National Hispanic Science Network 5th Annual Meeting

1. National Hispanic Science Network 5th Annual Meeting Pain and Clinical Use of Opiates in Hispanic Populations Guadalupe R. Palos, RN, LMSW, DrPH Department of Symptom Research Email address: gpalos@mdanderson.org

2. Self-Reflection Exercise • Dependency on narcotics for pain relief is different from narcotic addiction or use for recreational purposes, thus narcotic addiction is rarely relevant in patients with cancer. • Strong narcotics should not be use to control pain before a patient is terminal because tolerance may develop, resulting in ineffective analgesia at a later point. • A patient’s request for increasing amounts of analgesic to control pain typically indicates increasing pain due to worsening of disease.

3. Research and Clinical Questions • Is cancer pain (or other types of pain) managed well in Latinos/Hispanics? • What are the barriers to effective cancer pain management in Latino populations? • What can be done to improve cancer pain management practice? • What can be done to minimize fear of addiction as a risk factors for disparities in effective pain management?

4. 20 Years Ago – Cancer Pain Assertions • Intractable cancer pain is infrequent and is easily treated • Narcotic medications should be used at the “lowest” effective dose and at the longest “effective” interval to protect against addiction • Pain perception and the need for analgesics varies widely by race, ethnicity, and cultural background

5. Documenting the Problem Research findings continue to document that: • Race and ethnicity are risk factors for the undertreatment of pain • Certain types of pain (acute and cancer pain) are often poorly treated among certain ethnic groups Bonham, VL, 2001 Todd, Samaroo & Hoffman, 1993, 1994; Karpman, Del Mar & Bay, 1996; Todd, Deaton, D’Adamo & Goe, 2000 Cleeland, Gonin, Baez, et. al, 1997; Anderson et. al., 2002.

6. Disparities in Acute Pain • Hispanics were twice as likely than white, non-Hispanics to receive inappropriate doses of analgesics for pain related to long-bone fractures (Todd, Samaroo & Hoffman, 1993, 1994). • Subsequent studies conducted seven years later found that the risk of receiving no analgesics was 66% greater for black patients compared to white patients (Todd, Deaton, D’Adamo & Goe, 2000).

7. Disparities in Cancer Pain • Minority patients were found to have greater discrepancy between their provider and their own estimates of pain severity • Patients cared for at minority treatment centers were three times more likely to be undermedicated with analgesics Cleeland CS et. al. Annals of Internal Medicine, 27: 9, 1997.

8. Can We Trust Pain Measurement • Medical management depends on systems of measurement • Pain is a subjective state; can we measure it? • Can we believe patients? • Can we base treatment on what patients tell us? Cleeland CS et. al. Annals of Internal Medicine, 27: 9, 1997.

9. Components of Pain • Sensory • Intensity • Quality • Reactive • Affective • Motivational • Interference with activities Cleeland CS et. al. Annals of Internal Medicine, 27: 9, 1997.

10. Brief Pain Inventory (Severity) 2. Please rate your pain by circling the one number that best describes your pain at its WORST in the last 24 hours. 0 1 2 3 4 5 6 7 8 9 10 No Pain as bad as Pain you can imagine

11. Brief Pain Inventory (Interference) Circle the number that describes how, during the past 24 hours, pain has interfered with your: A. General activity 0 1 2 3 4 5 6 7 8 9 10 Does not Completely Interfere Interferes

12. Activities Impaired by Increasing Pain relate walk sleep active mood work enjoy walk sleep active mood sleep active mood work enjoy sleep active mood work enjoy enjoy work work enjoy enjoy 3 4 5 6 7 8 > > > > worst pain rating > > > > n = 186 Multi-institutional study

13. NCCN* Guidelines History • Intensity – use a 0 to 10 scale - 7 to 10 = Pain Emergency - 4 to 6 - below 4 • Location (drawing of location of painful areas on the body helpful) *National Comprehensive Cancer Network

14. NCCN GuidelinesInitial Opioid Titration Pain of 7 or more Morphine 15-30 mg PO q 4h ATC 5 to 15 mg. PO q 2h prn Pain of 4 to 6 Morphine 15-30 mg PO q 4h ATC 5 to 15 mg. PO q 2h prn Or Oxycodone or 1- 2 tabs PO q 4h ATC Hydrocodone ½ tab – 1 q 2h prn

15. Measuring Adequate Pain Treatment The Pain Management Index (PMI) • Mild pain (1 - 4) • Moderate Pain (5 - 6) • Severe Pain (7 - 10) NSAIDS = 1 Codeine = 2 Morphine = 3 Pain = 8; Med = Codeine = 2 2 - 8 = - 6 = Poor Pain Treatment Serlin, Mendoza, Nakamura, Cleeland, 1995 National Comprehensive Cancer Network, 2000

17. Predictors of Negative PMI(Undertreated with Analgesics) Odds Ratio 3.06 2.33 1.95 1.76 1.53 1.53 • Minority vs Non-Minority • Discrepancy (pt. - physician) • Cause of pain (ca vs non-ca) • Performance Status (good vs bad) • Age (70 > vs 18 - 52) • Gender (female vs male)

18. Undertreatment of Cancer Patients % with Negative PMI 31 28 % MD Under-estimate 74 64 % with Severe Pain 72 57 African - American or Black Caribbean Hispanic or Latino Anderson et. al., 2000

19. Results From PREMO Studies Findings from structured interviews • Hispanics expressed concerns about opioid analgesics being too strong, addictive, and not effective when needed (n = 64) • Majority of patients said they would wait until their pain reached a 9 or 10 before calling their provider Anderson et. al., 2000

20. Patient Trade - offs“Pain vs. Side Effects” Cancer Pain Health States Health State 1 - mild pain and presence of the three worst side effects. Trade-off is more side effects and less pain Health State 2 - moderate pain and presence of the one worst side effect. Trade-off is more pain but less side effects Palos et. al., 2001

21. Mean Preference Score forCancer Pain Health States More pain and less side effects 58.9 49.2 More side effects and less pain 57.8 58.1 Preferred Language Spanish English Palos et. al., 2001

22. Provider Barriers to Cancer Pain Management • Poor clinical pain assessment • Conflicting patient - physician communication • Poor staff knowledge of pain control Von Roenn et. al., 1993; Cleeland et. al, 1997

23. Patient Barriers to Cancer Pain Management • Concern over being a “good” patient • Not wanting to distract the physician • Afraid of new treatments or addiction • Saving the effectiveness of medications • Not wishing to complicate the treatment • Wanting to be “well enough” for new treatment options

24. Cancer Pain and Addiction In patients with chronic pain who are taking opioids on a long-term basis, we expect: -Tolerance – requirements for increased dose to produce the same effect - Physical dependence – receptor tachyphylaxis that results in the development of a withdrawal syndrome when the drug is withdrawn Penson, RT, Nunn C, Younger J, etl al., (2003). Trust Violated: Analgesics for Addicts. The Oncologist. 8:199-209.

25. Pain Management in Patients with a History of Substance Abuse • One study found evidence of addiction in 4 out of 12,000 patients with no prior history of addiction (Porter J, 1980) • Another study found that 40% of cancer patients believed ¼ of their peers were addicted to drugs (Passik SD et. al, 2000) • “With a people who have a history of substance abuse and develop cancer pain, my attitude is – they win. We’ll do everything we can to get them out of pain…” (Penson RT et. al, 2003)

26. JCAHO Pain Standards for 2001 Rights and Ethics Functional Chapter Standard RI.1.2.8 Patients have the right to appropriate assessment and management of pain.. . . After taking into account personal, cultural, spiritual, and/or ethnic beliefs, communicating to patients and families that pain management is an important part of care.

27. Standards and Civil Rights • Several JCAHO standards guarantee language access to patients. Joint Commission on Accreditation of Healthcare Organizations, 2001 • If health care providers do not provide information in the patient’s language of choice -- are we violating their civil rights? Title VI - Civil Rights Act of 1964

28. Warning – Use of Placebos • Inactive substances (e.g. saline injections) used to determine if the effects are due to the ADMINSTRATION of the placebo rather than the pharmacological purpose • Used to assess if one’s pain is real – if an individual’s response is positive, it may be viewed as evidence of malingering, faking or exaggerating pain Oncology Nurses Society Position Statement, 1996

29. Warning – Use of Placebos • Often used in vulnerable populations, such as those with histories of substance abuse or psychiatric problems • The use of placebo involves deception and raises serious ethical concerns • Placebos should not be used in the assessment and management of cancer pain Oncology Nurses Society Position Statement, 1996

30. Conclusions • In addicts, methadone may be used as an alternative to other opioids • Educate the patient and family about early signs of dependency • Develop contractual agreements with patient for medications and prescriptions • Empower the patient and their family through trust and open communication

31. Conclusions • Conduct additional research that addresses the fear of addiction in different subgroups of Latino patients and their families • Adequate pain and symptom management are a critical prerequisite for a better quality of life in patients who suffer from pain • Remind ourselves that every person has a right to appropriate assessment and effective pain management

32. Acknowledgements • Department of Symptom Research • Charles Cleeland, PhD, Chair • Karen Anderson, PhD • Tito Mendoza, PhD • Maria Sanchez, LVN • Ibrahima Gning MPH • Hispanics and Latinos patients with cancer willing to participate in pain research and clinical trials • National Cancer Institute funding