Barriers to Successful Treatment of Cancer PainSuresh Kannan, MDFlorida Hospital, Orlando

ObjectivesTo highlight the discrepancy between current state of medical knowledge and prevailing practice of pain management in cancer patientsTo 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)

SufferingSuffering 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 Pain10 million new cases diagnosed annually*Moderate to severe pain experienced by 40% to 50% of cancer patientsVery 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

Chronic pain in Cancer SurvivorsPost treatment pain syndromesPost-surgical pain syndromesPost radiation therapy neuralgiasPost-chemotherapy neuropathyBurton AW, et al. Chronic Pain in the Cancer Survivor: A New Frontier. Pain Medicine 2007; 8: 189-198.

Approaches to cancer pain managementPrimary TherapiesRadiation TherapyChemotherapyImmunotherapySurgeryAntibioticsSymptomatic TherapiesPharmacotherapyInterventionalPhysical ModalitiesPsychologicalComplementary & Alternative

AMA CME Module 11: Pain Management. Cancer Pain: Pharmacotherapy

Assessment of Pain

COGNITIONEMOTIONSOCIO-ENVIRONMENTPSYCHO-SOCIAL THERAPIESSomatic Therapies Multidimensional aspect of Cancer pain

Barriers to treatmentBarriers related to health care professionals

Barriers related to patients

Barriers related to the healthcare system

Barriers related to patientsReluctance to report painBelief that cancer is inevitable in cancerFear pain portends progress of cancerFear of alienating care giversReluctance to take pain medication*High costs of medications and treatmentsFear of addiction, side effects of medication

Barriers related to health care systemLow priority given to cancer pain treatmentPriority on curing cancer Restrictive regulation of controlled substancesInadequate reimbursementFailure to recognize pain as a major cause of disabilityProblems of availability of treatments

Barriers related to healthcare professionalsUnbelievably, 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 professionalsInadequate knowledge/training in pain managementInadequate pain assessmentConcerns about regulation of controlled substancesFear of patient addictionEthnic/racial/gender/age biasesNegative feelings towards pain patients

Barriers to cancer pain managementVon Roenn, J. H. et. al. Ann Intern Med 1993;119:121-126

Legal BarriersEstate of Henry James v. Hillhaven Corporation (1991)

Bergman v. Chin(1999)

Ethical Analysis of the Barriers to Effective Pain ManagementMajor criticism of the barriers literature is the failure to analyze these barriers from an ethical perspectiveCurative versus palliative models of medicineDisparity between current state of medical knowledge and prevailing practice of pain managementIrrational beliefs about addiction, tolerance and adverse side effectsRich 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 Physicians responsibility towards hopelessly ill patients a second look. N Engl J Med 1989; 320:844-9

Matching Interventions to BarriersBarriers related to patientsBarriers related to healthcare professionalsBarriers related to healthcare systems

Patient Barriers/InterventionsInevitability of Pain

Distracting from cancer treatment.

Fears of Addiction

Inadequate Pain reliefPatient Education

Pt. Bill of Rights

Information on narcotics

Empower patient (PCA-IV/Oral)

Physician Barriers/InterventionsLack of Knowledge Lack of Motivation -Education (Topmed) - Incentives/sanctions-EBM Guidelines

Beliefs/Attitudes Turf Issues-Peer Influence -Multidisciplinary -Opinion leaders approach

Legal Barriers?

Prescribing PracticeEvaluationIndividualized Treatment PlanInformed ConsentTreatment (narcotic) AgreementPeriodic ReviewMultidisciplinary ConsultationMedical RecordsComply with Laws and Regulations

Prescribing PracticeRequest old medical recordsCollaborate with pharmacistsPhoto identificationPrescription padsPrescription monitoring programsIdentifying the drug seeking patient*

Opioid abuse-deterrent technologiesPhysical barriersRelease of sequestered toxic componentsRelease of opioid antagonistsProdrugs that require hepatic metabolism to release active metabolite

Institutional approachesOrganizational commitment to pain treatmentDedicated hospital- wide pain serviceAnalyze current pain management practiceStandards for pain assessmentImplement policies to treat cancer pain

Institutional approachesMulti-disciplinary workgroupRegular assessment of pain and effective treatmentEducation for clinicians, patients and family Establish accountability for pain managementContinuous evaluation and improvement of pain management process

Pain Management: A Fundamental Human RightEducationUniversal pain management standardsLegislative reformLiberalization of national policies on opioid availabilityProvision of affordable opioidsPain control programs in all nationsContinued 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

The very thought and diagnosis of cancer causes immense fear and dread.With advances in the field of oncology, diagnosis and treatment of cancer it is a given that eradication of cancer is and must be the priority when it comes to cancer! Why then should one focus on pain? Pain is the symptom most expected and feared by cancer patients. Unrelieved pain can have enormous physiological and psychological effects on the patient and family. Pain negatively effects quality of life by impairing daily functions, social relationships, sleep and self worth. Unrelieved pain can cause tremendous suffering.* By 2020 the that figure will double with 70% occurring in developing countries; prevalence of pain at the time of cancer diagnosis and early in the course of disease is estimated to be about 50% and increases to 75% in advanced stages; large studies of patients in France/USA and China reveal that 51/ 42 and 59% of cancer patients received inadequate analgesia. Most studies contemporary emanate from developed world. They indicate a global failure to adequately respond to the challenge of pain mangement.In the USA, 75% of children and two out of three adults will survive cancer whereas 50 years ago one out of four survived. Post Breast Cancer Therapy Pain Syndrome affects 5 to 15% of patients who survive breast cancerThese validated pain scales are effective in cognitively intact patients. There are different scales for the cognitively impaired patients like (PAINAID-Pain assessment in Advanced Dementia, NOPPAIN-Non communicative patients pain assessment Instrument, check list for Nonverbal Pain Indicators etc. Cognitively impaired patients are at higher risk for undertreatment, they are able to report feeling pain, assessment tools suited to the patient should be usedThe WHO has been involved with pain in three overlapping areas: the promotion and dissemination of guidelines on pain management, advocacy of improved access to opioid analgesics, and national programs of palliative care and pain relief.Reluctance to report pain- fear that pain means disease is worse, concern about not being a good patient, concern about distracting physician from treatment of cancer. Cost is also a factor in preventing patients taking medicationA Canadian Survey published in 2006 stated that 35% of physicians would never prescribe opioids and 37% identified addiction as a major barrier to their prescribing opioids

Higher priority given to cure rather than treating patients for symptomsEthicists argue that: Failure of physicians to identify pain relief as priority in healthcare( obsession with cure, there could be a fate worse than death), insufficient knowledge, insufficient knowledge about assessment and management of pain, fear of regulatory scrutiny of prescribing practices of opioid analgesics, failure of healthcare systems to hold physicians responsible, persistence of irrational beliefs and fears about addiction, tolerance, dependence and adverse effects of opioids. Regulation of physicians by Board as opposed to federal agencies.