Evidence Based Pain Management and Palliative Care

Author: Arthur G. Lipman, Pharm.D.

Description: Interview with Arthur G. Lipman, Pharm.D.

Byline: Arthur G. Lipman, Pharm.D., is a Professor of Pharmacy Practice in the College of Pharmacy, Director Clinical Pharmacology at the University Hospitals and Clinics Pain Management Center and a member of the Huntsman Cancer Institute Pain Medicine and Palliative Care Advisory Group at the University of Utah Health Sciences Center in Salt Lake City. Before moving to Salt Lake City in 1977 to become chairman of his academic department, Dr. Lipman was Drug Information Director at the Yale-New Haven Medical Center and held concurrent faculty appointments at the Yale University School of Medicine, Yale University Graduate School of Nursing and University of Connecticut School of Pharmacy. He served on both the Acute Pain Management and Cancer Pain Management Guidelines Panels of the U.S. Public Health Service Agency for Health Care Policy and Research. He been a hospice board member and consultant for over 30 years, is a past president of Hospice of Salt Lake and was a founder and past president of Cancer Pain Relief-Utah. He serves on the Board of Directors of the American Alliance of Cancer Pain Initiatives. He has been a consultant and special grants reviewer for the National Cancer Institute, National Institute of Nursing Research and other governmental agencies. His current research is in pharmacotherapy outcomes in chronic pain and evidence-based symptom control in palliative care.

Dr. Lipman is co-chair of the Arthritis Pain Management Clinical Guideline Panel of the American Pain Society. His professional service includes the American Cancer Society National Advisory Group on Cancer Pain Relief, the American Pain Society Analgesic Regulatory Affairs Committee and the joint Ethics Task Force of the American Pain Society and American Academy of Pain Medicine.

He has published books on Drug Use in Assisted Suicide and Euthanasia, Evidence-Based Symptom Control in Palliative Care and Pain Management for Primary Care Clinicians; over 90 articles, chapters and monographs and over 300 reviews and editorials. Dr. Lipman edited the journal Hospital Formulary for ten years, is former editor of the Research Update of the American Pain Society Bulletin and is the founding editor of the Journal of Pharmaceutical Care in Pain & Symptom Control which will merged with The Hospice Journal in 2002 to become the Journal of Pain & Palliative Care Pharmacotherapy.

Pain.com: What is evidence-based health care and why do you believe it is important in pain management and palliative care?
Dr. Lipman: Much of what we now do in pain management and palliative care is based on relatively new science. Both fields are evolving. We do not always know what are the best practices. Therapeutic approaches vary greatly between localities, and even among clinicians in the same location. Few physicians, nurses, pharmacists or other health professionals learned how to provide good, evidence-based pain management or end-of-life care during their professional education and training; it simply wasn't taught until recently. And much of what clinicians now believe to be true has been learned through trial and error or emulation of others who learned through this same "unscientific" technique". Therefore, it is understandable that anecdote is the basis of clinical decisions in pain and palliative care as often — perhaps even more often — than evidence. Often, we do not know what are the best way to address difficult symptom control issues. Evidence-based medicine may provide solutions to some of these knowledge deficits. Evidence-based medicine (EBM) has been defined as:

The conscientious, explicit and judicious use of current best evidence in decision making about the care of individual patients.1
When we look objectively at evidence, we often reach different conclusions that those held by experienced clinicians, even some "expert" panels that publish clinical practice guidelines based on individuals' opinions rather than evidence. Evidence-based care does not preclude clinicians using their experience and judgment. Indeed, it mandates that such valuable perspectives be integrated with evidence derived from systematic reviews, because only such reviews provide an unbiased approach to assembling the evidence through systematic appraisal and synthesis research data.2 This concept is revolutionizing the way that many clinicians make decisions. Aggregated evidence, not single marketing-oriented studies or local normative practices, becomes the basis of therapeutic decisions. Too few evidence-based resources are now available for pain and palliative care clinicians, but the number of clinically useful sources of this type of evidence is increasing.

Pain.com: What are some evidence-based resources that clinicians can consult relating to pain management and palliative care?
Dr. Lipman: The federal clinical practice guidelines on the management of acute pain (1992)3 and cancer pain (1994)4 were among the early clinical guidance documents that were based upon scientific evidence. While millions of copies of these documents have been distributed, some clinicians have not adopted many of the recommendations, perhaps because those clinicians do not understand how the recommendations were formulated. The panel appointed by the federal agency to address pain management worked with the National Library of Medicine whose staff searched the entire corpus of clinical and scientific literature. Published reports that met stringent criteria were reviewed in detail. Meta-analyses of randomized controlled trials (RCTs) were completed to identify true and consistent outcomes. When too few RCTs were available for meta-analysis, best evidence synthesis methods were employed. The result was recommendations based on evidence, not individuals opinions or normative practices. Interestingly, the recommendations often varied from common practice, e.g., meperidine should be used for no more than a day or two and the intramuscular route is a poor choice for analgesic administration.

Both of these guidelines are now available in a searchable format on the World Wide Web at www.ahrq.gov. (under guidelines).
The federal government no longer publishes clinical practice guidelines, but the American Pain Society (APS) has picked up the gauntlet and is now doing so. In 1999, the APS published a guideline on management of acute and chronic pain in sickle celldisease,5 and at the end of this year (2001) will publish a guideline on the management of pain in osteoarthritis, rheumatoid arthritis and chronic juvenile arthritis.6 Information on both of these resources is available through the APS website (www.ampainsoc.org). The APS also is developing an update of the 1994 federal guidelines. A full book of systematic reviews in analgesia was published by members of the Oxford Pain Relief Unit in 1998.7

A major international repository of evidence based clinical information is the Cochrane Library.

Pain.com: What is the Cochrane Library and does it specifically include pain and palliative care information?
Dr. Lipman: The Cochrane Collaboration is an international organization of individuals committed to preparing, maintaining and updating systematic reviews, and providing access to them through the Cochrane Library. The collaboration began at Oxford University in 1992 with support from the British National Health Service. Since that time, it has expanded greatly in scope, number of Cochrane Centers and numbers of users. There are now several American Cochrane Centers.

The Cochrane Library is an electronic full text database available through subscription. Most academic health science libraries have subscriptions that make the Cochrane Library available to their users. In 1998, the Pain Palliative and Supportive Care (PaPaS) Cochrane collaborative review group (CRG) came into being. This CRG is based at Oxford University in the United Kingdom and the New England Medical Center in Boston. The coordinating editor is Phillip Wiffen, Regional Pharmaceutical Adviser for the Anglia & Oxford Region of the National Health Service and a member of the Pain Research Unit, Churchill Hospital at Oxford University. Papas CRG members hand search relevant journals around the world and have generated many useful reviews that are available on the Cochrane Library. Members of the group also conduct periodic short courses on how to conduct evidence-based systematic reviews. Information about the Cochrane Collaboration and the Papas CRG can be obtained through the Internet at the Papas web site (http://www.jr2.ox.ac.uk/Cochrane).

Pain.com: You used the words palliative care, supportive care and end-of-life care, and we frequently hear about hospice care. What are these, and are they all the same?
Dr. Lipman: Hospice is a medieval French word referring a resting place for travelers. In the modern context, it refers to a program for care for terminally ill patients. Palliative care has been defined and described by the World Health Organization (WHO) as the active, total care of patients whose disease is not responsive to curative treatment. Control of pain and other symptoms, and of psychological social and spiritual problem sis paramount. The goal of palliative care is achievement of the best quality of life for patients and their families. Many aspects of palliative care are also applicable earlier in the course of the illness in conjunction with (active treatment of the disease).8

Hospice is based on these same principles. Most hospice programs are home-care based while many palliative care units are within or affiliated with hospitals or other inpatient facilities. Some persons distinguish between hospice being only end-of-life care and palliative care often being integrated into total care earlier in the course of the disease. But this distinction is not made by most care providers. The term supportive care originated in the oncology arena as supportive oncology. Today, all of these terms are commonly used interchangeably. The former National Hospice Organization has been renamed the National Hospice and Palliative Care Organization; the former Academy of Hospice Physicians is now the American Academy of Hospice and Palliative Medicine.

Pain.com: Are there specific evidence-based resources for palliative care?
Dr. Lipman: The Cochrane Papas group is developing systematic reviews directly relevant to palliative care, and the number of these in the Cochrane Library is increasing. However, there are few randomized controlled trials conducted in terminally ill patients, and these are the only types of trials eligible for inclusion in Cochrane reviews. For that reason, we recently developed systematic reviews of the limited evidence in 15 common symptoms among patients with life limiting illnesses and published these as a book on evidence-based symptom control in palliative care.9

Several journals also provide periodic evidence based reviews that relate to palliative care. Names and web sites for additional information about three such journals are:

• Journal of Pain and Symptom Control www.elsevier.nl
• Journal of Palliative www.liebertpub.com
• Journal of Pain & Palliative Care Pharmacotherapy www.haworthpress.com

Pain.com: Do you anticipate increased use in the future of evidence based resources in pain and pallative care?
Dr. Lipman: Yes I do. Studies of several diseases states have demonstrated better patient outcomes at lower cost when standardized protocols are used than when individualized, often anecdotally-driven medical practice is provided. New science on pain management and palliative care come to light continually, and clinically useful evidence is becoming available increasingly. Much of what we learn will most probably come from epidemiological and outcomes research using extensive patient data bases. New outcomes instruments allow more sensitive and specific determination of the values of different interventions.10 This approach will permit definition of best practices without interventions. The need for such an aporioach is especially acute in palliative care where interventional studies are ethically questionable and difficult to control.

The new pain management standards of the Joint Commission on the Accreditation of Health Care Organizations (JCAHO) have greatly increased the focus of all types of health care systems on improved assessment and management of pain. Recent legal decisions have held clinicians liable for inadequate pain control. And the explosive growth of hospice programs in the United States, from one in 1974 to over 3000 today, all indicate that the public will demand improved pain and palliative care. Public advocacy organizations such as the American Pain Foundation (www.painfoundation.org), and both state and federal governmental examination of pain related topics are increasing the public demand for more and better pain management and palliative care. In the Autumn of 2000, Congress declared this as the "Decade of Pain Control of Research".

All clinicians now have a mandate to improve quality of and accessibility to pain management and palliative care. It is time for us to examine the basis for our practices and to question those for which clear evidence is not the foundation. Use of evidence-based resources will help to assure that we are providing the best quality and most cost-effective care to our patients.

Pain.com: Thank you Dr. Lipman
 
References:
1. Greenhalg T. Is my practice evidence-based? BMJ 1996;313:957-8.
2. Hewarn J, Feuer D, Higginson D, Sheldon T. Systematic reviews. Pall Med 1999;13:75-78.
3. Acute Pain Management Guideline Panel. Acute Pain Management: Operative or Medical Procedures and Trauma; Clinical Practice Guideline. AHCPR Publication Number 92-0032, Rockville MD, Agency for Health Care Policy and Research, U.S. Department of Health and Human Services, Public Health Service, 1992)
4. Jacox A, Carr DB, Payne R, et al. Management of Cancer Pain. Clinical Practice Guideline. AHCPR Publication Number 94-0592, Rockville MD. Agency for Health Care Policy and Research, U.S. Department of Health and Human Services, Public Health Service, 1994.
5. Benjamin LJ, Dampier CD, Jacox A, et al. Guideline for the Management of Acute and Chronic Pain in Sickle Cell Disease, Glenview IL, American Pain Society, 1999.
6. Simon L., Lipman AG. Guideline for the Management of Pain in Osteoarthritis, Rheumatoid Arthritis and Chronic Juvenile Arthritis. Glenview IL, American Pain Society, 2001.
7. McQuay HJ, Moore RA. An Evidence-based Resource for Pain Relief, Oxford and New York, oxford University Press, 1998.
8. Cancer Pain Relief and Palliative Care. Report of a WHO Expert Committee. (Technical Report Series 804), Geneva, World Health Organization, 1990.
9. Lipman AG, Jackson KC, Tyler LS, editors. Evidence Based Symptom Control in Palliative Care: Systematic Reviews and Validated Clinical Practice Guidelines for 15 Common Problems in Patients with Life Limiting Disease. Binghamton NY, Haworth Press, 2000. (information web site: www.haworthpress.com)
10. Lipman AG, Carr DB, Rogers WH, et al. Measuring health related quality of life in chronic pain patients. (abstract) American Pain Society, 19th Annual Meeting, Atlanta GA, November 2000.