US cancer patients still plagued by undertreated pain

ABSTRACT: Fear of addiction, abuse, and law enforcement still drive the system, and inadequate pain relief is the result.

The truth about cancer pain hurts: Many oncology patients still suffer needlessly from unrelieved pain. This quandary is underscored by two disconcerting facts: We have the tools to alleviate upwards of 90% of cancer pain, and the problem was identified decades ago.

In 1993, ECOG conducted a survey to assess the knowledge of cancer pain and its treatment among physicians practicing in ECOG-affiliated institutions: 86% felt that a majority of cancer patients with pain were undermedicated, and 31% said they would wait until the patient’s prognosis was 6 months or less before initiating maximal analgesia. Lack of pharmacological education on opioid analgesics was cited as a major barrier to pain management (see poll question on p. 2).

Kathleen M. Foley, MD, of Memorial Sloan-Kettering Cancer Center’s Pain and Palliative Care Service, said that the pain education void cited in the ECOG study still exists. “We continue to struggle with a lack of infrastructure to educate doctors on pain management, in part because the basic medical school courses in clinical pharmacology do not necessarily attend to the complicated issues of pain management,” Dr. Foley told ONI.

Although pain management guidelines have been established by the International Association for the Study of Pain, “current surveys indicate that guideline compliance is spotty, at best,” she said.

Undertreatment of pain is further exacerbated by societal attitudes toward opioid analgesics. “Tolerance and physical dependence are still being confused with addiction, which certainly influences the way physicians and their patients view pain drugs,” Dr. Foley said.

She pointed out that lack of access to opioids also contributes to poor pain control. “Studies show that black and Hispanic cancer patients are less likely to receive proper pain relief because pharmacies in their neighborhoods don’t adequately stock opioids for fear of illicit use and theft,” she commented.

A positive trend

Many of the restrictive state pain policies that unwittingly created barriers to care were developed in the 1970s, when pain management was not an accepted medical practice.

In 2003, The Pain & Policy Study Group (PPSG) at the University of Wisconsin School of Medicine and Public Health began a national study of state-level pain management policies.

The PPSG study examined how policies encourage pain management, address physicians’ fears of regulatory scrutiny, and draw distinctions between physical dependence and addiction.

Aaron M. Gilson, PhD, PPSG US program director, told ONI that their recent findings point to a positive trend. “We grade states on a scale of F to A. In 2000, about half the states received a grade above a C, yet in 2007, 86% received a grade above a C,” Dr. Gilson said.

The 2007 report card showed that California and Wisconsin had the greatest grade improvement.

“In 2000, no state received an A, but as of 2007, four states have an A. So we’re making progress, but there’s still a long way to go to improve state policies and to address the other impediments to pain relief,” Dr. Gilson said.

For more information on the University of Wisconsin’s PPSG, visit www.painpolicy.wisc.edu.

Opiophobia

Pain management is also adversely affected by fear generated by the mass media, which was highlighted by the widespread coverage given to prescription OxyContin abuse.

“These stories help perpetuate long-standing misconceptions about pain management,” Dr. Foley said. She added that surveys have demonstrated that sensational coverage of opioid abuse has a negative impact on patients’ access to pain treatment.”

In an interview with ONI, Russell K. Portenoy, MD, chairman of Pain Medicine and Palliative Care at Beth Israel Medical Center, New York, said that misperceptions about opioid addiction have the theoretical power to affect prescribing patterns, but there’s simply no way to accurately quantify that kind of behavioral phenomenon.

“However,” Dr. Portenoy added, “the increasing number of physicians who treat chronic noncancer pain with opioids has captured the attention of the law enforcement community, largely because of the well-publicized increase in abuse. Consequently, the whole pain community is undergoing a period of retrenchment.”

He said that while pain experts are seeking better pharmacological ways to achieve balance at the bedside, “what we’re seeing in the public and regulatory community-who tend to focus more on the negative side-is fear, which tends to push the pendulum back to more opiophobia and a reluctance to prescribe.”

Cure vs comfort

“An artificial dichotomy still exists in our healthcare system-cure vs comfort. And forcing a choice between cure and comfort results in preventable suffering,” Diane Meier, MD, told ONI.

Dr. Meier, director of the Center to Advance Palliative Care at Mount Sinai School of Medicine, New York, contends that undertreated cancer pain should be addressed, in part, by aggressively expanding access to palliative care.

“Research indicates that for most people, advanced disease is characterized by big trouble: inadequately treated pain; a fragmented care system; poor communication among physicians, patients, and families; and enormous strains on family caregivers,” Dr. Meier said.

On a positive note, Dr. Meier noted that in recent years hospital-based palliative care programs have grown rapidly, from almost none to 50% of all hospitals over 75 beds. “That’s the good news; the bad news is that it’s only 50%. And given our aging population, hospital palliative care programs are a necessity, not an option,” Dr. Meier said.

The community setting

Most of today’s cancer care is delivered in the community setting, but is it reasonable to expect busy community doctors to have the expertise and time to manage pain?

Eduardo Bruera, MD, professor of palliative care and rehabilitation medicine, M.D. Anderson Cancer Center, told ONI, “This question raises an important point. In effect, most early cancer pain can be managed by the community oncologist, but when situations become more extensive, a palliative care specialist should become involved.” However, he said, “the problem of pain control is complicated because unlike hospital-based care, many community oncologists don’t have ready access to a palliative care team.”

He noted that ASCO is developing task forces to look at ways to better integrate community doctors and advanced palliative services. “We have good measurement tools to gauge pain. We just have to use them on every patient we see. Then it’s up to us to relieve their pain,” he said.