Pain and opioid use in cancer survivors: should we account for perceived injustice?   July 9th, 2022

Pain and opioid use in cancer survivors: should we account for perceived injustice?

Pain is one of the most disabling and occurring symptoms in cancer survivors (1). About 5-10% of people surviving cancer develop chronic severe pain, which is up to 40% in the early post-treatment period of cancer (2). Up to now, pain medication is still the recommended standard treatment for cancer-related pain (3). However, many cancer survivors are not primarily treated for their pain complaints during their rehabilitation (4). It is worrying that the survival rate of cancer survivors can be decreased due to opioid use (5). In addition, opioid use can be addictive and can lead to respiratory depression and constipation (6). Long-term opioid use can even lead to opioid-induced hyperalgesia (7). As you can read, opioids have a lot of side effects and are thus not the best treatment option for cancer pain. That is why we should focus more on the development of non-pharmacological treatment approaches.

Maybe we should account for perceived injustice? It is shown that feelings and thoughts of injustice play an important role in developing and maintaining chronic pain following cancer (8). Perceived injustice has been conceptualized as a multidimensional appraisal process characterized by a tendency to interpret one’s losses as severe and irreparable, to attribute blame to others for one’s suffering, and to experience a sense of unfairness (9) (e.g., someone who never smoked was nevertheless diagnosed with lung cancer, or someone who survived cancer must still deal with pain complaints afterward).

Patients with beliefs of injustice are seen with worse pain-related outcomes. For example, they report higher pain intensity, more disability, and worse mental health (10). Perceived injustice thus impacts the quality of life and social functioning in a bad way (10). Perceived injustice also leads to a discrepancy between what is expected compared to the actual situation, which possibly leads to frustration, anger, and other forms of emotional distress (11). Knowing that anger is associated with endogenous opioid dysfunction in response to painful stimuli, increased muscle tension, and systolic blood pressure, anger in turn can lead to an increased pain intensity (12,13). In terms of rehabilitation, perceived injustice is associated with prolonged and problematic recovery, poorer treatment outcomes, and a reduced likelihood of return to work at 1-year follow-up (9,14).

Besides all of that, perceived injustice contains a strong aspect of social comparison that may lead to greater distress and social conflicts (e.g., the nature of a stressor is not only negative but also unjust in comparison to the experiences of others) (11). Taken together, injustice beliefs address a maladaptive pattern of cognitive appraisal which might be a remarkable objective for adaptive pain coping (11). Therefore, the recognition and reduction of perceived injustice may be important to incorporate as a treatment strategy in the rehabilitation of cancer survivors.

Has this piqued your interest in perceived injustice in cancer survivors? I am conducting research, especially on breast cancer survivors with pain and perceived injustice. Find all information about my research here:


Eva Roose obtained her Master in Physiotherapy at the Vrije Universiteit Brussel (VUB) in 2020. Immediately after graduating, she became a Pain in Motion member at the VUB.

2022 Pain in Motion

References and further reading:

1. Leysen, L., Beckwee, D., Nijs, J., Pas, R., Bilterys, T., Vermeir, S., & Adriaenssens, N. (2017). Risk factors of pain in breast cancer survivors: a systematic review and meta-analysis. Supportive Care in Cancer, 25(12), 3607-3643.

2. Glare, P. A., Davies, P. S., Finlay, E., Gulati, A., Lemanne, D., Moryl, N., ... & Syrjala, K. L. (2014). Pain in cancer survivors. Journal of Clinical Oncology, 32(16), 1739.

3. De Groef, A., Penen, F., Dams, L., Van der Gucht, E., Nijs, J., & Meeus, M. (2019). Best-evidence rehabilitation for chronic pain part 2: pain during and after cancer treatment. Journal of Clinical Medicine, 8(7), 979.

4. Oldenmenger, W. H., Geerling, J. I., Mostovaya, I., Vissers, K. C., de Graeff, A., Reyners, A. K., & van der Linden, Y. M. (2018). A systematic review of the effectiveness of patient-based educational interventions to improve cancer-related pain. Cancer treatment reviews, 63, 96-103.

5. Boland, J. W., Allgar, V., Boland, E. G., Bennett, M. I., Kaasa, S., Hjermstad, M. J., & Johnson, M. (2020). The relationship between pain, analgesics and survival in patients with advanced cancer; a secondary data analysis of the international European palliative care Cancer symptom study. European journal of clinical pharmacology, 76(3), 393-402.

6. Massaly, N., Temp, J., Machelska, H., & Stein, C. (2020). Uncovering the analgesic effects of a pH-dependent mu-opioid receptor agonist using a model of nonevoked ongoing pain. Pain, 161(12), 2798-2804.

7. Paice, J. A. (2011). Chronic treatment-related pain in cancer survivors. Pain, 152(3), S84-S89.

8. Leysen, L., Cools, W., Nijs, J., Adriaenssens, N., Pas, R., van Wilgen, C. P., ... & Beckwée, D. (2021). The mediating effect of pain catastrophizing and perceived injustice in the relationship of pain on health-related quality of life in breast cancer survivors. Supportive Care in Cancer, 29(10), 5653-5661.

9. Sullivan, M. J., Scott, W., & Trost, Z. (2012). Perceived injustice: a risk factor for problematic pain outcomes. The Clinical journal of pain, 28(6), 484-488.

10. Carriere, J. S., Donayre Pimentel, S., Yakobov, E., & Edwards, R. R. (2020). A systematic review of the association between perceived injustice and pain-related outcomes in individuals with musculoskeletal pain. Pain Medicine, 21(7), 1449-1463.

11. Bissell, D. A., Ziadni, M. S., & Sturgeon, J. A. (2018). Perceived injustice in chronic pain: an examination through the lens of predictive processing. Pain management, 8(2), 129-138.

12. Burns, J. W., Holly, A., Quartana, P., Wolff, B., Gray, E., & Bruehl, S. (2008). Trait Anger Management Style Moderates Effects of Actual (″State ″) Anger Regulation on Symptom-Specific Reactivity and Recovery Among Chronic Low Back Pain Patients. Psychosomatic Medicine, 70(8), 898.

13. Burns, J. W., Bruehl, S., & Quartana, P. J. (2006). Anger management style and hostility among patients with chronic pain: effects on symptom-specific physiological reactivity during anger-and sadness-recall interviews. Psychosomatic Medicine, 68(5), 786-793.

14. Lahousse, A., Ivakhnov, S., & Roose, E. (2021). The Mediating Effect of Perceived Injustice and Pain Catastrophizing in the Relationship of Pain on Fatigue and Sleep in Breast Cancer Survivors: A Cross-Sectional Study. Pain Medicine.

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