Barriers to Successful Barriers to Successful Treatment of Cancer Treatment of Cancer

PainPain

Suresh Kannan, MDSuresh Kannan, MD

Florida Hospital, OrlandoFlorida Hospital, Orlando

ObjectivesObjectives

To highlight the discrepancy between current To highlight the discrepancy between current state of medical knowledge and prevailing state of medical knowledge and prevailing practice of pain management in cancer patientspractice of pain management in cancer patients

To analyze barriers that prevent effective To analyze barriers that prevent effective treatment of cancer pain treatment of cancer pain

To propose solutions to promote effective To propose solutions to promote effective cancer pain management cancer pain management

The Scream Edvard Munch

PainPain

An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.

International Association for the Study of Pain (IASP)

SufferingSuffering

Suffering is experienced by persons, not merely by bodies, and has its source in challenges that threaten the intactness of the person as a complex social and psychological entity. Suffering can include physical pain but is by no means limited to it.

Eric J Cassel The Nature of Suffering and the Goals of Medicine, N Engl J of Med 1982; 306:639-45.

The Broken Column

Frida Kahlo

Cancer PainCancer Pain

10 million new cases diagnosed annually*10 million new cases diagnosed annually* Moderate to severe pain experienced by Moderate to severe pain experienced by

40% to 50% of cancer patients40% to 50% of cancer patients Very severe pain experienced by 25% to Very severe pain experienced by 25% to

30% of cancer patients 30% of cancer patients 80% of terminal stage cancer experience 80% of terminal stage cancer experience

moderate to severe painmoderate to severe pain

Brennan F, Carr DB, Cousins MJ. Pain Management: A Fundamental Human Right. Anesth Analg 2007; 105:205-21

Cancer PainCancer Pain

Pain Syndromes in Cancer Patients

Pain caused by anticancer

therapy25%

Coincidental Pain

<10%

Pain caused by cancer>65%

Chronic pain in Cancer SurvivorsChronic pain in Cancer Survivors

Post treatment pain syndromesPost treatment pain syndromes Post-surgical pain syndromesPost-surgical pain syndromes Post radiation therapy neuralgiasPost radiation therapy neuralgias Post-chemotherapy neuropathyPost-chemotherapy neuropathy

Burton AW, et al. Chronic Pain in the Cancer Survivor: A New Frontier. Pain Medicine 2007; 8: 189-198.

Approaches to cancer pain Approaches to cancer pain managementmanagement

Primary TherapiesPrimary Therapies Radiation TherapyRadiation Therapy ChemotherapyChemotherapy ImmunotherapyImmunotherapy SurgerySurgery AntibioticsAntibiotics

Symptomatic Symptomatic TherapiesTherapies

PharmacotherapyPharmacotherapy InterventionalInterventional Physical ModalitiesPhysical Modalities PsychologicalPsychological Complementary & Complementary &

AlternativeAlternative

AMA CME Module 11: Pain Management. Cancer Pain: Pharmacotherapy

Assessment of PainAssessment of Pain

COGNITION

EMOTION

SOCIO-ENVIRONMENT

PSYCHO-SOCIAL THERAPIES

Somatic Therapies

Multidimensional aspect of Cancer pain

Barriers to treatmentBarriers to treatment

Barriers related to health care Barriers related to health care professionalsprofessionals

Barriers related to patientsBarriers related to patients

Barriers related to the healthcare systemBarriers related to the healthcare system

Barriers related to patientsBarriers related to patients

Reluctance to report painReluctance to report pain Belief that cancer is inevitable in cancerBelief that cancer is inevitable in cancer Fear pain portends progress of cancerFear pain portends progress of cancer Fear of alienating care giversFear of alienating care givers Reluctance to take pain medication*Reluctance to take pain medication* High costs of medications and treatmentsHigh costs of medications and treatments Fear of addiction, side effects of medicationFear of addiction, side effects of medication

Barriers related to health care Barriers related to health care systemsystem

Low priority given to cancer pain treatmentLow priority given to cancer pain treatment Priority on curing cancer Priority on curing cancer Restrictive regulation of controlled Restrictive regulation of controlled

substancessubstances Inadequate reimbursementInadequate reimbursement Failure to recognize pain as a major cause Failure to recognize pain as a major cause

of disabilityof disability Problems of availability of treatmentsProblems of availability of treatments

Barriers related to healthcare Barriers related to healthcare professionalsprofessionals

“Unbelievably, American doctors regularly refuse to prescribe effective doses of narcotic pain killers to dying patients on the grounds that the patients might become addicted. The treatment of cancer pain, clearly, is still not based solely on scientific fact but draws on ignorance, fear, prejudice, and on an invisible, unacknowledged moral code expressing half-baked notions about evil of drugs and the duty to bear affliction.”

- Dick Morris from The Culture of Pain

Barriers related to healthcare Barriers related to healthcare professionalsprofessionals

Inadequate knowledge/training in pain Inadequate knowledge/training in pain managementmanagement

Inadequate pain assessmentInadequate pain assessment Concerns about regulation of controlled Concerns about regulation of controlled

substancessubstances Fear of patient addictionFear of patient addiction Ethnic/racial/gender/age biasesEthnic/racial/gender/age biases Negative feelings towards pain patientsNegative feelings towards pain patients

Barriers to cancer pain Barriers to cancer pain managementmanagement

Von Roenn, J. H. et. al. Ann Intern Med 1993;119:121-126

Barriers PercentageBarriers Percentage

Inadequate pain assessment 76%Inadequate pain assessment 76%

Pt. reluctance to report pain 62%Pt. reluctance to report pain 62%

Pt. reluctance to take opioids 62%Pt. reluctance to take opioids 62%

Physician reluctance to prescribe opioids 61%Physician reluctance to prescribe opioids 61%

Inadequate knowledge of pain mgt. 52%Inadequate knowledge of pain mgt. 52%

Excessive regulation of opioids 18%Excessive regulation of opioids 18%

Legal BarriersLegal Barriers

Estate of Henry James v. Hillhaven Estate of Henry James v. Hillhaven Corporation (1991)Corporation (1991)

Bergman v. Chin(1999)Bergman v. Chin(1999)

Ethical Analysis of the Barriers to Ethical Analysis of the Barriers to Effective Pain ManagementEffective Pain Management

Major criticism of the “ barriers literature” is the Major criticism of the “ barriers literature” is the failure to analyze these barriers from an ethical failure to analyze these barriers from an ethical perspectiveperspective

Curative versus palliative models of medicineCurative versus palliative models of medicine Disparity between current state of medical Disparity between current state of medical

knowledge and prevailing practice of pain knowledge and prevailing practice of pain managementmanagement

Irrational beliefs about addiction, tolerance and Irrational beliefs about addiction, tolerance and adverse side effectsadverse side effects

Rich BA. An Ethical Analysis of the Barriers to Effective Pain Management. Cambridge Quarterly of Healthcare Ethics 2000, 9, 54-70.

EthicsEthics

“ To allow a patient to experience unbearable pain or suffering is unethical medical practice.”

Wanzer SH, et al. The Physician’s responsibility towards hopelessly ill patients – a second look. N Engl J Med 1989; 320:844-9

Matching Interventions to BarriersMatching Interventions to Barriers

Barriers related to patientsBarriers related to patients Barriers related to healthcare Barriers related to healthcare

professionalsprofessionals Barriers related to healthcare systemsBarriers related to healthcare systems

Patient Barriers/InterventionsPatient Barriers/Interventions

Inevitability of PainInevitability of Pain

Distracting from Distracting from cancer treatment.cancer treatment.

Fears of AddictionFears of Addiction

Inadequate Pain reliefInadequate Pain relief

Patient EducationPatient Education

Pt. Bill of RightsPt. Bill of Rights

Information on Information on narcotics narcotics

Empower patient Empower patient

(PCA-IV/Oral)(PCA-IV/Oral)

Physician Barriers/InterventionsPhysician Barriers/Interventions

Lack of KnowledgeLack of Knowledge Lack of MotivationLack of Motivation

-Education (Topmed) - Incentives/sanctions-Education (Topmed) - Incentives/sanctions

-EBM Guidelines-EBM Guidelines

Beliefs/Attitudes Beliefs/Attitudes Turf IssuesTurf Issues

-Peer Influence -Multidisciplinary -Peer Influence -Multidisciplinary

-Opinion leaders approach-Opinion leaders approach

Legal Barriers?Legal Barriers?

Prescribing PracticePrescribing Practice

EvaluationEvaluation Individualized Treatment PlanIndividualized Treatment Plan Informed ConsentInformed Consent Treatment (narcotic) AgreementTreatment (narcotic) Agreement Periodic ReviewPeriodic Review Multidisciplinary ConsultationMultidisciplinary Consultation Medical RecordsMedical Records Comply with Laws and RegulationsComply with Laws and Regulations

Prescribing PracticePrescribing Practice

Request old medical recordsRequest old medical records Collaborate with pharmacistsCollaborate with pharmacists Photo identificationPhoto identification Prescription padsPrescription pads Prescription monitoring programsPrescription monitoring programs Identifying the drug seeking patient*Identifying the drug seeking patient*

Opioid abuse-deterrent Opioid abuse-deterrent technologiestechnologies

Physical barriersPhysical barriers Release of sequestered toxic componentsRelease of sequestered toxic components Release of opioid antagonistsRelease of opioid antagonists Prodrugs that require hepatic metabolism Prodrugs that require hepatic metabolism

to release active metaboliteto release active metabolite

Institutional approachesInstitutional approaches

Organizational commitment to pain treatmentOrganizational commitment to pain treatment Dedicated hospital- wide pain serviceDedicated hospital- wide pain service Analyze current pain management practiceAnalyze current pain management practice Standards for pain assessmentStandards for pain assessment Implement policies to treat cancer painImplement policies to treat cancer pain

Institutional approachesInstitutional approaches

Multi-disciplinary workgroupMulti-disciplinary workgroup Regular assessment of pain and effective Regular assessment of pain and effective

treatmenttreatment Education for clinicians, patients and Education for clinicians, patients and

family family Establish accountability for pain Establish accountability for pain

managementmanagement Continuous evaluation and improvement Continuous evaluation and improvement

of pain management processof pain management process

Pain Management: A Fundamental Pain Management: A Fundamental Human RightHuman Right

EducationEducation Universal pain management standardsUniversal pain management standards Legislative reformLegislative reform Liberalization of national policies on opioid Liberalization of national policies on opioid

availabilityavailability Provision of affordable opioidsProvision of affordable opioids Pain control programs in all nationsPain control programs in all nations Continued WHO activismContinued WHO activism

Brennan F, Carr DB, Cousins, MJ. Anesth Analg 2007; 105: 205-21.

The nature of suffering and goals of The nature of suffering and goals of medicine.medicine.

Suffering is experienced by persons, not merely by Suffering is experienced by persons, not merely by

bodies, and has its source in challenges that bodies, and has its source in challenges that threaten the intactness of person as a complex threaten the intactness of person as a complex social and psychological entity. Suffering can social and psychological entity. Suffering can include physical pain but is by no means limited include physical pain but is by no means limited to it. to it. The relief of suffering and the cure of the The relief of suffering and the cure of the disease must be seen as twin obligations of a disease must be seen as twin obligations of a medical profession that is truly dedicated to the medical profession that is truly dedicated to the care of the sick.care of the sick.

Eric J CasselEric J Cassel