Pain medicine as a separate subspecialty is in its infancy, only fairly recently being
recognized as such by the American Board of Medical Specialities.1 As it continues
to find its way in the ever-changing world of medicine, terminology becomes an important
consideration. Terms carry tremendous impact: for example, when a patient is told
he or she has “cancer”, the impact emotionally will undoubtedly make further explanation
difficult. To patients and their families, the word “cancer” has the effect of being
hit with an emotional baseball bat. In the pain world, there was a recent, albeit
failed, attempt to change the name of pain specialists to “algiatrists”.2 It was thought
this would help define what such specialists did as opposed to other specialties.
Accordingly, terminology matters, yet little attention has been paid to the terms
we use to categorize and diagnose our patients. “Chronic cancer pain” and “chronic
noncancer pain” are replete in the literature; however, the distinction here is actually
obscure. A patient with pain from a cancer etiology has no different physiology than
a patient with pain of noncancer etiologies.
Much of the development in the literature defining these two different categories
came from the move in the 1990s to change the way chronic pain in patients without
cancer was treated.3 It was postulated that if opioids worked for pain in cancer patients,
then we should accordingly use these same agents in those with pain not related to
cancer. Further, it was posited that these patients were suffering, and opioids were
one more tool to help ease their suffering. Those using the term “chronic noncancer
pain” were in two camps: those who felt that opioids should be avoided in patients
without cancer, and those who felt they were yet one more tool for the treatment of
Interestingly, these claims are primarily philosophical, rather than medical or physiologic.
As mentioned, pain mechanisms do not discriminate between cancer and noncancer pathophysiology.
Patients with cancer or those without cancer have essentially identical pain-generating
physiologies, and thus the same mechanisms for the development of their pain (eg,
inflammatory pain in a cancer patient will be the same physiological process as in
a noncancer patient). Further, cancer patients are living longer and their original
pain generators become chronic pain in and of themselves, little different from patients
without cancer. Frequently, the claim is that those without cancer should not have
to undergo the side effects of opioids, and they should not have to take on the potential
burden of iatrogenic addiction. Furthermore, they note that there are few data to
support opioid use in these patients. Interestingly, the data on the use of opioids
in cancer patients suffer from the same criticism, lack of long-term data, and lack
of data demonstrating increased functionality.5,6 However, there is frequently the
caveat that those with cancer should receive opioids, which represents a rather strange
dichotomy. This line of reasoning can be interpreted as follows:
We do not care if the patient with cancer suffers from side effects, fatal or otherwise
from opioids, and/or develops a substance-use disorder. But we do care if a patient
with chronic “noncancer” pain develops these problems.
We do not care if patients with noncancer pain suffer; they are not “worth” the effort
of adding opioids to their regimens.
The purpose of this commentary is not to develop a foundation for increased use of
opioids, nor are we suggesting that opioids be used more in patients without cancer.
However, a thorough evaluation, followed by a clear delineation of the pain generators,
will help define potential treatments, which may (or may not) include opioids. This
should not be based on philosophical biases, or at least those biases should be stated
openly up front as having no scientific foundation. Obviously, given other considerations
associated with initiating chronic opioid therapy and the need for continued reevaluation,
opioids may not be the best option. However, simply the label of “chronic noncancer
pain” should not immediately place that patient in a category that eliminates certain
potential therapies, eg, opioids.
Therefore, we suggest that the terminology be changed to help us better to understand
and treat all of our chronic pain patients who are suffering. Categorization into
“cancer” and “noncancer” does not help us better understand mechanisms underlying
pain or guide us to appropriate treatment strategies. Further, these categories are
philosophical and neither scientific nor of clinical relevance. Perhaps a more prudent,
less charged set of terms would indicate the origin and generator of the pain. Therefore,
a patient with chest-wall pain from radiation due to breast cancer would be labeled
“chronic pain of breast cancer radiation-treatment origin”. The patient with pain
from an advanced spondylolisthesis would be diagnosed with “chronic pain of spondylolisthesis
origin”. The goal here is to continue to be patient-focused, relieve their suffering
(instead of contributing to it), and help improve their lives. Language, in and by
itself, is obviously not a “cure” for pain. However, clinicians and society as a whole
need to appreciate language’s potential to further stigmatize and marginalize all
patients suffering from chronic pain, and accordingly we are obliged to work toward
a more language-neutral system of pain classification.