In a 1993 ECOG Study published in Annals of Internal Medicine, Jamie Von Roenn and colleagues stated that US oncologists were not doing a very good job in treating cancer pain in the early 90s. This and other papers from ECOG, often under the leadership of Charlie Cleeland, were the impetus for efforts to improve cancer pain management around the county and the globe.
But Dr Bruerer and colleagues from Beth Israel, NY have repeated that often quoted study and their results almost 20 years later suggest that not much has changed. US Oncologists are still not getting cancer pain management right. Some of the results from the Journal of Clinical Oncology (DOI: 10.1200/JCO.2011.35.0561) are listed here:
The authors go onto to state.
These data suggest that, for more than 20 years, a focus on cancer pain has not adequately addressed the perception of treatment barriers or limitations in pain-related knowledge and practice within the oncology community. Additional efforts are needed to achieve meaningful progress.
So is this true? The survery went onto in include some clinical vignettes. 89% of oncologists included an incorrect answer in the first and 60% did not have a correct answer in the second. How would you answer these questions?
Your colleague is treating a patient for painful malignant brachial plexopathy by using gabapentin and long-acting morphine at 300 mg twice daily plus short-acting morphine 30 mg up to every 2 hours, as needed. He tells you that the patient’s pain is severe despite five to six rescues per day and that the patient appears to have no adverse effects. He proposes to increase the long-acting morphine to 600 mg twice daily plus shortacting morphine 90 mg up to every 2 hours, as needed. What do you say? (check all that apply)
- Good idea
- Not a good idea because of the risk of serious toxicity, particularly respiratory depression
- Not a good idea because of the likelihood of adverse effects of somnolence and mental clouding
- Not a good idea because of the risk of drug abuse or addiction at the higher dose
- Not a good idea because of more rapid tolerance leading to ineffective opioid therapy later
- Not a good idea because of the phenomenon of opioid-induced hyperalgesia
- Not a good idea because of the regulatory climate that puts doctors under scrutiny if relatively high doses are prescribed
- No comment
A 40-year-old man with metastatic lung cancer reports that bone pain is steadily worsening despite treatment with long-acting oxycodone 160 mg twice daily. There are no adverse effects, and the patient continues to receive chemotherapy and is working part-time. What would you recommend? (check all that apply)
- Increase the oxycodone to 160 mg three times daily
- Add a rescue medication, specifically oxycodone 5 mg plus acetaminophen 325 mg, two tablets four or five times daily, as needed
- Add a short-acting opioid such as morphine
- Add a rapid onset opioid such as oral transmucosal fentanyl citrate
- Switch to the transdermal fentanyl patch, 50 g/h, patch changed every 3 days
- Add pregabalin
- I would recommend something else
The challenge remains not only to improve opioid access globally by removing regulatory barriers and increasing availability but to improve physician education around the world, including that of US oncologists.