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Are We the Barrier?

Northwestern University Medical School, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL

THE KNOWLEDGE AND means to provide adequate pain relief for the vast majority of patients with cancer-related pain have been available for more than 20 years. Despite this, numerous studies continue to demonstrate widespread undertreatment of cancer-related pain. The development of guidelines for pain management by both national and international organizations (the American Pain Society,¹ World Health Organization,² National Comprehensive Cancer Network,³ and Agency for Healthcare Research and Quality⁴) validates the imperative for effective cancer pain management. These guidelines detail the principles of effective pain management, but consistent integration of them into medical practice has not yet been achieved. What are the persistent barriers that have delayed the implementation of effective pain management as the standard of care for all cancer patients?

Barriers to effective cancer pain management include patient-, professional-, and systems-related issues. Patient-related barriers generally fall into two major categories: reluctance to report pain and reluctance to take opioids. Patients are frequently reluctant to report pain because they want to be the "good," noncomplaining patient. They fear that pain signifies progression of their cancer, or they have concerns about distracting physicians from focusing on or treating their cancer. Ongoing patient and family misconceptions about tolerance, dependence, and addiction to opioids and concern over potentially unmanageable opioid side effects further contribute to ineffective pain management.

In this issue of the Journal of Clinical Oncology, Miaskowski et al⁵ suggest an additional patient-related barrier to effective cancer pain management: the lack of adherence with the analgesic regimen. The authors report on the rate of adherence to prescribed analgesics of 65 adult oncology outpatients with radiographic evidence of bone metastases and mean average daily pain intensity scores of 4.9 (on a scale of 1 to 10). Overall, the adherence rate for around-the-clock (ATC) opioid analgesics was 88.9%, while adherence to prescribed as-needed (PRN) medications was 24.7%. It is noteworthy that the adherence rates did not change over the course of the study, nor did the reported intensity or daily duration of pain reported by study participants. Only a minority of the patients, however, was prescribed ATC opioid analgesics. Overall, patient adherence to the analgesic regimen is more accurately reflected by the Medication Quantification Scale. This instrument provides a method for quantitating analgesic use (both opioids and nonopioids) by calculating scores for each prescribed analgesic weighted on the basis of dosage and class of medication. Patient adherence as measured by the Medication Quantification Scale score was poor, only approximately 55%. Nonadherence with prescribed therapeutic regimens for chronic disease, such as human immunodeficiency virus infection, is well recognized^6,7 and is likely an additional patient-related barrier to effective cancer pain management.

The study from Miaskowski et al also underscores professional barriers to adequate pain relief. At baseline, 92% of study participants reported pain of more than 2 months duration, and a similar percentage of working patients reported that pain limited their work activities. The average intensity of pain at baseline was 4.3 (on a scale of 0 to 10), with an average duration of pain of 10.8 hours per day. These data suggest a low priority for pain and symptom management by health care professionals. Furthermore, lack of adequate knowledge or assessment of pain management by physicians is suggested by the pattern of analgesic prescriptions. Effective pain management requires repeated assessment and adjustments in dosage, much like diabetes management requires continued assessment of blood glucose level and modification of the insulin prescription. No significant change in prescribed opioids occurred over the study period, despite the patients’ continued pain. Cancer pain management guidelines for chronic pain recommend an ATC, long-acting opioid analgesic in combination with a short-acting opioid analgesic for breakthrough pain, yet 56.9% of study participants had been prescribed opioid analgesics only on a PRN basis. ATC and PRN analgesics were prescribed in combination for only 29.2% of study participants. Poor adherence may, therefore, in part reflect the lack of relief from inadequate analgesic prescriptions.

The lack of adequate training for physicians in pain assessment and management remains a major barrier for the relief of cancer pain. The majority of medical schools and residency programs in the United States provide little or no formal education in pain and symptom management. The dearth of role models skilled in cancer symptom management further undermines the recognition of effective pain control as a priority of cancer care as well as educational activities.⁸

Education is essential but inadequate as a stimulus for major change in medical culture.^9,10 The recently published report from the Institute of Medicine and the National Research Council, "Improving Palliative Care for Cancer," supports the use of quality indicators for pain management.¹¹ To meet the mandate of excellent palliative care for all patients, health care providers and institutions must be held accountable for the quality of care delivered. The Joint Commission on Accreditation of Healthcare Organizations has implemented a new standard for the assessment and management of pain, which took effect January 1, 2001. All Commission-approved medical facilities are now required to ensure staff competency in pain assessment and management and to establish policies and procedures to support effective pain management. With this mandate to improve the knowledge base and pain management skills of pharmacists and nurses, how can we fail to accelerate the integration of cancer pain management skills into physician practice? Identifying effective pain control as a measure of the quality of care may provide the necessary stimulus to translate knowledge into practice improvements.¹⁰

The American Society of Clinical Oncology (ASCO) has taken important steps to integrate pain and symptom management into its educational activities. In September 2000, ASCO established the Pain and Symptom Management Task Force to identify strategic imperatives for educational needs in this area. With oversight from the task force, ASCO will publish a new curriculum, "Optimizing Cancer Care: The Importance of Symptom Management," in 2001. This comprehensive, multifaceted educational program is composed of 32 modules that address the management of psychologic, physical disease-, and treatment-related symptoms. It is through educational efforts such as this and future programs that ASCO and the Pain and Symptom Management Task Force will achieve the mandate to integrate optimal symptom management into the continuum of oncologic care for all patients.

REFERENCES

1. American Pain Society: Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain (ed 4). Glenview, IL, American Pain Society, 1999, pp 1-64

2. World Health Organization: Cancer Pain Relief and Palliative Care: Report of a WHO Expert Committee. Geneva, Switzerland, World Health Organization, 1990, pp 1-73

3. Liter ME: Cancer pain management. Oncology 4: 69-73, 2001

4. Jacex A, Carr D, Payne R, et al: Management of cancer pain, in : Clinical Practice Guideline No. 9. Washington, DC, Agency for Healthcare Policy and Research, U.S. Department of Health & Human Services, Public Health Service, 1994

5. Miaskowski C, Dodd MJ, West C, et al: Lack of adherence with the analgesic regimen: A significant barrier to effective cancer pain management. J Clin Oncol 19: 4275-4279, 2001[Abstract/Free Full Text]

6. Bayer R, Stryker J: Ethical challenges posed by clinical progress in AIDS. Am J Public Health 87: 1599-1602, 1997[Free Full Text]

7. Mehta S, Moore RD, Graham NM: Potential factors affecting adherence with HIV therapy. AIDS 11: 1665-1670, 1997[Medline]

8. Weissman DE: Cancer pain education: A call for role models. J Clin Oncol 6: 1793-1794, 1988[Medline]

9. Max MB: Improving outcomes of analgesic treatment: Is education enough? Ann Intern Med 113: 885-889, 1990

10. Hill CS Jr: When will adequate pain treatment be the norm? JAMA 274: 1881-1882, 1995[Abstract/Free Full Text]

11. Foley KM, Gelband H (eds): National Cancer Policy Board–Institute of Medicine and National Research Council: Improving Palliative Care for Cancer—Summary and Recommendations. Washington, DC, National Academy Press, 2001, pp 1-64

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