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 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. 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 * 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. Brennan F, Carr DB, Cousins MJ. Pain Management: A Fundamental Human Right. Anesth Analg 2007; 105:205-21

Cancer Pain

Chronic pain in Cancer Survivors Post treatment pain syndromes Post-surgical pain syndromes Post radiation therapy neuralgias Post-chemotherapy neuropathy 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 cancer 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 These 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 used

The 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.

Multidimensional aspect of Cancer pain COGNITION Somatic Therapies PSYCHO-SOCIAL THERAPIES EMOTION NOCICEPTION SOCIO-ENVIRONMENT

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 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 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 A 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

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 Higher priority given to cure rather than treating patients for symptoms

Barriers to cancer pain management Barriers Percentage Inadequate pain assessment 76% Pt. reluctance to report pain 62% Pt. reluctance to take opioids 62% Physician reluctance to prescribe opioids 61% Inadequate knowledge of pain mgt. 52% Excessive regulation of opioids 18% Von Roenn, J. H. et. al. Ann Intern Med 1993;119:121-126

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 Ethicists 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.

Matching Interventions to Barriers Barriers related to patients Barriers related to healthcare professionals Barriers related to healthcare systems

Patient Barriers/Interventions Inevitability of Pain Distracting from cancer treatment. Fears of Addiction Inadequate Pain relief Patient Education Pt. Bill of Rights Information on narcotics Empower patient (PCA-IV/Oral)

Physician Barriers/Interventions Lack of Knowledge Lack of Motivation -Education (Topmed) - Incentives/sanctions -EBM Guidelines Beliefs/Attitudes Turf Issues -Peer Influence -Multidisciplinary -Opinion leaders 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