Transcript Barriers to Successful Treatment of Cancer Pain

Barriers to Successful
Treatment of Cancer
Pain
Suresh Kannan, MD
Florida Hospital, Orlando
Objectives
 To
highlight the discrepancy between current
state of medical knowledge and prevailing
practice of pain management in cancer patients
 To analyze barriers that prevent effective
treatment of cancer pain
 To propose solutions to promote effective
cancer pain management
The Scream
Edvard Munch
Pain
An unpleasant sensory and emotional
experience associated with actual or
potential tissue damage, or described in
terms of such damage.
International Association for the Study of Pain (IASP)
Suffering
Suffering is experienced by persons, not merely by
bodies, and has its source in challenges that threaten
the intactness of the person as a complex social and
psychological entity. Suffering can include physical
pain but is by no means limited to it.
Eric J Cassel The Nature of Suffering and the Goals of Medicine, N
Engl J of Med 1982; 306:639-45.
The Broken Column
Frida Kahlo
Cancer Pain
 10
million new cases diagnosed annually*
 Moderate to severe pain experienced by
40% to 50% of cancer patients
 Very severe pain experienced by 25% to
30% of cancer patients
 80% of terminal stage cancer experience
moderate to severe pain
Brennan F, Carr DB, Cousins MJ. Pain Management: A Fundamental
Human Right. Anesth Analg 2007; 105:205-21
Cancer Pain
Pain Syndromes in Cancer Patients
Coincidental
Pain
<10%
Pain caused by
anticancer
therapy
25%
Pain caused by
cancer
>65%
Chronic pain in Cancer Survivors
 Post
treatment pain syndromes
 Post-surgical pain syndromes
 Post radiation therapy neuralgias
 Post-chemotherapy neuropathy
Burton AW, et al. Chronic Pain in the Cancer Survivor: A New Frontier. Pain
Medicine 2007; 8: 189-198.
Approaches to cancer pain
management
Primary Therapies
 Radiation Therapy
 Chemotherapy
 Immunotherapy
 Surgery
 Antibiotics
Symptomatic
Therapies
 Pharmacotherapy
 Interventional
 Physical Modalities
 Psychological
 Complementary &
Alternative
AMA CME Module 11: Pain Management. Cancer Pain: Pharmacotherapy
Assessment of Pain
Multidimensional aspect of Cancer pain
Somatic
Therapies
COGNITION
EMOTION
SOCIOENVIRONMENT
PSYCHOSOCIAL
THERAPIES
Barriers to treatment
 Barriers
related to health care
professionals
 Barriers
related to patients
 Barriers
related to the healthcare system
Barriers related to patients
 Reluctance
to report pain
 Belief that cancer is inevitable in cancer
 Fear pain portends progress of cancer
 Fear of alienating care givers
 Reluctance to take pain medication*
 High costs of medications and treatments
 Fear of addiction, side effects of medication
Barriers related to health care
system
 Low
priority given to cancer pain treatment
 Priority on curing cancer
 Restrictive regulation of controlled
substances
 Inadequate reimbursement
 Failure to recognize pain as a major cause
of disability
 Problems of availability of treatments
Barriers related to healthcare
professionals
“Unbelievably, American doctors regularly
refuse to prescribe effective doses of
narcotic pain killers to dying patients on the
grounds that the patients might become
addicted. The treatment of cancer pain,
clearly, is still not based solely on scientific
fact but draws on ignorance, fear, prejudice,
and on an invisible, unacknowledged moral
code expressing half-baked notions about
evil of drugs and the duty to bear affliction.”
- Dick Morris from The Culture of Pain
Barriers related to healthcare
professionals
 Inadequate
knowledge/training in pain
management
 Inadequate pain assessment
 Concerns about regulation of controlled
substances
 Fear of patient addiction
 Ethnic/racial/gender/age biases
 Negative feelings towards pain patients
Barriers to cancer pain
management
Barriers
Percentage
Inadequate pain assessment
Pt. reluctance to report pain
Pt. reluctance to take opioids
Physician reluctance to prescribe opioids
Inadequate knowledge of pain mgt.
Excessive regulation of opioids
Von Roenn, J. H. et. al. Ann Intern Med 1993;119:121-126
76%
62%
62%
61%
52%
18%
Legal Barriers
 Estate
of Henry James v. Hillhaven
Corporation (1991)
 Bergman
v. Chin(1999)
Ethical Analysis of the Barriers to
Effective Pain Management
Major criticism of the “ barriers literature” is the
failure to analyze these barriers from an ethical
perspective
 Curative versus palliative models of medicine
 Disparity between current state of medical
knowledge and prevailing practice of pain
management
 Irrational beliefs about addiction, tolerance and
adverse side effects

Rich BA. An Ethical Analysis of the Barriers to Effective Pain Management.
Cambridge Quarterly of Healthcare Ethics 2000, 9, 54-70.
Ethics
“ To allow a patient to experience
unbearable pain or suffering is unethical
medical practice.”
Wanzer SH, et al. The Physician’s responsibility
towards hopelessly ill patients – a second look. N Engl J
Med 1989; 320:844-9
Matching Interventions to Barriers
 Barriers
related to patients
 Barriers related to healthcare
professionals
 Barriers related to healthcare systems
Patient Barriers/Interventions

Inevitability of Pain

Patient Education

Distracting from
cancer treatment.

Pt. Bill of Rights

Fears of Addiction

Information on
narcotics

Inadequate Pain relief

Empower patient
(PCA-IV/Oral)
Physician Barriers/Interventions
Lack of Knowledge
-Education (Topmed)
-EBM Guidelines
Lack of Motivation
- Incentives/sanctions
Beliefs/Attitudes
-Peer Influence
-Opinion leaders
Turf Issues
-Multidisciplinary
approach
Legal Barriers?
Prescribing Practice
 Evaluation
 Individualized
Treatment Plan
 Informed Consent
 Treatment (narcotic) Agreement
 Periodic Review
 Multidisciplinary Consultation
 Medical Records
 Comply with Laws and Regulations
Prescribing Practice
 Request
old medical records
 Collaborate with pharmacists
 Photo identification
 Prescription pads
 Prescription monitoring programs
 Identifying the drug seeking patient*
Opioid abuse-deterrent
technologies
 Physical
barriers
 Release of sequestered toxic components
 Release of opioid antagonists
 Prodrugs that require hepatic metabolism
to release active metabolite
Institutional approaches
 Organizational
commitment to pain treatment
 Dedicated hospital- wide pain service
 Analyze current pain management practice
 Standards for pain assessment
 Implement policies to treat cancer pain
Institutional approaches
 Multi-disciplinary
workgroup
 Regular assessment of pain and effective
treatment
 Education for clinicians, patients and
family
 Establish accountability for pain
management
 Continuous evaluation and improvement
of pain management process
Pain Management: A Fundamental
Human Right
 Education
 Universal
pain management standards
 Legislative reform
 Liberalization of national policies on opioid
availability
 Provision of affordable opioids
 Pain control programs in all nations
 Continued WHO activism
Brennan F, Carr DB, Cousins, MJ. Anesth Analg 2007; 105: 205-21.
The nature of suffering and goals of
medicine.
Suffering is experienced by persons, not merely by
bodies, and has its source in challenges that
threaten the intactness of person as a complex
social and psychological entity. Suffering can
include physical pain but is by no means limited
to it. The relief of suffering and the cure of the
disease must be seen as twin obligations of a
medical profession that is truly dedicated to the
care of the sick.
Eric J Cassel