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© 2002 American Society for Clinical Oncology
Lack of Adherence With the Analgesic Regimen: The Cancer Patients’ Perspective on a Two-Sided ProblemRegional Hospital, Aosta, Italy To the Editor:In the December 1, 2001, issue of the Journal of Clinical Oncology, Miaskowski et al1 reported on a series of 65 adult cancer patients with bone metastases and found that, despite a substantial pain score, they omitted a proportion of the prescribed analgesic regimen (overall adherence was 88.9% for around-the-clock opioids and only 24.7% for as-needed [PRN] medications). The authors affirm that the lack of adherence is an additional patient-related barrier to effective cancer pain management and is a major factor that contributes to undertreatment of cancer pain. The accompanying editorial, pointing out that no significant change in prescribed opioids occurred over the study period, despite the patients’ continued pain, suggests that the poor adherence may be in part the consequence of lack of relief from inadequate analgesic prescription.2 Therefore, "one approach to improving pain management in this patient population would be to encourage patients to increase their level of adherence."1 On the other hand, physicians’ skills and practice should be improved through education and integration of cancer pain management into quality-of-care standards.2 These unquestionable conclusions, expressing the view of the beneficent doctor or nurse committed to the best interest of patients through the relief of disturbing symptoms, reflect the traditional view of nonadherence/noncompliance as a failure on the part of the patient to follow the doctor’s instructions.3 This way, the patient is considered a quite passive recipient of the medical advice.3 From the patients’ side of the problem, why don’t they comply? Why don’t patients with a mean current worst pain score of 6.9/10 and a mean average pain score of 4.3/10, for a mean 10.8 hours per day, take more opioid, prescribed on an PRN basis and easily available to them? (In fact, they take 24.7% of PRN opioid.) A few recent articles suggest some possible responses and strongly support a different view of the phenomenon of nonadherence in cancer patients. Weiss et al4 describe a series of patients, 51% with cancer and 50% with moderate or severe pain. Ten percent of those with moderate pain and 9% of those with severe pain reduced or stopped taking treatment. Surprisingly, only 30% declared that they wanted additional pain treatment. Most patients were willing to tolerate pain rather than, among other reasons, experience the physical or mental side effects of treatment. In a different setting5 but in a similar way, after the start of morphine therapy and a significant reduction in pain score (from 65 to 41), cancer patients chose to stop dose escalation and reported satisfactory pain relief at a pain score level above the reference value of 24 measured in the general population. In this study, the start of morphine therapy had no major influence on aspects of health-related quality of life (HRQL) other than pain: the global HRQL and the functional scores, measured by the European Organization for Research and Treatment of Cancer’s Quality of Life Questionnaire C30, did not improve from the impaired baseline level. The authors affirm that it is "unrealistic to believe that even successful symptomatic treatment can reinstate a premorbid level of quality of life." A third study, by Wang et al,6 showed that the relationship between pain severity and HRQL was nonlinear. Although increasing severity of pain was associated with worsening health-related functioning, when pain was well controlled (mild), functional status did not differ from that of patients without pain. The three studies show (1) that analgesia has a price for patients, in terms of side effects and concerns, (2) that this price has to be balanced against the limited effect of analgesia on HRQL, and (3) that complete analgesia sometimes may not be the goal, since mild pain is compatible with normal functioning. Thus, patients may actually have several good reasons for partial nonadherence, not to mention the ethnocultural and spiritual domains. Their behavior must be considered, at least in part, the result of an active, reasoned process of decision making.3 "The traditional notion of compliance is outmoded in a health care system that aims to foster collaborative doctor-patient relationships and to encourage patient autonomy."3 On this basis, "it is not always clear exactly how much adherence is enough,"7 nor is it always clear how accurate we are in defining pain control as inadequate or patients in pain as insufficiently treated, especially when patients refuse to modify or take only in part their analgesic regimen. Patient education, aimed at removing misconceptions, as well as professional commitment to offer patients an effective analgesic treatment both remain fundamental, but they should be paired with a deep insight and a profound respect for the complex pharmacologic, medical, psychologic, and social considerations underlying each individual-based decision.3,7 REFERENCES
1.
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
2.
Von Roenn JH: Are we the barrier? J Clin Oncol 19: 4273-4274, 2001 (editorial) 3. Donovan JL: Patient decision making: The missing ingredient in compliance research. Int J Technol Assess Health Care 11: 443-455, 1995[Medline] 4. Weiss SC, Emanuel LL, Fairclough DL, et al: Understanding the experience of pain in terminally ill patients. Lancet 357: 1311-3115, 2001[CrossRef][Medline] 5. Klepstad P, Borchgrevink PC, Kaasa S: Effects on cancer patients’ health-related quality of life after the start of morphine therapy. J Pain Symptom Manage 20: 19-26, 2000[CrossRef][Medline] 6. Wang XS, Cleeland CS, Mendoza TR, et al: The effect of pain severity on heath-related quality of life: A study of Chinese cancer patients. Cancer 86: 1848-1855, 1999[CrossRef][Medline] 7. Fishman SM, Wilsey B, Yang J, et al: Adherence monitoring and drug surveillance in chronic opioid therapy. J Pain Symptom Manage 20: 293-307, 2000[CrossRef][Medline]
ResponseUniversity of California, San Francisco, San Francisco, CA In Reply:We appreciate the comments of Dr Musci and agree with his major points. It was not our intent to suggest any failure on the part of the patient. Our intent was to emphasize that clinicians need to include an evaluation of the patient’s level of adherence with the analgesic regimen as part of the ongoing evaluation of the effectiveness of a pain management plan.1 Equally important, as Dr Musci points out, is the need to determine why patients are not taking their analgesic medications as prescribed and what their specific goals are. Pain management is much more than decreasing pain intensity scores and increasing analgesic intake. Effective pain management includes caring for the whole person and assisting patients in achieving optimal pain control with minimal side effects. REFERENCES
1.
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
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Copyright © 2002 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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