Lie: “Cancer Pain and Non-Cancer Pain Should Be Treated Differently”

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💥 Debunking the Lie: “Cancer Pain and Non-Cancer Pain Should Be Treated Differently”

⚠️ THE TRUTH:

Pain is pain. There’s no scientific reason to treat it differently based on whether someone has cancer. Yet this false divide has been embedded in guidelines, laws, and policies — not because of medical evidence, but because of stigma, litigation strategy, and political convenience.

📌 TL;DR

  • There’s no scientific or physiological difference in how opioids treat cancer vs. non-cancer pain.
  • The cancer vs. non-cancer distinction was invented by PROP and others to support restrictive opioid policies and litigation.
  • The FDA rejected the distinction as unscientific — but it still made its way into guidelines and laws.
  • Even cancer patients are now being denied opioids.
  • This arbitrary divide must end. Pain is pain.

📚 Table of Contents

  1. The Myth of a Medical Divide
    • Where the Split Began: AMDG, CDC, and Policy Language
    • PROP’s Citizen Petition to the FDA
    • Who Signed the Petition — and Why It Mattered
    • Public Pushback and FDA’s Official Rejection
    • Why the Distinction Persisted Anyway

  2. What the Science Says
    • “A Distinction Without a Difference”
    • Schatman & Peppin on the Flawed Terminology
    • The Rise of “Cancer Pain” as a Policy Term
    • Why the Diagnosis Doesn’t Change the Physiology

  3. The Real-World Harm
    • April’s Story: When Even Cancer Isn’t Enough
    • 2024 Studies: The Pendulum and UW Blog
    • Declining Opioid Access and Rising ER Visits
    • How Guidelines Are Misapplied to Cancer Patients
    • Cancer Patients Facing the Same Stigma

  4. What Needs to Change
    • Eliminate the Distinction from Policy and Practice
    • Stop Prosecuting Based on Diagnosis
    • Let Clinicians Treat the Patient in Front of Them
    • Hold PROP Accountable for the Harm
    • Build a New Framework Centered on Compassion and Evidence

  5. Citations

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1️⃣ The Myth of a Medical Divide

📍 Where the Split Began: AMDG, CDC, and Policy Language

Historically, pain was treated based on its severity, not its cause. Guidelines didn’t divide patients into “cancer” and “non-cancer” groups until the mid-2000s.

  • In 2007, Washington State’s AMDG released the Interagency Guideline on Opioid Dosing for Chronic Non-Cancer Pain. It was one of the first major documents to introduce this split.

  • The 2016 CDC Guideline followed suit, stating opioids should be reserved for “pain outside of active cancer treatment, palliative care, and end-of-life care.”
    👉 Read the CDC Guideline

This phrasing would go on to shape state laws, insurance coverage, prescribing limits, and criminal indictments.

🧾 PROP’s Citizen Petition to the FDA

In 2012, the advocacy group PROP (Physicians for Responsible Opioid Prescribing), led by Andrew Kolodny, submitted a citizen petition to the FDA. It requested label changes, but only for non-cancer pain:

  • ❌ Remove the word “moderate” from opioid indications

  • 📉 Cap the daily dose at 100 MME

  • ⏳ Add a 90-day limit on continuous use

🧠 Who Signed the Petition — and Why It Mattered

The petition had over 35 signers, including:

  • Andrew Kolodny (PROP President)
  • Anna Lembke, MD
  • Jane Ballantyne, MD
  • Roger Chou, MD — who would later lead development of both the 2016 and 2022 CDC Guidelines

None of the signers provided scientific evidence supporting a distinction between cancer and non-cancer pain. But this framing created a policy wedge — defining one group as “legitimate” pain patients and the other as suspect.

📛 Public Pushback and FDA’s Official Rejection

The FDA convened two major meetings in response:

🔹 ASA (American Society of Anesthesiologists):
“Non-cancer pain is impossible to define. Cancer survivors often live with chronic pain caused by treatment.”

🔹 Dr. Bob Twillman:
“When does cancer pain become non-cancer pain? After remission?”

🔹 American Cancer Society:
“Opioid receptors don’t know or care whether someone has cancer.”

📄 Why the Distinction Persisted Anyway

Despite the objections, PROP’s framing took hold. In September 2013, the FDA responded:

“FDA knows of no physiological or pharmacological basis upon which to differentiate the treatment of chronic pain in cancer patients from the treatment of chronic pain in the absence of cancer.”
👉 Read the full FDA response

Even though the FDA rejected it, the distinction persisted — not because it was medically valid, but because it was politically and legally useful. It allowed:

  • Lawmakers to restrict opioid access while claiming to protect cancer patients
  • Insurers to deny coverage
  • Prosecutors to build cases based on whether a patient’s pain was “cancer-related”
  • The groundwork for the MDL - leading to the $60 billion you see flowing

2️⃣ What the Science Says

🧠 “A Distinction Without a Difference”

In 2016, a Pain Medicine article titled “Chronic Cancer vs. Non-Cancer Pain: A Distinction Without a Difference?” challenged the growing divide between cancer and non-cancer pain. The author explained how the term became a “sham distinction” — a logical fallacy that appeals to a difference where none meaningfully exists.

“When it comes to cancer and non-cancer pain, one really must question why we are drawing a distinction between these two entities — and whether it is science or politics that demands there be a difference.”

The piece also showed that the terms “cancer pain” and “non-cancer pain” only became common in the literature in recent decades — a politically motivated shift, not a scientific one.

🧾 Schatman & Peppin on the Flawed Terminology

In another 2016 article titled “Terminology of Chronic Pain: The Need to Level the Playing Field”, pain experts Dr. Michael Schatman and Dr. Brian Peppin argued that the cancer vs. non-cancer split had no medical basis:

“A patient with pain from a cancer etiology has no different physiology than a patient with pain of non-cancer etiologies.”

They suggested the real meaning behind the distinction could be interpreted as:

  • “We don’t care if the cancer patient suffers side effects from opioids...
    But we do care if a chronic pain patient develops these problems.”

  • “We don’t care if patients with non-cancer pain suffer.
    They are not ‘worth’ the effort of adding opioids to their regimens.”

Schatman and Peppin urged clinicians and policymakers to abandon these biased categories in favor of a more humane, patient-focused language system.

📈 The Rise of “Cancer Pain” as a Policy Term

The terms “cancer pain” and “non-cancer pain” weren’t widely used until the late 20th century. According to the Pain Medicine article, usage of these terms in the literature spiked in the 1990s and 2000s, not because of a scientific breakthrough — but as part of a shift in how chronic pain was framed in public health discourse. This linguistic shift allowed guidelines and laws to differentiate who “deserved” opioids and who didn’t — despite no evidence that opioids work differently in either group.

⚠️ Why the Diagnosis Doesn’t Change the Physiology

Even the FDA said there’s no physiological or pharmacological difference in how opioids treat pain in cancer vs. non-cancer patients. Yet the distinction stuck, becoming embedded in policy. The result? Guidelines and laws justified denying pain relief to entire patient populations — based not on evidence, but on narratives about morality, survivability, and risk.

3️⃣ The Real-World Harm

💔 April’s Story: When Even Cancer Isn’t Enough

For years, we believed that cancer patients were “safe” from the opioid crackdown — protected by the policy carveouts. But reality tells a different story. Take April, a terminal cancer patient who was denied opioid medication at the pharmacy — despite being in palliative care. She shared her story before she passed away, exposing a truth we can no longer ignore: even patients with cancer are being cut off.

This isn’t an isolated incident. It's part of a growing pattern.

📉 What Recent Studies Reveal

Two new publications highlight the shrinking access to opioids — even for cancer patients.

🔹 A 2022 study in JAMA Oncology found that from 2007 to 2017:

  • Opioid prescribing for poor-prognosis cancer patients declined significantly
  • Pain-related emergency department visits increased
  • Researchers concluded that end-of-life pain management may be worsening

🔹 A 2024 article in Dove Medical Press warned of a troubling shift. In a piece called "The Pendulum", authors urged policymakers to stop overcorrecting and start protecting access to appropriate opioids for cancer patients — before more people suffer.

🔹 And a 2024 UW Medicine blog asked whether chronic cancer pain should still qualify for opioid therapy at all, signaling another step toward restriction.

🚪 Cancer Patients Now Face the Same Barriers

The idea that cancer patients still “get opioids” isn’t just outdated — it’s dangerous. Today, they face many of the same barriers as people with chronic non-cancer pain:

  • Pharmacist refusals
  • Red-flagging in the PDMP
  • Insurance denials
  • Doctors afraid to prescribe
  • Accusations of drug-seeking
  • Misinterpretation of “safe prescribing” guidelines

The stigma and scrutiny that once only applied to “non-cancer pain” has crept into oncology, palliative care, and even hospice settings.

🔄 How Guidelines Are Misapplied

Guidelines like the CDC’s were supposed to exclude cancer, palliative, and end-of-life pain — but these exclusions mean little in practice.

  • Some clinicians mistakenly apply the CDC guidelines to all pain

  • Others fear scrutiny or liability, regardless of diagnosis

  • Many institutions create blanket policies to avoid risk altogether

As a result, patients who should be protected are often left unmedicated, suffering from untreated or under-treated pain.

😔 Stigma Doesn’t Stop at the Cancer Diagnosis

A 2023 study in JAMA Network Open explored oncologists' attitudes about prescribing opioids for cancer-related pain. Key findings:

  • Patients report feeling stigmatized — by providers, pharmacists, and the public
  • Many fear addiction, which affects their willingness to take prescribed opioids
  • Prescribers often misunderstand or misapply safety guidelines

Even terminally ill patients are sometimes denied care due to the opioid climate. And cancer survivors — dealing with chemotherapy-induced neuropathy or post-surgical pain — often no longer qualify for “cancer pain” protections, even though their pain stems directly from cancer treatment.

4️⃣ What Needs to Change

🧹 Eliminate the False Divide from Guidelines and Laws

There is no scientific reason to treat cancer pain and non-cancer pain differently when it comes to opioid access. This arbitrary distinction should be:

  • Removed from clinical guidelines like the CDC opioid prescribing guidance

  • Eliminated from insurance policy exclusions

  • Banned from being used in legal indictments or regulatory decisions

Pain relief should be based on the needs of the individual — not whether their diagnosis fits a government-created exception.

⚖️ Stop Prosecuting Based on Diagnosis

Doctors have been criminally prosecuted for prescribing opioids to people with “non-cancer pain” — while cancer patients were carved out as more “acceptable.” But this approach is:

  • Ethically indefensible
  • Medically meaningless
  • Legally arbitrary

Diagnosis-based exemptions are a tool of convenience — not science. We must stop using the absence of cancer as a reason to punish providers and abandon patients.

🩺 Let Clinicians Treat the Patient in Front of Them

Every patient deserves a care plan based on their condition, their risks, and their preferences — not a label. Providers should be trusted to:

  • Assess pain on a case-by-case basis
  • Use clinical judgment when deciding whether opioids are appropriate
  • Document reasoning without fear of punishment

Blanket policies that treat all non-cancer pain as unworthy of opioid treatment are both cruel and ineffective

🧨 Hold PROP Accountable

The harm from the cancer vs. non-cancer distinction was not accidental. It was introduced by PROP and its allies to build a framework for:

  • Cutting off long-term opioid prescribing
  • Supporting mass tort litigation
  • Creating a “safe” political carveout to shield backlash

This distinction gave public health officials and legal actors cover — but it cost patients their care. There must be transparency and accountability for those who manufactured this division.

🛠 Build a New Framework Centered on Compassion and Evidence

We need pain care policy that:

  • Respects all patients — regardless of diagnosis
  • Rejects moral hierarchies in pain treatment
  • Recognizes that suffering is suffering, whether it comes from cancer, trauma, injury, or chronic illness
  • Ends the use of unscientific categories as gatekeeping tools

The system must evolve from distinction-based denial to compassionate, patient-centered care.

5️⃣ Citations

📚Full Formatted Citations

🖨️ Printable Resources

For free printable resources, go to our Patreon Page. You will need to subscribe (free) to access printable free resources. 

Included Printable Resources:

  1. ✅ Condensed Summary of Main Points
    A quick-reference overview of why the cancer vs. non-cancer pain distinction is flawed and harmful.

  2. 🧠 Myths vs. Facts Handout
    A side-by-side breakdown of common misconceptions and the truth behind the science and policy.

  3. ❓ Q&A Sheet
    A clear, patient-friendly guide answering the most common questions about the cancer vs. non-cancer divide.

  4. 📚 Full Citations List
    All sources referenced in the article, formatted and linked for easy access and credibility.

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