Barriers to Successful Treatment of Cancer Pain

1. Barriers to Successful Treatment of Cancer Pain Suresh Kannan, MD Florida Hospital, Orlando

2. Objectives • To highlight the discrepancy between current state of medical knowledge and prevailing practice of pain management in cancer patients • To analyze barriers that prevent effective treatment of cancer pain • To propose solutions to promote effective cancer pain management

3. The Scream Edvard Munch

4. Pain 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)

5. Suffering 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.

6. The Broken Column Frida Kahlo

7. Cancer Pain • 10 million new cases diagnosed annually* • Moderate to severe pain experienced by 40% to 50% of cancer patients • Very severe pain experienced by 25% to 30% of cancer patients • 80% of terminal stage cancer experience moderate to severe pain Brennan F, Carr DB, Cousins MJ. Pain Management: A Fundamental Human Right. Anesth Analg 2007; 105:205-21

8. Cancer Pain

9. Chronic pain in Cancer Survivors • Post treatment pain syndromes • Post-surgical pain syndromes • Post radiation therapy neuralgias • Post-chemotherapy neuropathy Burton AW, et al. Chronic Pain in the Cancer Survivor: A New Frontier. Pain Medicine 2007; 8: 189-198.

10. Approaches to cancer pain management Primary Therapies • Radiation Therapy • Chemotherapy • Immunotherapy • Surgery • Antibiotics Symptomatic Therapies • Pharmacotherapy • Interventional • Physical Modalities • Psychological • Complementary & Alternative AMA CME Module 11: Pain Management. Cancer Pain: Pharmacotherapy

11. Assessment of Pain

14. Multidimensional aspect of Cancer pain COGNITION Somatic Therapies PSYCHO-SOCIAL THERAPIES EMOTION NOCICEPTION SOCIO-ENVIRONMENT

17. Barriers to treatment • Barriers related to health care professionals • Barriers related to patients • Barriers related to the healthcare system

18. Barriers related to patients • Reluctance to report pain • Belief that cancer is inevitable in cancer • Fear pain portends progress of cancer • Fear of alienating care givers • Reluctance to take pain medication* • High costs of medications and treatments • Fear of addiction, side effects of medication

19. Barriers related to health care system • Low priority given to cancer pain treatment • Priority on curing cancer • Restrictive regulation of controlled substances • Inadequate reimbursement • Failure to recognize pain as a major cause of disability • Problems of availability of treatments

20. Barriers related to healthcare professionals “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

21. Barriers related to healthcare professionals • Inadequate knowledge/training in pain management • Inadequate pain assessment • Concerns about regulation of controlled substances • Fear of patient addiction • Ethnic/racial/gender/age biases • Negative feelings towards pain patients

22. Barriers to cancer pain management Von Roenn, J. H. et. al. Ann Intern Med 1993;119:121-126

23. Legal Barriers • Estate of Henry James v. Hillhaven Corporation (1991) • Bergman v. Chin(1999)

25. Ethical Analysis of the Barriers to Effective Pain Management • Major criticism of the “ barriers literature” is the failure to analyze these barriers from an ethical perspective • Curative versus palliative models of medicine • Disparity between current state of medical knowledge and prevailing practice of pain management • Irrational beliefs about addiction, tolerance and adverse side effects Rich BA. An Ethical Analysis of the Barriers to Effective Pain Management. Cambridge Quarterly of Healthcare Ethics 2000, 9, 54-70.

26. Ethics “ 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

28. Matching Interventions to Barriers • Barriers related to patients • Barriers related to healthcare professionals • Barriers related to healthcare systems

29. Inevitability of Pain Distracting from cancer treatment. Fears of Addiction Inadequate Pain relief Patient Education Pt. Bill of Rights Information on narcotics Empower patient (PCA-IV/Oral) Patient Barriers/Interventions

30. Physician Barriers/Interventions Lack of KnowledgeLack of Motivation -Education (Topmed) - Incentives/sanctions -EBM Guidelines Beliefs/Attitudes Turf Issues -Peer Influence -Multidisciplinary -Opinion leaders approach

31. Legal Barriers?

32. Prescribing Practice • Evaluation • Individualized Treatment Plan • Informed Consent • Treatment (narcotic) Agreement • Periodic Review • Multidisciplinary Consultation • Medical Records • Comply with Laws and Regulations

33. Prescribing Practice • Request old medical records • Collaborate with pharmacists • Photo identification • Prescription pads • Prescription monitoring programs • Identifying the drug seeking patient*

34. Opioid abuse-deterrent technologies • Physical barriers • Release of sequestered toxic components • Release of opioid antagonists • Prodrugs that require hepatic metabolism to release active metabolite

35. Institutional approaches • Organizational commitment to pain treatment • Dedicated hospital- wide pain service • Analyze current pain management practice • Standards for pain assessment • Implement policies to treat cancer pain

36. Institutional approaches • Multi-disciplinary workgroup • Regular assessment of pain and effective treatment • Education for clinicians, patients and family • Establish accountability for pain management • Continuous evaluation and improvement of pain management process

38. Pain Management: A Fundamental Human Right • Education • Universal pain management standards • Legislative reform • Liberalization of national policies on opioid availability • Provision of affordable opioids • Pain control programs in all nations • Continued WHO activism Brennan F, Carr DB, Cousins, MJ. Anesth Analg 2007; 105: 205-21.

39. The nature of suffering and goals of medicine. Suffering is experienced by persons, not merely by bodies, and has its source in challenges that threaten the intactness of person as a complex social and psychological entity. Suffering can include physical pain but is by no means limited to it. The relief of suffering and the cure of the disease must be seen as twin obligations of a medical profession that is truly dedicated to the care of the sick. Eric J Cassel