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David E. Joranson
In this issue, Dr. Arsenio H. P. Paes presents a study of Dutch physicians' compliance with health care insurance industry and government published step-wise analgesic guidelines for cancer pain that were first published more than ten years ago. It should provoke thought among those working to improve cancer pain relief in any country.
The investigator surveyed 194 family practice physicians on what drugs they would choose for a hypothetical "paper" patient with increasing cancer pain. He found that less than 42% of his sample of physicians would move up the analgesic ladder and use an opioid analgesic when acetaminophen (paracetamol) no longer relieved the patient's pain. Further, he found that a significant number of physicians would prescribe drugs that are not indicated for chronic pain management. Of particular interest is his finding of great variability from good medical practice norms, despite the publication of oncologic analgesic guidelines by the Dutch government.
Paes concludes that a majority of family practice physicians in the Netherlands do not follow general recommendations on how to manage cancer pain and that many patients are therefore at risk for undertreatment of the pain associated with cancer.
This study adds weight to the findings of other pain researchers; i.e., it is true that the undertreatment of cancer pain is a very real problem of serious international proportions. Also, more than ten years ago the World Health Organization determined that cancer pain was inadequately relieved throughout the world.1 WHO concluded that most if not all cancer pain could be relieved by using a simple analgesic ladder, beginning with non-opioids for mild pain and progressing to weak opioids, and then to strong opioids as pain becomes more severe.2
Documentation that people with cancer and pain are not receiving relief is the first step in addressing undertreatment of cancer pain. The next step is to assess why the problem exists in a particular country. It is essential to identify and understand the barriers in any country in order to be effective.
In general, WHO has found that pain and palliative care are poorly understood and are traditionally a low priority in national health care systems; that there is a lack of education for health care professionals, policy-makers and the public; that exaggerated fears of the effects of morphine-like drugs limit their use by patients and health care workers alike; that some anti-drug abuse laws and regulations restrict their medical availability and use.1,3
What are the barriers to cancer pain relief in the Netherlands or any other country? A useful approach to defining the barriers in any country would be a review of national health policy in relation to cancer pain and palliative care, a study of drug laws in relation to opioid availability, and a survey of the knowledge and attitudes of health care workers toward pain and opioids.
The next step is to develop an action strategy.4 WHO has recommended a broad three-part strategy to establish national health policy for cancer pain relief and palliative care, to assure availability of opioid analgesics and other medications, and to educate health care workers, policy makers and the public about their appropriate use.1 Strong leadership from the cancer care community will be necessary to establish new standards delivering pain-related services.
It has been recognized that legal restrictions on the prescribing and dispensing of opioid analgesics, as well as the perception of the risks of regulatory scrutiny, can interfere with the use of opioids for pain management. 1,6-10 Therefore, it will be important for health care professionals to identify the specific barriers to opioid availability in their country. A model survey is available 11 as well as WHO guidelines for working with regulators to improve the availability of opioid analgesics. 12 There is some indication that the Netherlands, like many other countries, may be making progress in the last several years. For example, its consumption of morphine-a WHO indicator of progress in cancer pain relief-increased 476% (from 29 to 98 kg) from 1984 to 1991.11
Indeed, there are hopeful signs that progress is being made in many countries. With the guidance of the WHO and the International Association for the Study of Pain, there is a growing international network of health professionals who are taking action in their countries to establish national programs to improve cancer pain relief.13 In the United States, there are many important developments. The federal government will disseminate clinical practice guidelines for cancer pain relief, several national organizations are developing programs and the state cancer pain initiatives are expanding throughout the country.14
The ultimate question is how to assure that people with cancer and pain receive and continue to receive the relatively simple method of pain relief that medical science has to provide. Amidst an explosion of new informational materials, conferences, products and papers, we must consider carefully what actions beyond education and the availability of guidelines will be necessary to produce the significant improvements that are necessary in clinical outcomes.15,16 What can the US learn from the Netherlands, where variability in reported prescribing practices for cancer pain continue to exist, despite the availability for more than ten years of government-published guidelines for managing cancer pain?
REFERENCES
1. WHO Expert Committee. Cancer Relief and Palliative Care. Geneva, World Health Organization, 1990.
2. WHO. Cancer pain relief. Geneva, World Health Organization, 1986.
3. Angarola RT. National and international regulation of opioid drugs: Purpose, structures, benefits and risks. Journal of Pain and Symptom Management 1990; 5:S6-S11.
4. Cleeland CS. Strategies for improving cancer pain management. Journal of Pain and Symptom Management 1993; 8:361-364.
5. Ferrell BR. The challenge for leadership in the national agenda for relief of cancer pain. Journal of the National Cancer Institute 1993; 85:1034-1037.
6. Weissman DE, Joranson DE, Hopwood MB. Wisconsin physicians' knowledge and attitudes about opioid analgesic regulations. Wisconsin Medical Journal 1991; 90:671-675.
7. INCB. Demand for and supply of opiates for medical and scientific needs. Vienna, International Narcotics Control Board, 1989.
8. Hill CS. The negative influence of licensing and disciplinary boards and drug enforcement agencies on pain treatment with opioid analgesics. Journal of Pharmaceutical Care in Pain & Symptom Control 1993; 1(1):43-62.
9. Joranson DE. Regulatory influence on pain management: Real or imagined? Journal of Pharmaceutical Care in Pain & Symptom Control 1993; 1(1):113-118.
10. Portenoy RK. Chronic opioid therapy in nonmalignant pain. Journal of Pain and Symptom Management 1990; 5:S46-S62.
11. Joranson DE. Availability of opioids for cancer pain: Recent trends, assessment of system barriers, new World Health Organization guidelines, and the risk of diversion. Journal of Pain and Symptom Management 1993 8:353-360.
12. WHO Cancer and Palliative Care Unit. Cancer pain relief: A guide to opioid availability. Geneva, World Health Organization (in press).
13. Foley KM, Portenoy RK. World Health Organization - lnternational Association for the Study of Pain: Joint initiatives in cancer pain relief. Journal of Pain and Symptom Management 1993; 8:335-339.
14. Dahl IL. State Cancer Pain Initiatives. Journal of Pain and Symptom Management 1993; 8:372-375.
15. Max MB. Improving outcomes of analgesic treatment: Is education enough? Ann Intern Med 1990; 113:885-889.
16. Cleeland CS. Analgesic trials to clinical practice: When and how does it happen? In: Max M, Portenoy R. Laska E, editors, Advances in Pain Research and Therapy, Volume 18, New York, Raven Press Ltd., 1991.