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.
REFERENCES:
> 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 [abstract].
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4 comments:
Unfortunately, doctors really do not understand the pharmacokinetics of drugs. This applies not only to the opiate/opioid family but pretty much acros the board.
Not understanding the pharmacology is one issue, but when Schedule II drugs are involved, doctors' fear of DEA scrutiny is a major factor in the under-prescibing of these important pain medications.
I volunteer at 2 cancer centers, and am a patient advocate for the American Pain foundation. What I see is that people with cancer are being prescribed around the clock medicine but that there is very little education on the part of the providers about the difference between long-acting and short-acting medication, when they should take each, and how they are different. Typically, the prescriptions are handed to the patient with a brief note like, "This will help with your pain." Clearly, everyone involved needs more education, the docs, PA's and NP's who often write the scripts, overworked nurses, and most importantly, the patients and their family members who are last in line to know what's going on.
As a chronic pain patient for 18 years, when we are experiencing a major flare up and are directed to go to the closest Emergency Department for care, we receive less pain meds than a Cancer patient does. The pain syndrome I suffer from on the McGill Pain Scale, states our pain is double that of a Cancer patient, yet we are treated as drug seekers due to lack of adquate knowledge of some of the rare pain syndromes. I certainly don't expect an Emergency Department Physician to know all the rare pain syndromes people suffer from, all they have to do is contact our Pain Management Physicians or PCP to confirm our meds and doses. When I was working in Healthcare in an ICU, I saw so many Cancer patients undertreated for their pain for fear they might become addicted. The first thing the Physician should determine is the pain as severe as the patient says. Any patient on Opioids is obviously being treated for pain, either by a Pain Management Center, the patients Oncology Physician or PCP. If a Cancer patient is an end stage patient, why worry about addiction, just give them relief. If not yet designated terminal, or the patient is like myself, a chronic pain patient, What is needed is more education, an Emergency Department Physician who is more willing to spend just five more minutes with us when we present and provide adequate medical information. We would be treated appropriately, even if it meant being on a gurney for 8 to 12 hours in order to receive an adequate IV Doses of our pain meds or even admitted for pain control. But we are looked at like drug seekers, or drug addicts. It is unfortunate Emergency Departments don't have more Phyicians trained in Pain Management to care for patients like us, as heat or cold can cause an excruciating pain flare and our home oral pain meds, just do not work. I often feel more sorry for the Cancer patient than myself at times, as they often are dying and to deny them pain medication due to whatever caused their pain flare is cruel. The same with the elderly. There need to be clearer pain guidelines, as JCAHO's for the most part are not followed in the ED, which is part of the main hospital. This is because most Emergency Department Physicians are "Contractors" and have actually told me they are aware of JCAHO's Pain Guidelines, but because they are not a regular employee, they are exempt, which is a false understanding on their part. If a patient is in obvious severe pain, confirm if unsure how to treat them, and then treat the patient with adequate doses of IV Pain Medications, no matter what the disease is that is causing the pain. It doesn't matter what the name of the disease is that is causing the pain, understanding how to treat patients in severe pain is paramount to age or other criteria. If the patient is showing signs of being overmedicated, it's far easier to catch it and treat it in the ED, than at home.
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