Wednesday, May 29, 2013

Cancer Pain Finally Sees Proper Focus: Report

Cancer pain is one of the most consistently experienced pain. And despite all the availability of pain management products, cancer pain is often poorly managed. Pain management involves a complex system of service providers and consumers, each operating with a combination of knowledge, beliefs and attitudes that affect their behavior related to pain and its control. The healthcare system itself, which represents the supply of the resources necessary for pain control and the regulation of its use, places limits on the quality of pain control that can be achieved. A growing body of research is documenting the relative importance of multiple potential barriers to pain control. Only when these barriers are understood can action be taken to reduce their impact.  Some of these barriers have been clearly identified, others have been suggested. However, more research is needed to fully understand the impact of pain management.  The  world market for pain management drugs and devices reached $34.9 billion in 2012, growing at a rate of 2.9% from 2010 to 2012.

“One of the biggest barriers to controlling cancer pain has been the lack of consistent evidence that large numbers of cancer patients experienced pain and that often this pain was poorly managed.  As recently as the late 1970s, there was considerable debate as to whether or not there really was a problem.”

According to Kalorama Information’s report, Between 30% and 75% of individuals with cancer experience moderate to severe pain depending on the stage of the disease, despite the fact that studies have shown cancer pain can be well managed in up to 90% of patients. Pain is most common in the patient with bone disease, but cancer-related conditions such as decubitus ulcers, cancer therapy, and pain related to the cancer itself also contribute significantly to the patient’s pain experience.

 Extensive studies have been done for the past two decades documenting that significant pain is experienced by large numbers of patients with metastatic cancer. These studies have forced a reevaluation of the association between disease stage and the onset of pain due to cancer. Prior to these studies, it was thought that cancer pain was limited to far-advanced disease and not earlier stages. The majority of patients, approximately 60% to 80%, with far-advanced cancer will need careful pain management due to significant pain. However, pain is also a problem for patients with months or years to live. Once the disease has metastasized, approximately 40% of patients report significant pain.

The factors that are responsible for poor pain control include those linked with healthcare professionals such as:

  • Inadequate knowledge
  •  Reluctance to treat pain aggressively
  • Fear of controlled substance regulations
  •  Patient-related barriers such as reluctance to report pain and to take pain medications appropriately
  • Healthcare system barriers such as regulatory constraints on analgesic use, cost containment, and low priority given to pain control.

Barriers associated with health care professionals involve nurses, physicians, and other health care providers who treat cancer. These providers have been identified as those most responsible for under treatment of cancer pain. The attitudes, practice characteristics, and lack of knowledge of these health professionals have all been suggested to be problematic.  For physicians, the threat of regulatory scrutiny makes physicians hesitant to prescribe opioids for management of cancer pain in the United States and thus, may alter prescribing practices and may interfere with the management of pain in cancer patients. Nurses’ perceptions of barriers to optimal pain management tend toward minimizing the pain reported by the patient and a lack of adequate assessment by the nurse to adequately assess pain levels. These are just some of the problems that may exist in the way health care professionals practice cancer pain management. Oncologic specialists express dissatisfaction with their education in pain control. Inadequate knowledge about opioid pharmacology and about side-effect management is seen in both physicians and nurses. Nurses and physicians together identify inadequate pain assessment as a major problem, coupled with lack of professional knowledge and reluctance to treat pain aggressively.

In addition to health care professionals, patients and their families may also contribute to the under treatment of pain. Several reasons have been cited for why patients may be unwilling to inform health care professionals when they have pain, may attempt to minimize its severity, or may be frightened of taking potent analgesics to control their pain. These concerns are especially understandable where physicians have limited time with each patient.  Patients often feel that their behavior will influence the quality of their care. They may assume that good patients will receive proportionately more time and attention from the health care team. Patients are left to their own devices, however, when trying to figure out what a good patient is. They are given no set of rules for this role. It is fairly easy to figure out that complaining of discomfort is not part of the good patient role.

As they test this assumption in the treatment setting, patients are liable to be reinforced with more attention when they minimize their complaints. Physicians especially dislike spending time with patients who have unresolved pain issues. Some family members may reinforce the patient’s lack of complaining, both because they are themselves made uncomfortable by it and because they view it as socially embarrassing.  For many of the same reasons, some patients may be reluctant to tell staff that pain therapy is not effective.  They also may view pain as an inevitable result of their disease and treatment, and adequate pain management is beyond realistic expectations.

Several factors of the system of healthcare delivery limit that effectiveness of cancer pain management as well. These factors include the low priority that has traditionally been assigned to pain management by health policy makers, the concerns of policy makers and regulators about the use of potentially addicting medications, the frequent lack of resources available for pain treatment, and the potential impact of the regulation of health care costs. It is difficult to determine the role of cost containment as a potential barrier to pain management, although it is easy to think of hypothetical examples where diagnosis-related groups and other cost containment methods may limit pain control. Previously, the lack of Medicare reimbursement for outpatient medications limited the patient’s ability to afford adequate analgesia. Those involved in pain management will have to be vigilant in order to see that the changing health care reimbursement scheme does not limit the provision of optimal pain control. Careful documentation of the impact of reimbursement for cancer pain management is very much needed.

Lastly, another major barrier has been a lack of traditional controlled clinical trials examining the relative effectiveness of cancer pain management strategies. Without documentation of effectiveness, pain management is open to cost-containment measures. There are many important clinical questions that cannot be answered by the typical single-dose assay. Some pharmacological interventions may take several days to reach maximum effectiveness, and the latency of their effectiveness may vary from patient to patient. Finally, it is increasingly apparent that optimal cancer pain management may involve the simultaneous applications of different pain control methods. The role of documentation and evaluation is critical in addressing the cancer pain problem. Once the problem is identified and its size understood, the reasons for the problem need to be highlighted, and the relative importance of the barriers to cancer pain management needs to be determined.

Kalorama Information’s report contains more information on the market size, forecast and can be purchased from Kalorama Information at: