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Professionals Consumers Pain Resources        Monday, December 01, 2008
 
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 Home : Professionals : Pain Reports : Pain Report No. 2
Dannemiller Memorial Educational Foundation
An Update on Issues, Research and Treatment Trends
Volume 1, Number 2

Editorial Board
Neil M. Ellison, MD
Lynn McPherson, PharmD
Lora McGuire, RN, MS

Supported by an unrestricted educational grant from Purdue Pharma L.P.
The Ongoing Challenges of Cancer Pain Control
It has been more than 10 years since the World Health Organization (WHO) issued its publication Cancer Pain Relief and Palliative Care. The Agency for Health Care Policy and Research then released its clinical practice guideline, Management of Cancer Pain: Adults. Following this, the American Academy of Pain Medicine (AAPM) and the American Pain Society (APS) focused on encouraging the proper use of opioids. Their consensus statement, "The Use of Opioids for the Treatment of Chronic Pain," was intended to "help foster a practice environment in which opioids may be used appropriately to reduce needless suffering and pain." In January, 2001, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) put into effect guidelines requiring hospitals and other healthcare institutions in the United States to comply with up-to-date pain assessment and management standards.

Progress in managing cancer pain during the past several decades has involved new drugs, new routes of administration, improved control of side effects, new insights into the anatomy and physiology of pain perception, and a greater understanding of how to integrate pharmacotherapeutic, psychological, and behavioral pain management approaches.1, 2 Significant educational efforts have been directed at both healthcare providers and patients. "It is now possible to be optimistic about cancer pain control," writes Dr. Declan Walsh, in a recent issue of Seminars in Oncology.3

The promise of cancer pain relief is not, however, being realized for many patients. In 1998, the Eastern Cooperative Oncology Group (ECOG) assessed the adequacy of pain relief in 1,308 outpatients with metastatic cancer. More than two-thirds of these patients (n = 871) (67 percent) had pain or were using analgesics. Of the 597 who received analgesics, 250 (42 percent) self judged their pain control to be inadequate.4

One reason cancer pain management is not more effective is that patient barriers remain to be overcome. Patients may not provide an adequate account of their pain, may feel suffering has a positive value, may fear that if pain medications are started too soon they will not be effective later, or may fear addiction and other toxicities.5 These concerns may result in poor potential compliance with recommended therapies. 6 These obstacles still exist despite increased efforts to educate patients about pain management and effective options for relief.

Healthcare professionals also must accept some responsibility for certain problems resulting in ineffective cancer pain management. A study of 243 physicians from Duluth, Minnesota, illustrates the serious level of misinformation about cancer pain and its treatments: Twenty percent stated that cancer inevitably is accompanied by pain and that treatment is not capable of fully alleviating this pain.6 Such misinformation exists despite the availability of excellent guidelines on pain management.6

The same study revealed physician misunderstandings about drug tolerance. Approximately half did not realize that the reason larger doses of morphine are needed over time is because the etiology of the pain worsens, and not because of tolerance.6

Another common misconception is that tolerance is a sign of addiction. In an effort to prevent tolerance or physical dependance from being confused with addiction, the American Academy of Pain Medicine, the American Pain Society, and the American Society of Addiction Medicine have issued a consensus document that explains that these are "discrete and different phenomena that are often confused."7 According to the document, proper definitions of these terms are:
Addiction is a primary, chronic, neurobiologic disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving.7

Physical dependence is a state of adaptation that is manifested by a drug classspecific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist.7

Tolerance is a state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drug's effects over time.7

Several studies have determined that physicians are misinformed about risks of addiction in cancer patients (although oncologists are more knowledgeable).6 Many do not realize that the risk of causing addiction for the subpopulation of patients receiving medically appropriate opioid therapy has been reported to be rare.

Healthcare providers often fail to adequately assess pain in the cancer patient.6, 8

Treating patients in pain with quality pain management and palliative care involves a holistic approach to assessment and management.8

Suffering (depression and existential distress) may be mistaken for pain and vice versa. Even if the perfect analgesic were available, the healthcare professional would not be able to use it prudently if understanding of the whole person did not guide the way the patient was being managed.8

Another essential issue is the timeliness of pain consultations in order to avoid unnecessary suffering. According to a recent study of 45 patients with pain at a tertiary care cancer center, the mean current pain intensity score was 5.2 (0 - 10 Visual Analogue Scale) before a pain consultation and 2.7 after the consultation. 9 Other recent studies of pain in cancer patients also strongly recommend that more frequent reassessment of both analgesia and side effects is mandatory to ensure optimal cancer pain relief.10, 11

It should be emphasized that we could be doing better. Currently, 70 to 90 percent of patients receiving analgesic drug therapy for cancer pain report adequate analgesia. Yet, various hospices, pain services, and palliative care programs are able to provide effective analgesia to 95 percent of patients.2 If the approach to cancer pain management used by the finest programs were to be applied nationwide, cancer patients would receive a higher level of pain relief. Instead, 45 percent of patients in the early stages of cancer and 75 percent of patients with advanced cancer currently experience some level of pain.6

Adequate knowledge of pain assessment and treatments by providers and more effective system-wide approaches to pain management are needed if overall rates of effectiveness are to be achieved. The result of adequately controlled pain will be a more functional and happier patient and family.2, 6, 8

References
  1. Fields HL, Martin JB. Pain. In: Fauci A, Braunwald E, Isselbacher Kj, et al. Harrison's Principles of Internal Medicine 14th ed New York: McGraw-Hill, 1998: 55-58.
  2. Foley KM. Supportive care and quality of life: management of cancer pain. In: DeVita VT Jr, Hellman S, Rosenberg SA. Cancer: Principles & Practice of Oncology. 6th ed. Philadelphia, Lippincott Williams & Wilkins, 2001: 2977-3010.
  3. Walsh D. Pharmacological management of cancer pain. Semin Oncol. 2000, 27, 45-63.
  4. Landis SH, Murray T, Bolden S, et al. Cancer Statistics 1998. CA Cancer J Clin 1998;48:6-29.
  5. Hartmann LC, Zahasky KM, Grendahl DC, Management of cancer pain: safe, adequate analgesia to improve quality of life. Postgrad Med 2000;107:267-276.
  6. Pargeon KL, Hailey BJ. Barriers to effective cancer pain management: a review of the literature. Journal of Pain and Symptom Management 1999;18:358-368.
  7. American Academy of Pain Medicine, American Pain Society, American Society of Addiction Medicine. Definitions related to the use of opioids for the treatment of pain. Consensus Statement, 2001. Available at: http://www.painmed.org/productpub/statements/. Accessed August 14, 2001.
  8. Payne R. Chronic pain: challenges in the assessment and management of cancer pain. J Pain Symptom Manage 2000;19:S12-S15.
  9. Manfredi, PL, Chandler S, Pigazzi A, Payne R. Outcome of cancer pain consultations. Cancer. 2000;89:920-924.
  10. Cleary JF. Cancer pain management. Cancer Control 2000;7:120-131.
  11. Lesage P, Portenoy RK. Trends in cancer pain management. Cancer Control 1999;6:136-145.

Communicating with Patients for Better Pain Management
Effective communication between the physician and patient has therapeutic benefit independent of other treatments provided. This is especially true in the management of pain where patient reports of symptoms have a paramount role. Good outcomes may result from listening, understanding, and empathizing with patients while encouraging them to discuss their pain symptoms. The effectiveness of such communication affects both the patient's willingness to report pain and his adherence to treatment recommendations. The patient's level of satisfaction with the care provided also can be enhanced with these communication techniques.1-4

For example, a 75-year-old man with residual metastatic cancer of the prostate was being treated for chronic back pain. Pain symptoms, although stable for months, had suddenly become more severe even while tests indicated the cancer had not progressed. Additional tests showed that arthritis was not causing the pain. Increased doses of pain medications did not remedy the problem. The physician began to consider "psychological factors (the stress of malignancy and its treatment), family matters (deteriorating relationships with his wife and children) and social issues (financial pressures, loss of a supportive friend)." Gradually, the physician discovered that the patient's wife had expressed concern about the level of care she was providing and the patient felt his sons were visiting less frequently. The patient saw himself "becoming a burden to his family." The physician arranged for family counseling. Afterwards, the patient continued to require pain medication at established doses, but did not complain of back pain nor request additional pain medications.5

Patients may consciously or unconsciously place impediments in the way of discussing their pain symptoms. For example, the patient may believe it is socially unacceptable to discuss pain, that stoicism is a virtue, or that "good" patients do not complain of pain.2,3 Other patients are reluctant to say anything about pain fearing it will distract the provider from the goal of achieving a cure of the medical problem causing the pain symptom.2, 6

Patient misconceptions about opioids are extremely common. A misguided fear of addiction occurs in the majority of patients. Many do not understand that, unlike physical dependance and tolerance, addiction is characterized by "impaired control over drug use," "compulsive use," and "continued use despite harm and craving."7 Secondary side effects of opioids such as loss of functionality are major concerns also. Healthcare professionals should explain the facts about physical dependence, addiction, and tolerance. Tolerance refers to "a state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drug's effects over time."7 Gradual increases in opioid doses should overcome this. Although most patients will become physically dependent on opioids when used regularly for more than several weeks, opioids can be easily tapered and discontinued if the source of the pain is treated and eliminated. No prolonged detoxification or withdrawal program is necessary as would be needed for the patient who is psychologically addicted to narcotics.2, 8

Opioids are effective analgesic medications for moderate to severe pain. The most common side effects are usually not serious (nausea, somnolence, constipation) and can be effectively managed. Patients and families should understand that the goal of opioid use for pain management should be to decrease the pain in order to improve functionality.2, 8

Subgroups of patients exist that are predictably more likely to be undermedicated with analgesics for pain syndromes. These include patients with cultural, educational, or socioeconomic backgrounds significantly different from their physician's. Other groups present special challenges, such as the frail elderly, babies and children, the cognitively and emotionally impaired, and patients with a current or previous history of substance abuse.9-11

Professional educational deficiencies about pain assessment and management are likewise problematic. Some professionals assume that if pain were a serious problem the patient would complain about it spontaneously. Other professionals feel greater competency at providing therapy for diseases than at managing pain symptoms. Still others rush through discussions about pain because time may not permit them to address both disease management and pain management.2

The American Academy on Physician and Patient has formulated helpful suggestions about how to improve the clinical negotiation that occurs during the medical interview.1,12 Recommended strategies for resolving impediments to provider-patient communication include:12
  • Educate and empower the patient. This approach is most successful when an effective relationship between the patient and the professional has been established.
  • Expand the way you define the nature of the patient's problem. Make use of the patient's own language, cultural beliefs, and attitudes in doing so.
  • Discuss possible treatment alternatives. Avoid premature, negative, or sharp criticism of suggestions formulated by patients and develop a new list of options.
  • Share decision making with the patient. Patients who are reluctant to use opioids might be more compliant if the drugs are presented as being one part of the recommended solution, such as patient-controlled analgesia. Volunteer to delay a decision until the patient is comfortable with it. Offer to call or meet with a member of the patient's family, if that is what the patient wants.
Fundamental strategies for improving the effectiveness of your discussions with patients about pain symptoms emphasize active and reflective listening, empathy, and nonjudgemental discussions.3 Explore the patient's frame of reference. (Does the patient say he has arthritic pain even though you realize the pain is due to metastatic cancer to the bone? What is the effect of the pain on the patient's overall well being? Will the reality of the discussion about pain be difficult for the patient? Should support mechanisms be in place when you initiate the conversation?)12

Oftentimes a conflict between the patient and the provider is caused by a misunderstanding or miscommunication. For example, your goal may be to relieve the patient's pain while his may be to retain his dignity and sense of control. The fear that pain may indicate disease progression, cessation of anticancer treatments, and "giving up" can thwart discussions. Adequately address concerns. This will facilitate cooperation toward the goal of pain relief.12

References
  1. Lipkin M Jr, Putnam SM, Lazare A. The Medical Interview: Clinical Care, Education, and Research. New York, Springer-Verlag, 1995:1-643.
  2. Portenoy RK. Quality-of-life issues in patients with head and neck cancer. In: Harrison LB, Sessions RB, Hong WK. Head and Neck Cancer: A Multidisciplinary Approach. Philadelphia, Lippincott-Raven, 1999: 217-230.
  3. Matthews DA, Suchman AL, Branch WT. Making 'connexions': enhancing the therapeutic potential of patient-clinician relationships. Ann Intern Med 1993;118:973-977.
  4. Thomason, TE, McCune JS, Bernard SA, et al. Cancer pain survey: patient-centered issues in control. J Pain Symptom Manage 198, 15:275-284.
  5. Kaplan C. Hypothesis Testing. In: Lipkin M Jr, Putnam SM, Lazare A. The Medical Interview: Clinical Care, Education, and Research. New York, Springer-Verlag, 1995:20-31.
  6. Cleeland CS, Gonin R, Hatfield AK, et al. Pain and its treatment in outpatients with metastatic cancer. N Engl J Med 1994;330:592-596.
  7. American Academy of Pain Medicine, American Pain Society, American Society of Addiction Medicine. Definitions related to the use of opioids for the treatment of pain. Consensus Statement, 2001. Available at: http://www.painmed.org/productpub/statements/. Accessed August 14, 2001.
  8. Fields HL, Martin JB. Pain: pathophysiology and management. In: Braunwald E, Fauci AS, Kasper DL, et al. Harrison's Principles of Internal Medicine 15th ed. New York; McGraw-Hill, 2001:55-60.
  9. Turk DC, Okifuji A. Assessment of patients' reporting of pain: an integrated perspective. Lancet 1999;353:1784-1788.
  10. Mance R, Cohen-Cole SA. Interviewing the psychotic patient. In: Lipkin M Jr, Putnam SM, Lazare A. The Medical Interview: Clinical Care, Education, and Research. New York, Springer-Verlag, 1995:275-283.
  11. Putnam SM, Lipkin M Jr, Lazare A, et al. Personality styles. In: Lipkin M Jr, Putnam SM, Lazare A. The Medical Interview: Clinical Care, Education, and Research. New York, Springer-Verlag, 1995:251-274.
  12. Lazare A. The interview as a clinical negotiation. In: Lipkin M Jr, Putnam SM, Lazare A. The Medical Interview: Clinical Care, Education, and Research. New York, Springer-Verlag, 1995: 50-62.

Evidence-Based Strategies Improve Pain Management Outcomes
Healthcare institutions are faced with the task of formulating and implementing plans that will effectively change how professionals and patients address pain management. What specific policies, procedures, and leadership activities should these institutions — and the doctors, nurses, pharmacists and administrators who run them — adopt?

One useful model of successful institution-wide transformation in pain management is provided by The Pain Project of the Abbott Northwestern Hospital in Minneapolis and described in a recent edition of Quality Management in Health Care.1

Applying guidelines and implementation suggestions developed by the Agency for Health Care Quality and Research (AHCQR) [formerly, the Agency for Health Care Policy and Research (AHCPR)], the project demonstrated that evidence-based content can be used to improve pain management and achieve "measurable improvement in patient, provider, and system outcomes."1

The first of the project's four objectives was to "increase evidence-based pain management by physician, nurses, and pharmacists." To achieve this, the project conducted an 8-hour education program for all nurses and pharmacists, and implemented standard physician orders for surgical and oncology patients' pain management. The actual orders, as written by inspanidual physicians, were revised if necessary. Variation was permitted depending upon the clinical situation. Models of "pain plans of care" were developed and provided. The project developed specific outcome measures to quantify successes in achieving each desired outcome.1

The second project objective was to educate patients about pain management. The goal was to achieve prompt evaluation and effective treatment. This would result in a decreased incidence and severity of surgical and cancer-related pain, and, hopefully, increased patient satisfaction with pain management. The third objective was to reduce the incidence and severity of surgical and cancer-related pain, and increase patient satisfaction with pain management. The final objective was ensuring ongoing institutional commitment and accountability to pain management.1

Project team members, all of whom participated for the entirety of the 3-year project period, included a clinical nurse specialist, a clinical pharmacist, a physician, a researcher, and the program director.1

A review of data and outcomes was used to assess the impact of implementation of the overall program.1 Institutional commitment and support, and "relentless leadership," were important components of the approach taken. Outcomes were measured using data collected by interview, questionnaire, and chart audit. Patients' pain experience and knowledge and providers' knowledge and attitude were measured.

Additional data was also acquired using the hospital information system.1

The article in Quality Management in Health Care analyzed project outcomes across populations of patients and providers. The following outcomes were achieved:
  • Patient satisfaction with pain management increased from 14% to 19%. (Precisely how patient pain interviews and patient pain questionnaires were graded was not described)
  • Ambulation improved. The number of patients reporting that moderate or severe pain interfered with walking decreased from baseline determinations (gynecology patients decreased by 24%, orthopedic patients decreased by 14%, and oncology patients decreased by 13%; there was no change among the coronary artery bypass patients)
  • Overall opioid-related side effects (nausea, constipation, and drowsiness) did not increase despite an increase in opioid analgesia use. The number of patients reporting moderate or severe nausea decreased by 22 %
  • Documentation of "pain plans of care" increased by an average of 40%
  • Morphine use increased and meperidine use decreased
  • Intramuscular opioid administration was virtually eliminated
  • Patient-controlled analgesia and epidural pain management were utilized more frequently.1
Other institutional examples of effective plans for improved pain management also have been reported.2-6 Some models have been specifically designed to teach clinical nurses how to improve cancer pain management. Others were designed to provide a model and guide for nursing managers who are attempting to organize an effective 'Pain Management Task Force.' Another article describes issues encountered by a team of physicians and other professionals who worked together to implement the acute pain and cancer pain guidelines issued by the Agency for Health Care Policy and Research at an academic medical center.2-6

Providers and administrators seeking other models of successful institution-wide transformation in pain management might also consult an account of the use of 'critical pathways' to increase awareness of problematic aspects of pain management and to institutionalize pain management.5 Critical pathways are tools used to plan and document care for patients within a system of case management. A report on the collaborative quality improvement project instituted in 15 collaborating hospitals presented outcome data related to 6 quality indicators. The quality indicators examined whether an intramuscular route of administration, administration on an as-needed basis, and the drug meperidine were avoided; whether nonpharmacological pain control and self-report pain scales were used; and whether pain assessment was frequent or not. Statistically significant improvements in all of these quality indicators were achieved using the approach described.6

Institution-wide improvement of pain management is a major objective for many hospitals and achieving success requires overcoming numerous obstacles. Foremost among these obstacles reported in The Pain Project's article in Quality Management in Health Care was overcoming the "mindset" of health care providers regarding the importance of pain and its treatments.1

For detailed information see the project's Manual, which is available by writing to Abbott Northwestern Hospital B11404, Clinical Research Office, 800 East 28th Street, Minneapolis, MN 55407-3799.

References
  1. Miller EH, Belgrade MJ, Cook M, et al. Institutionwide pain management improvement through the use of evidence-based content, strategies, resources, and outcomes. Qual Manag Health Care 1999;7:28-40.
  2. Grant M, Rivera LM, Alisangco J, Francisco L. Improving cancer pain management using a performance improvement framework. J Nurs Care Quality 1999;13:60-72.
  3. Angelucci D, Quinn L, Handlin D. A pain management relief plan. Nurs Manage 1998;29:49-54.
  4. Schmidt KL, Alpen MA, Rakel BA. Implementation of the Agency for Health Care Policy and Research Pain Guidelines. AACN Clin Issues 1996;7:425-435.
  5. Gordon DB. Critical pathways: a road to institutionalizing pain management. J Pain Symptom Manage 1996;11:252-259.
  6. Tavris DR, Dahl J, Gordon D., et al. Evaluation of a local cooperative project to improve postoperative pain management in Wisconsin hospitals. Qual Manag Health Care 1999;7:20-27.
  7. Kilo CM. A framework for collaborative improvement: lessons from the Institute for Healthcare Improvement's Breakthrough Series. Qual Manag Health Care 1998;6:1-13.

Hospice Pain Management – The Role of the Interdisciplinary Hospice Team
Pain is a common problem for patients admitted to hospice programs. The hospice team should move rapidly to achieve pain control. Inadequate pain control can contribute to insomnia, anxiety, depression, and hostility. Patients may have been taking several medications to address these symptoms. Once pain is adequately addressed and assessed, other medications with significant toxicities and costs may be eliminated if they are no longer necessary.1

A major problem the hospice team faces is the undertreatment of pain. Cancer is the most common diagnosis among hospice patients and cancer pain is the most common symptom described by patients with malignancies.2,3 "Even if the ideal analgesic drug was discovered, it would probably be as underused as are current analgesic drugs," writes Michael H. Levy, M.D., in The New England Journal of Medicine.3

"One key to multiplying a hospice's success in ensuring comfort at the end of life lies in educating health professionals (and correcting miseducation) about the properties and use of opiates," according to a JAMA article by Zail S. Berry, MD, and Joanne Lynn, MD.2

Tips on how an interdisciplinary hospice team can improve pain management are discussed in a recent Journal of the American Medical Association (JAMA) article. The article reports on presentations by Joni Berry, MS Pharm, and Stephen Arter, RPh, BS Pharm.1 Their recommended strategy for achieving pain control in newly admitted hospice patients often involves doubling — and then, if necessary, doubling again — the opioid dose the patient was receiving prior to admission. Only then can the patient's overall symptoms be evaluated effectively, according to Joni Berry.1 "Almost never" is true drug-seeking behavior seen with this approach, she added, although patients exhibit "pain-relief-seeking behavior, which is appropriate for anyone who's been in pain for any length of time."1

Hospice patients should be screened at the initial assessment for duplications or unnecessary drugs and evaluated to determine whether any additional medications might be of benefit. A helpful tip is to make use of the chaplain or social worker on the interdisciplinary hospice team to provide hints about the relationship between physical symptoms and psychosocial events impacting the inspanidual patient.1

Another important focus of the hospice team should be to address the patient as well as the family. Family members are actively involved in the care of the patient, telephoning healthcare professionals and providing information about the patient's condition.4 If the family is opiophobic, the patient may suffer for it. Thus, the hospice team must educate the family about pain management in general and about the safety and effectiveness of opioids specifically.

The probability that a nursing home will be the site of death had increased to 20 percent as of 1995.5, 6 An attempt is being made to increase the hospice care provided in nursing homes. As recently as 1997, 70 percent of nursing homes had no hospice patients. Changes in health policy, quality standards, and reimbursement are essential to improving the quality of life and accessibility to quality care of dying patients.5

Ethical as well as medical imperatives require that hospice teams furnish adequate pain management. To inadequately treat patients who are suffering with pain is now considered unethical, according to Eric Kodish, MD, Peter. A. Singer, MD, and Mark Siegler, MD, writing on "Ethical Issues In Palliation and Hospice Care" in DeVita et al's, Cancer: Principles and Practice of Oncology. "The undertreatment of cancer pain is a formidable ethical problem in clinical oncology, which," the authors state, "merits the attention of all health care practitioners in this field."7

References
  1. Friedrich MJ. Experts describe optimal symptom management for hospice patients. JAMA 1999;282:1213-1214.
  2. Berry ZS, Lynn J. Hospice Medicine. JAMA 1993;270:221-222.
  3. Levy MJ. Pharmacologic treatment of cancer pain. N Engl J Med. 1996:335:112401132.
  4. Pickett M, McCorkle R. Care of the dying patient. In: Kelley WN. Textbook of Internal Medicine. 3rd ed. Philadelphia, Lippincott-Raven, 1997:215-219.
  5. Zeran J, Stearns S, Hanson L. Access to palliative care and hospice in nursing homes. JAMA 2000;284:2489-2494)
  6. Keay TJ, Lynn J. Care of the dying patient. In: Hazzard WR, Blass JP, Ettinger WH Jr., Halter JB, Ouslander JG. Principles of Geriatric Medicine and Gerontology. New York, McGraw-Hill, 1999: 537-544.
  7. Kodish E, Singer PA, Siegler M. Ethical Issues In: DeVita V, Hellman S, Rosenberg SA, Cancer: Principles and Practice of Oncology 5th ed. Philadelphia, Lippincott-Raven, 1997:2973-2981.

The Pharmacist's Role in Cancer Pain Management
There is conflicting data on how well pharmacists are prepared to address cancer pain management. A study of 141 pharmacists registered in North Carolina who responded to a survey determined that "pharmacists surveyed were knowledgeable regarding the problem of undertreatment of cancer pain." Of the 141 North Carolina pharmacists who responded to the survey, 38.5 percent practiced in a chain, 25.9 percent in a hospital, and 25.2 percent in a community pharmacy. Nursing homes, schools of pharmacy, and managed care sites constituted the remaining sites of practice.1

Over 80 percent of respondents were aware that most cancer patients experience pain at some time during the course of the illness and that over 85 percent realize that the nurse should believe the patient's report of pain and consider the patient to be the best judge of the intensity of the pain.1

Forty-four percent understood that the conservative opioid administration patterns of nurses is a potential barrier to effectively addressing cancer pain. Fifty-one percent of the North Carolina pharmacists perceived conservative prescribing patterns of physicians as a potential barrier to cancer pain management.1

Forty-three percent of the pharmacists surveyed had attended a continuing education program on cancer pain management. Eighty-five percent of those surveyed reported working with "fewer than 50 cancer patients within the previous six months." Twenty-nine percent of respondents spoke frequently with cancer pain patients about pain management therapy, and 54 percent spoke with the patient's family about pain management.1

A survey of physicians, pharmacists, and nurses in New Hampshire found that "nurses were the most knowledgeable and pharmacists the least knowledgeable about pain assessment."2 The New Hampshire study determined that although 12 percent of respondents overall believe a patient's report of pain is less reliable than her or his report of nausea, 22 percent of pharmacists hold this view. Although 47 percent of physicians and 47 percent of nurses reported that the adequacy of their training on cancer pain management was either good or excellent, 29 percent of pharmacists reported this. Physicians and nurses reported that 81 percent and 74 percent, respectively, were either comfortable or very comfortable in managing cancer pain; in contrast 60 percent of pharmacists self-reported the same comfort levels.2

Furthermore, the authors of the study observe that a "high percentage" of the pharmacists in the New Hampshire sample demonstrated lack of fundamental knowledge about doses, routes, and schedules of opioid administration. Fifty-four percent of pharmacists thought severe pain commonly required parenteral morphine; 14 percent did not believe that providing opioids on a regular schedule provided more effective analgesia than ‘as needed' (PRN) administration; 28 percent did not think that the appropriate dose of morphine is whatever relieves the pain.2

In addition, many of the New Hampshire pharmacists misunderstood issues relating to drug tolerance. Eighteen percent believed strong opioids should be saved until a patient is terminal because drug tolerance may develop and only 43 percent believed a patient's request for increasing amounts of analgesia is the result of disease progression. 2

The authors of the New Hampshire study recommended the development of novel educational initiatives to provide information on cancer pain even to professionals who see relatively few cancer patients. They also suggested an expansion of the availability of continuing education programs for cancer pain medicine be expanded.2

To place both the North Carolina and the New Hampshire studies in perspective, it should be stated that major positive developments in the field of pain management are occurring. This is summarized in a recent article on cancer pain management in the Journal of the American Pharmaceutical Association. The development of guidelines on pain medicine, the appearance of improved pharmaceuticals and improved delivery methods, the completion of important scientific studies on the adequacy of pain management, the availability of well-tested pain assessment instruments, and the efforts of patient and provider advocacy groups are all expanding the potentials for pain therapy.3 The same report, however, identified barriers to effective cancer pain management. These include inadequate provider training, patient reluctance to report pain, and "deficiencies within the health care infrastructure, such as restrictive regulation of controlled substances and inadequate insurance coverage."3

In addition, pharmacists' apprehensions about stocking and dispensing opioids constitutes a barrier,3,4 impacting upon the conservative prescribing patterns of many physicians. A study of 347 pharmacies in New York City found that while 72 percent of pharmacies in predominantly white neighborhoods carried adequate opioids to treat patients in severe pain only 25 percent of those in predominantly nonwhite neighborhoods stocked these opioid analgesics.4

Pharmacists' own "inability to adequately assess cancer pain" may also limit pharmaceutical care. For example, "pharmacists may not recognize when a patient is receiving inadequate analgesic relief."3 Bonomi et al., have published a follow-up article devoted to teaching pharmacists how to use quality-of-life measures in everyday practice.5

There is conflicting data on how well pharmacists are prepared to address cancer pain management. Pharmacists who practice in a hematology-oncology center frequently have a more in-depth comprehension of pain medications than other pharmacists. A recent study demonstrates that these pharmacists complete such important tasks as correcting prescribing errors, engaging in clinical consultations, and participating in patient treatment procedures.6 The authors of this study suggest that if pharmaceutical care efforts were documented more thoroughly, the importance of pharmacy staff interventions would be better appreciated and opportunities for quality improvement more readily recognized.6

The management of cancer pain in the United States is improving and pharmacists are playing key roles. "Pharmacists, because of their access to patients and their pharmacologic expertise," write Bonomi et al., in the Journal of the American Pharmaceutical Association, "are well positioned to contribute to and shape cancer pain management strategies in the United States today."3

References
  1. Krick SE, Lindley CM, Bennett M, Pharmacy-perceived barriers to cancer pain control: results of the North Carolina Cancer Pain Initiative pharmacist survey. Ann Pharmacother 1994;28:857-862.
  2. Furstenberg CT, Ahles TA, Whedon MB, et al. Knowledge and attitudes of health-care providers toward cancer pain management: A comparison of physicians, nurses, and pharmacists in the state of New Hampshire. J Pain Symptom Manage 1998;15:335-349.
  3. Bonomi AE, Ajax M, Shikiar R, Halpern M. Cancer pain management: barriers, Trends, and the role of pharmacists. J Am Pharm Assoc 1999;39:558-568.
  4. Morrison RS, Wallenstein S, Natale DK, Senzel RS, Huang LI. "We don't carry that" — failure of pharmacies in predominantly nonwhite neighborhoods to stock opioid analgesics. N Engl J Med 2000;342:1023-1026.
  5. Bonomi AE, Shikiar R, Legro MW. Quality-of-life assessment in acute, chronic, and cancer pain: a pharmacist's guide. J Am Pharm Assoc 2000;40:402-416.
  6. Waddell JA, Solimando DA Jr, Strickland WR, Smith BD, Wray MK. Pharmacy staff interventions in a medical center hematology-oncology service. J Am Pharm Assoc 1998;38:451-456.