1. Barriers to Successful Treatment of Cancer Pain
Suresh Kannan, MD
Florida Hospital, Orlando

2. 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

3. 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

4. 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)

5. 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:

6. The Broken Column
Frida Kahlo

7. 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

8. Cancer Pain

9. 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:

10. 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

11. 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

12. 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.

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

17. Barriers to treatment Barriers related to health care professionals
Barriers related to patients
Barriers related to the healthcare system

18. 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

19. 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

20. 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

21. 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

22. 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:

23. Legal Barriers Estate of Henry James v. Hillhaven Corporation (1991)
Bergman v. Chin(1999)

25. 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,

26. 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.

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

29. 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)

30. 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

31. Legal Barriers?

32. Prescribing Practice Evaluation Individualized Treatment Plan
Informed Consent
Treatment (narcotic) Agreement
Periodic Review
Multidisciplinary Consultation
Medical Records
Comply with Laws and Regulations

33. Prescribing Practice Request old medical records
Collaborate with pharmacists
Photo identification
Prescription pads
Prescription monitoring programs
Identifying the drug seeking patient*

34. Opioid abuse-deterrent technologies
Physical barriers
Release of sequestered toxic components
Release of opioid antagonists
Prodrugs that require hepatic metabolism to release active metabolite

35. 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

36. 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

38. 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:

39. 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