Saturday, May 1, 2010

Errors in Opioid Rx for Cancer Pain Revealed

Research Update Most persons with cancer experience pain but it can be effectively managed in almost all cases. Unfortunately, guidelines for effective opioid prescribing in these patients are not being followed, according to research evidence.

Past reports have noted that 70% of persons with cancer experience significant pain and, despite the fact that such distress can be effectively controlled in up to 90% of those patients by following currently available opioid-prescribing guidelines, fewer than half receive adequate pain relief. Writing in the April 2010 edition of the Journal of Pain and Symptom Management researchers at the Cleveland Clinic Palliative Medicine Program (PMP) examined the appropriateness of opioid-prescribing patterns in 186 consecutive patients with cancer [Shaheen et al. 2010]. Appropriateness criteria were derived from several well-established guidelines. In total, 63% (n=117) of the subjects had cancer pain and 151 opioid-prescribing errors were detected; in some patients multiple errors were present. Most common were failure to order around-the-clock opioids for constant pain and the failure to prevent or treat opioid-related side effects. Multiple errors were more common in females than males, but this difference did not reach statistical significance. There was no difference in the errors by level of pain severity.

COMMENT: This recent article by Shaheen and colleagues [2010] is actually an update of a conference presentation from more than 6 years ago by essentially the same group [Davis et al. 2004]. During those intervening years they accumulated only an additional 22 cases in their study, raising questions about timeliness of the data and publication bias. In the earlier presentation, 250 prescribing errors were reported in 164 subjects, with 70% of patients having at least one error. A significant portion (40%) were “strategy errors”; eg, not matching opioid therapy properly to the type, severity, and/or temporal patterns of cancer pain. Despite the inconsistencies of reporting between the original presentation and the final published study, and the relatively small size of the study overall, it seems apparent that many practitioners are not adequately trained in treating cancer pain and/or in following accepted opioid-prescribing guidelines.

> Davis MP, Estfan B, Declan W, et al. Errors in opioid dosing principles: A prospective survey. 2004 ASCO Annual Meeting Proceedings [post-meeting ed.]. J Clin Oncol. 2004;22(14S): Abstract #8059 [
available here].
> Shaheen PE, LeGrand SB, Walsh D, et al. Errors in opioid prescribing: A prospective survey in cancer pain. J Pain Sympt Manage. 2010(Apr);39(4):702-711 [