Friday, December 2, 2011

Acute & Cancer Pain Shamefully Undertreated

Acute Pain Two new surveys in the U.S. have found that nearly 45% of patients with acute pain may receive inadequate analgesia and a quarter of persons with cancer pain are not taking analgesics at all. Various factors contribute to insufficient pain relief, such as patient age, side effects of medications, fear of addiction, and inability to pay for analgesics. And, the problems are of worldwide crisis proportions.

Moderate-to-Severe Acute Pain Undertreated

Writing in the Journal of Opioid Management, Bruce L. Moskovitz, MD, and fellow researchers from Ortho-McNeil Janssen Scientific Affairs assessed data from the Physicians Partnering Against Pain (P3) survey to evaluate patients’ perceptions of the adequacy of analgesia for moderate-to-severe acute pain and the influence of opioid-related side effects [Moskovitz et al. 2011]. This largest survey of its kind involved 5,982 physicians — mainly primary care practitioners — who recruited 50,869 patients with acute pain to complete questionnaires between September and November 2008. All were ≥18 years of age, with 16% ≥65 years old (including 6% ≥ age 75), and 57% were female.

Results showed that 22,267 (44%) of all patients had received potentially inadequate analgesia, including 46% of those aged 65 to 74 years and 52% of those ≥75 years of age. Approximately 78% of all patients (39,675) were treated with an opioid and more than a quarter (28%) experienced at least one gastrointestinal side effect: nausea, vomiting, and/or constipation. Some of these patients experienced multiple adverse effects and many stopped taking the medication (13%) or reduced the dose (16%) to contend with them.

Reports of inadequate analgesia for moderate-to-severe acute pain encompassed all age groups; however, older patients were significantly less likely than younger patients to be afforded adequate pain relief. Merely receiving an opioid was insufficient for many patients, since weak opioids often were inappropriately prescribed for severe pain. The researchers do not report or comment on why common adverse effects such as nausea, vomiting, and/or constipation were such deterrents to patient compliance, since these are common side effects that either dissipate or can be medically managed.

The researchers do note that better education and counseling for patients is needed regarding potential adverse effects with opioid therapy and better training is needed for prescribers on proper acute pain management. Along with that, practitioners need better education on selecting analgesics that are appropriately strong enough to manage acute pain.

Most Patients with Cancer Have Pain; Many Not Taking Analgesics

Researchers from the University of Pennsylvania, Philadelphia, and the National Cancer Institute, Bethesda, Maryland, constructed an online survey questionnaire to assess pain control and analgesic usage among patients with cancer [Simone et al. 2011]. The survey was posted on the OncoLink website [] from November 2005 through July 2008, and 1,107 persons voluntarily participated.

Respondents were primarily female (73%), white (74%), educated beyond high school (64%), and had surgery (69%), chemotherapy (64%), and/or radiation (47%). Most had breast (30%), gastrointestinal (12%), gynecologic (11%), or lung (8%) malignancies.

A majority of respondents (67%) reported having pain, with 48% attributing pain to their cancer and 47% from their treatment for cancer. Among patients with pain, a surprising 25% reported not using analgesics at all. Overall, use of analgesics was significantly less in men, minorities, and patients with lower education levels. Usage varied by cancer diagnosis and was higher among patients who received chemotherapy and radiation. Reasons for not taking analgesics included: healthcare provider not recommending pain medications (85%), fearing addiction/dependence on pain relievers (80%), and inability to pay (76%).

COMMENTARY: Too Much Pain; Too Little Pain Relief

At the outset, it should be noted that both surveys above have limitations. First, there is the question of who volunteers for surveys of this sort and whether they represent an unbiased sampling of the affected population. Secondly, there are many potential sources of error or confusion when patients respond unassisted to paper or online questionnaires. The first study above by Moscovitz and colleagues may have been large enough to overcome these deficiencies but the second survey, with only about 1,100 respondents, probably had numerous sources of bias. Despite the limitations, these two studies suggest, at least anecdotally, alarming and disappointing prevalences of pain without adequate relief among many patients experiencing acute or cancer pain.

Still, the results are not entirely surprising. In previous Pain-Topics UPDATES articles [here] and [here] we observed how patients in America have only a 1 in 4 chance of receiving adequate acute pain relief following surgery, three-quarters of persons are discharged from hospital emergency departments with moderate-to-severe pain, and the elderly or economically disadvantaged are at special risk of receiving inadequate pain care. Another article [UPDATE here] commented on existing racial and ethnic inequities in the treatment of all pain conditions, across all age groups, and in all treatment settings throughout the U.S. And, most recently [here], we reported on a survey of cancer specialists (oncologists), which found that many have relatively little training and knowledge when it comes to assessing and managing their patients’ pain.

What is surprising is that, while there are ongoing controversies about appropriate analgesic therapies for noncancer chronic pain, it has been generally assumed by healthcare professionals and the public that the management of acute and cancer pain is well under control. Apparently, this is far from true — and it is shameful.

If there are overbearing concerns about opioid analgesics — many of which are unfounded myths but create “opiophobia” nonetheless — there are still many nonopioid analgesics to choose among for acute pain, as discussed in a recent evidence review [UPDATE here]. And, there seems no excuse for patients with cancer pain to suffer without any analgesic medication at all. Furthermore, reasons why older patients, minorities, and the socioeconomically disadvantaged do not have access to adequate relief for acute and cancer pain should be a high-priority topic for national discussion and legislative inquiry.

Finally, there is ample evidence that these problems are not unique to the U.S. and the undertreatment of acute and cancer pain is a crisis of global proportions. In a prior UPDATE [here] we discussed how disparities in access to adequate pain care worldwide are staggering and in some places pain is being mistreated or untreated almost to the point of being considered torture.

> Moskovitz BL, Benson CJ, Patel AA, et al. Analgesic treatment for moderate-to-severe acute pain in the United States: Patients’ perspectives in the Physicians Partnering Against Pain (P3) Survey. J Opioid Manag. 2011;7(4);277-286 [
> Simone CB 2nd, Vapiwala N, Hampshire MK, Metz JM. Cancer Patient Attitudes Toward Analgesic Usage and Pain Intervention. Clin J Pain. 2011; online ahead of print [