The management of chronic pain, both cancer-related and not, has gone through several iterations. In the 1980s and 1990s, there was a push against the undertreatment of pain and the call to designate pain as the Fifth Vital Sign. This, unfortunately, led to the over-prescription of pain medications, especially opioids, and the opioid crisis.
Today, clinicians better recognize the causes of chronic pain and realize that pain is multifactorial — physical, emotional, and spiritual. To help navigate the changing landscape, The Clinical Advisor’s Director, Nikki Kean, spoke with Rebecca B. Jones, PA-C, MSPAS, who presented at the recent American Academy of Physician Associates (AAPA) annual meeting in New Orleans, Louisiana. Ms Jones is a physician associate working at Methodist Health System in Fremont, Nebraska. Ms Jones has worked in a cancer clinic, home-based palliative care program, and inpatient palliative care.
Ms Kean: Traditionally, cancer-related pain was often managed separately from chronic pain. In palliative care patients, clinicians are typically less hesitant to use opioids.
Ms Jones: In my presentation, I address cancer-related pain and noncancer pain. I previously worked in an oncology clinic providing palliative care, so I shared insights regarding both clinic- and hospital-based management of cancer pain.
In the outpatient clinic setting, many palliative care patients are initially prescribed opioids with an expected prognosis of a few years. However, with advancing oncologic therapies, patients are living longer with cancer. Consequently, we must reevaluate whether maintaining patients on long-term opioid therapy makes sense or if there are better alternatives.
Ms Kean: If a patient on chronic opioid therapy requests to taper off their medication, how do you initiate that conversation, and what alternative modalities do you offer?
Ms Jones: Many audience members were primary care physicians (PCPs) seeking alternative strategies to help patients they inherited or who have been on long-term [chronic] opioid therapy. They were looking for safe management options and non-opioid alternatives.
I start by asking the patient to tell me more about their reasoning for wanting to discontinue opioids. I am certainly supportive of the goal, but understanding the underlying driver is essential. Often, the motivation stems from side effects, a loss of [analgesic] efficacy, or an interest in an alternative therapy they have heard about.
If a patient has been on chronic opioid therapy for a year or longer, we discuss that a gradual taper is required. There is no hard-and-fast rule for tapering, but [guidelines] suggest reducing the dose by no more than 10% per month for long-term users. The exact rate depends on the severity of their side effects and whether they are not getting much benefit from the opioid.
When discussing non-opioid alternatives, I gather details about the specific character of their pain and evaluate their comorbidities. If I am thinking about an alternative systemic medication, I look for agents that can safely manage concurrent comorbidities, allowing us to treat more than one condition simultaneously while minimizing the side effects.
Ms Kean: At that stage, you try to differentiate whether the underlying etiology is neuropathic, inflammatory, or something else?
Ms Jones: Exactly. We must also determine whether the pain is purely physical or if there is an element of spiritual or social pain as well. If a psychological component is present, it is highly appropriate to involve behavioral health colleagues. I also ask patients, “Who do you usually turn to for support?” to determine which interdisciplinary resources make the most sense for them.
Ms Kean: I am interested in the concept of spiritual pain. Does this present primarily in trauma patients, or is it widespread across the general patient population?
Ms Jones: It is quite common. I shared a case example in my lecture regarding opioid titration. We had an inpatient whose opioid doses were going up and up. Eventually, the patient developed opioid-induced neurotoxicity but continued to report severe pain.
It was not until we explored the broader clinical picture that we identified profound spiritual distress regarding end-of-life and what to expect. The patient also experienced a lot of social pain [in terms of] feeling like there were things they still wanted to share with their family. We began by addressing these underlying issues — which did not require specialized psychological training, but simply acting as a facilitator and sounding board—opening up the door for them to communicate with their family, and we answered their questions about end of life. Addressing that spiritual and social distress is what helped with their pain.
Ms Kean: Educating patients about the distinct sources of their pain seems crucial at that stage. Are those difficult conversations to navigate in clinical practice?
Ms Jones: I could certainly see how it would be difficult. I think at the same time, a lot of the patients, at least by the time they’ve seen me, they’ve already been dealing with their pain for an extended period. Our clinical focus is helping them identify strategies to live a functional life alongside their pain; patients generally understand that we cannot completely eliminate it.
In that sense, we help them identify their purpose despite the pain, which directly addresses the spiritual component of care. Keeping the conversation broad, open, and saying “tell me more” allows patients to feel heard and understood. Validating how chronic pain impacts their life is a powerful therapeutic intervention in itself.
Addressing profound spiritual and social distress serves as a powerful therapeutic intervention that can alleviate the psychological burden and helplessness experienced by patients with chronic pain.
Ms Kean: Alleviating the psychological burden and helping them find purpose despite chronic pain shows the patients that pain doesn’t have to control them.
Regarding the practical alternatives you outlined in your presentation, what options do you offer, and what is their clinical efficacy?
Ms Jones: We discuss safer opioid alternatives, such as buprenorphine. While buprenorphine is an opioid, it exhibits a ceiling effect on respiratory depression and possesses a more favorable side-effect profile. We also discuss methadone for specific indications.
Non-opioid alternatives include corticosteroids, gabapentinoids, and the off-label use of serotonin-norepinephrine reuptake inhibitors (SNRIs) and tricyclic antidepressants (TCAs) to help with neuropathic pain. I also reviewed compounded topical pain creams and other localized options.
I also talked about non-pharmacological modalities, such as acupuncture and mobile health apps, including meditation apps. There are also individualized pain management applications that function as digital pain diaries. Patients track how pain impacts their daily function and document the efficacy of various interventions. Reviewing this data with their provider allows patients a greater sense of autonomy and control over their pain management.
Ms Kean: So tracking data can serve as a positive distraction?
Ms Jones: Yes. In chronic pain states, the central nervous system undergoes [neuroplastic modifications] that perpetuate the pain cycle. Interruption often requires targeted cognitive distraction techniques, like mindfulness meditation and reframing the pain.
Ms Kean: I once worked with a clinician who recommended rocking chairs for chronic pain management, noting the rhythmic motion was both soothing and served as a physical distraction.
Ms Jones: In talking with patients, I hear how much distraction can help. Chronic pain patients frequently note that their pain escalates at the end of the day when they are resting in bed. Bedtime is when their pain is the worst.
Ms Kean: Pain management has transitioned from being historically under-treated to o