Pain Management Barriers Nurses Can Help Cancer Survivors Navigate

Oncology nurses have an important role to play in addressing cancer survivors’ unmanaged pain, a frequent and debilitating problem, according to speaker Victoria K. Marshall, PhD, RN, assistant professor at the University of South Florida College of Nursing. Marshall spoke about pain management and the barriers to and benefits of safe opioid use by patients with cancer and described an exploratory pilot study of opioid prescribing for these patients, on the Oncology Nursing Society (ONS) Bridge live virtual conference.

“Regardless of cancer type or treatment … chronic pain can impact individuals and their quality of life for years posttreatment,” Marshall said.

Chronic pain, neuropathy, arthralgia, and myalgia are common challenges for survivors, causing inadequate sleep or nutrition and declines in functional status and quality of life. An aging population, earlier detection, and advances in cancer care mean the problem will become more widespread throughout this decade.

“Cancer survivors have unmanaged pain due to a multitude of both internal and external factors,” Marshall explained. “Cancer survivors are caught between the discharge of oncology care and the reluctance of the primary care provider to provide ongoing pain management. They face barriers related to opioid access, including prescriber perceptions, new regulations specific to prescribing opioid medication, and pharmacy-related policies.”

Barriers to pain care include societal attitudes about pain control, including biased assumptions about “drug seeking” among patients based on their racial and socioeconomic backgrounds that drive disparities in care. Providers and healthcare systems frequently perpetuate these disparities, but patients themselves also commonly forego or alter prescribed pain medication over fear of opioid addiction and side effects, she noted.

Opioids are frequently an initially prescribed treatment for cancer survivors’ pain, but the opioid dependence and overdose deaths epidemic has led government and professional medical organizations to emphasize safe opioid prescribing. That is necessary but unfortunately, it also comes with stigmatizing misperceptions about patients who use opioids for pain management.

Marshall described a small, nonrandomized exploratory pilot study of opioid prescribing to 25 adult cancer survivors in southern Florida. “We completed individual in-depth qualitative interviews with cancer survivors who were prescribed an opioid medication for cancer related pain,” Marshall explained. “We distributed flyers throughout the community including the Tampa Bay Community Cancer Network, which serves underserved communities and vulnerable populations. We also used some social media websites.”

To participate in the study, patients must have had a diagnosis of cancer, have completed cancer treatment within the last 5 years, be cancer free, and have been prescribed opioid medication for cancer-related pain or treatment, and be at least 18 years old. Participants were interviewed by phone for 30 to 45 minutes, using a semi-structured script that captured patients’ understandings and demographics.

Nearly all (96%) patients were female, and most (87.5%) had breast cancer. Most (72%) had undergone surgery, chemotherapy, and radiotherapy. The mean age of participants was 56 years. Approximately one-third were White, nearly half were African American (48%), and 12% were Hispanic.

Overall, pain was not well controlled for these patients, and pain management referrals frequently took several weeks, Marshall reported. Cancer survivors were challenged about the validity of their reported pain levels, and others did not mention pain to clinicians for fear of being perceived as drug-seeking.