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A Physician’s Perspective on Pain Management

Second Issue 2013 series: Conquering the Cancer Care Continuum

Pain management is a critical component of patient care in any medical specialty, but particularly in oncology. The 2 case presentations and discussions by Beth Faiman and Steve Stricker are common cases in which pain management is integral to the overall care of the patient. As a medical oncologist specializing in gastrointestinal malignancies, I have to consider pain due to a patient’s metastatic disease, postoperative pain, and pain from treatment (eg, oxaliplatin-induced neuropathic pain). As Ms Faiman discussed, the type of pain needs to be considered when determining a relief strategy. However, sometimes pain can occur through multiple mechanisms, and a multipronged approach is required. I concur with both authors that the gamut of options needs to be considered and individualized to patients, including medications, localized intervention (eg, celiac nerve block or radiation), and surgery (eg, palliative resection of the mass contributing to the pain or kyphoplasty). Further, I would add consideration of complementary strategies that, though less tested in randomized controlled trials, seem to have benefits in certain patients, including acupuncture, massage therapy, relaxation therapy, and others.

Pain management requires a team approach. Pain and palliative care services are increasing across academic and community practices as well as hospitals. As a medical oncologist, these services have become invaluable partners in the management of pain for my patients. However, I also am a strong believer that every provider for these patients needs to have an understanding and comfort level with pain management. The Massachusetts Board of Registration in Medicine has recognized this need, and since February 2012, all physicians who treat pain have been required to complete at least 3 hours of continuing medical education in pain management. At my cancer center, we have annual training in pain management. In my own practice, my team (including me as the medical oncologist, the nurse practitioner I work with, and my group’s program nurses) are the frontline managers of pain medications for our patients. However, if the pain is not well controlled after multiple adjustments to long-acting and rescue medications or narcotic rotation is required (and after consideration of procedures that may help with pain control), I will involve our pain and palliative care providers to help comanage these patients. These partnerships have proven to be very successful for my patients both to improve quality of life and to continue other therapies for these patients as their performance status improves.

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