, like Ibuprofen, medication like that, topical medications. Antidepressants I use often, not because we think the person is depressed, but because pain travels using the same pathways and the same chemicals as depression. They really travel on the same pathways in the nervous system in the body. So, antidepressants are often helpful. Anti-seizure medications can also be very helpful for pain, especially neuropathic pain.

Having said that, if the pain is severe, we often consider starting with opioids. According to National Comprehensive Cancer Network guidelines, because most of these medications will take some time to work and if we have a person who comes in with severe pain, opioids are standard of care. It’s not uncommon that in the hospital setting this would be the first step.

Jamie DePolo: Okay. Can I ask you about, there’s a system I’ve heard called TENS where it’s kind of an electronical stimulation for the nerves to ease pain. Do you use that at all?

Dr. Natalie Moryl: Yes. We use it very frequently. The patient comes in and is trained how to do that at home. It’s a small machine. You attach electrodes. It’s similar to getting a cardiogram and you can regulate the current and use it as needed during the day and during the night. It can be very effective for mild neuropathic pain, mild to moderate pain due to nerve damage. 

Jamie DePolo: Okay. Thank you. I wanted to go back, you said that opioids are the standard of care. What if a person is very concerned and doesn’t want to take opioids? Is that their choice? Would you recommend that they do? What would you recommend instead? How do you handle that?

Dr. Natalie Moryl: That’s a very interesting question. Eight years ago, maybe 10, 15 years ago, physicians used to say, don’t worry if you had addiction because I’m giving you that Percocet or oxycodone for pain and I know what I’m doing and because it’s prescribed by a physician it’s okay. You should be okay. So, we don’t do it anymore because we really need to work with individual patient, and there are people who will go through addiction and lose everything and really hit their rock bottom and then when they are able to stop using, let’s say heroin or oxycodone, they are so determined never to cross that line again that they refuse to take opioids and then we work with that patient. 

We may use all other modalities other than opioids and we make a plan for if pain becomes unbearable, what are we going to do? And again, how do we manage both pain and addiction at the same time?

As I said, if there is a fear of addiction, we do assess the patient. We counsel the patient about his relative or her relative risk factors for addiction using tools like opioid risk tool, collecting information about the personal and family history and most often the patient is willing to try recommended medications as a trial and then work with us. It requires a relationship. It requires consistency. It requires commitment on both sides. And again, our message is: We’re on your side. Opioid use disorder is a medical condition, and we need to treat both. 

Having said that, stigma of opioid use disorder is an uncomfortable topic for both clinicians and patients. So, ideally we need to provide safe space to discuss the issue and plan how to move forward. I also want to use this forum to maybe suggest a patient advocacy group. Again, because it’s such a sensitive issue, it’s not discussed much. There is a lot of secrecy about that on both sides, the clinicians and patients, with some of negative outcomes that we know about. So, patient advocacy group for patients with breast cancer and concurrent addiction or past addiction I think would be very helpful because I know that breast cancer societies is very powerful, very verbal and very well received and supported.

Jamie DePolo: Yes, thank you. I’m wondering, you talked a lot about people with a history of opioid abuse but what if somebody, say, abused alcohol or cocaine, some other substance, is your approach the same even though it’s not an opioid abuse situation? 

Dr. Natalie Moryl: So, use of cocaine does not mean addiction. It depends on how the person is using cocaine. It is an illegal substance and we don’t want people to use it, but if this is not loss of control and if the patient can manage treatment and function in society, this is not called addiction per the medical definition. Treatment of cocaine addiction is a lot more complex and more difficult than opioid use disorder, treatment of opioid use disorder. That’s about cocaine. It’s not as often as what you mentioned, alcohol use disorder. So, alcohol abuse or alcohol use disorder is much more common but it’s interesting that most people are able to quit alcohol without any physician or going to an Alcoholics Anonymous or doing therapy or anything. 

It’s really in face of cancer treatment, in face of diagnosis of cancer, we often see that people are very motivated to abstain from alcohol or cut down on alcohol in order to get the best chance of survival, of going through treatment, because clearly any addiction including alcohol, if it’s active and ongoing, may interfere with treatment. The patients may not show up for appointments. May be non-compliant with treatment. They may not come to be checked for side effects of treatment, not even mentioning that chronic use of alcohol is detrimental. It worsens prognosis for breast cancer as far as I know. I’m not an oncologist but based on my knowledge as physician.

Jamie DePolo: Okay. Thank you. And then finally I’m wondering if you see any people like this, they themselves don’t have a substance abuse disorder or any history of it, but maybe they have a family member, a spouse, a child, and they are very concerned about any and all of the medicines that are going to be prescribed for them for pain. I’m assuming you would go use the tool and talk to them about their risk, but is it any different for them without that actual history?

Dr. Natalie Moryl: It depends. Immediately what I’m thinking about right now is I would be discussing safe storage, because having somebody in the home who has substance use disorder who, let’s say, has been using heroin or oxycodone and is now in remission or not in remission, let’s say a child, an adult child who has that and lives with a parent who is now struggling with breast cancer pain, would recommend the person buy a safe, keep medications locked, safe, away from the family member with history of substance use disorder. Most of the overdoses occur among non-patients and I’ll explain that. 

The drug overdoses by prescription pain killers happen not between the clinician who prescribes the medication and the patient who takes the medication. Usually the clinician prescribes, patient brings it home, and then either somebody steals the medication or somebody borrows medication and then the kind of third-line of people experience drug overdose. So, safe storage in a locked space away from others, definitely away from the medicine cabinet in the bathroom because that’s the only place in your house where stranger can walk in and look for it. 

So, things like that are very, very important, both for the patient, for the family and caregivers, and also for society. So, that is the way we can decrease drug overdoses in society. Another thing, at Memorial, we’re now prescribing naloxone to everybody we’re giving chronic opioids to. 

Jamie DePolo: Just so they have it on hand?

Dr. Natalie Moryl: Actually, also most patients think it’s a great idea to have it on hand if there is any accidental overdose either in the household or on the street, again to help society decrease the drug overdoses.

Jamie DePolo: That’s very interesting and I’ll ask you just to explain just in case anybody isn’t familiar with what naloxone does or how it’s prescribed if you could explain that. 

Dr. Natalie Moryl: If somebody overdoses on drugs and EMS comes, they give an injection of medication that counteracts the effect of a narcotic, of opioid, and the person wakes up within seconds from listless body, unresponsive to pain, the person just sits up within seconds. It’s actually amazing. I mean I’ve done it in my clinical practice, but it is amazing transformation. You can achieve the same by using either injectable naloxone or with prescribed naloxone spray, which is like regular nasal spray and you can spray it in the nose of a person and again within seconds, literally, like five, 10 seconds the person sits up, wakes up, and if that happens you also need to call 911 because naloxone only works for half an hour but it’s enough to save life while EMS is on the way.

Jamie DePolo: Okay. Thank you. Yeah. That’s very interesting that you prescribe it. I can see where that would reassure somebody, especially, say, if they were somebody who had difficulty opening childproof caps and maybe had to flip the cap over and use the non-childproof part and were worried about young children coming over. So, that’s a very interesting development.

So, finally, I guess I’m going to ask you to sort of reemphasize the whole idea of always discussing this with your doctor if you have cancer pain and bringing up any concerns, and if you could just sort of reiterate for us again how important this is to break up this stigma surrounding opioid use.

Dr. Natalie Moryl: Yes. So, pain management during cancer treatment and after cancer treatment is essential part of cancer treatment. If the patient has pain and opioid use disorder, we need to address both. Both are medical conditions that unless you manage them, the person cannot successfully be treated for cancer. Both uncontrolled pain can interfere with successful outcomes and uncontrolled opioid use disorder can interfere with successful outcomes.

The last thing I just want to again suggest patient advocacy groups to focus on patients with concurrent pain and opioid addiction because these patients really should not be marginalized. 

If anything, they require higher doses of opioids to control the same pain because they are more sensitive to pain and they require higher doses to achieve the same pain control. They need more support and they need more support during cancer treatment and after cancer treatment to come off opioids, especially as what I shared, most cancer centers do not have structured treatment for these patient population.

Jamie DePolo: Dr. Moryl, thank you so much. I really appreciate your insights on this very sensitive topic and I’m hoping that it will break down some of the stigma. Thank you. 

Dr. Natalie Moryl: Thank you. 

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