Correspondence
Treating Cancer Pain
N Engl J Med 1994; 331:199-201July 21, 1994
- Article
To the Editor:
The truth often hurts. Being a medical oncologist, I had pain that reached a score of 10 on reading the article by Cleeland and colleagues (March 3 issue)1 on the inadequate management of pain in outpatients with cancer. Like many medical oncologists, I find myself staying busy just fighting pain, and I take pride in the superb level of pain control achieved in most of my inpatients and hospice patients. However, the management of pain in outpatients with cancer remains challenging for several reasons. First, inadequate tools alone cannot be blamed for poor assessment of pain as a barrier to pain control. Assessment of pain takes time, and the great variability in pain and opioid requirements demands frequent reassessment for optimal pain control -- a tall order in busy outpatient clinics2. Second, as the study by Cleeland et al. suggests, education in the control of cancer pain appears to be substandard even among oncologists, despite a comprehensive curriculum for pain control developed by the American Society of Clinical Oncology3. These guidelines must be taught and put into practice at every level of training and in every setting (inpatient, outpatient, and hospice). Finally, morphine (called “G.O.M.,” God's own medicine, by William Osler and “the gift of God” by Francis Peabody, who while dying of metastatic cancer wrote about his personal experience with morphine4) is the drug of choice for pain from cancer. However, morphine is expensive when used in the popular and convenient slow-release form (MS Contin, Purdue Frederick, Norwalk, Conn.), costing $132.78 for 100 30-mg tablets, which is less than a five-day supply for some of my patients.
Unless we are willing to devote adequate time and attention to pain assessment, follow our own curriculum guidelines faithfully, and use adequate doses of immediate-release morphine as the drug of choice for cancer pain, we will all have to live with the pain of having watched Jack Kevorkian honored as “Person of the Week” on ABC News.
4 ReferencesAnand B. Karnad, M.D.
East Tennessee State University, Johnson City, TN 37614-06221
Cleeland CS ,Gonin R ,Hatfield AK , et al. Pain and its treatment in outpatients with metastatic cancer. N Engl J Med 1994;330:592-596
Full Text | Web of Science | Medline2
Brescia FJ ,Portenoy RK ,Ryan M ,Krasnoff L ,Gray G . Pain, opioid use, and survival in hospitalized patients with advanced cancer. J Clin Oncol 1992;10:149-155
Web of Science | Medline3
Ad Hoc Committee on Cancer Pain of the American Society of Clinical Oncology
Web of Science | Medline4
Peabody FW. Notes on the effects of morphine. In: Oglesby P. The caring physician: the life of Dr. Francis W. Peabody. Boston: Francis A. Countway Library of Medicine, 1991:175-82.
To the Editor:
The inability to deal effectively with pain through the use of opioids is due to the reluctance on the part of physicians to prescribe large doses of narcotics, even when the level of discomfort and increasing tolerance to these drugs require such doses. I have seen a number of cases in which the opioid dose was reduced or the drug was eliminated because of the development of tolerance and the need for larger amounts and more potent opioids. Many physicians mistake the phenomenon of drug tolerance for abuse. The bureaucrats at the Drug Enforcement Agency cannot seem to understand tolerance either.
Two years ago, I recommended, without success, that the Connecticut General Assembly enact a statute whereby patients with intractably painful illnesses would be registered with the state and federal narcotics agencies and cared for by their personal physicians without investigation of either the patients for using large amounts of opioids or the physicians for prescribing them. Genuine fear of such bureaucratic scrutiny and reprisal has led us to underprescribe analgesic drugs of the opioid class, to the detriment of those we serve. The medical profession needs to take back full responsibility for analgesic-drug use from an unsympathetic, rigid, rule-bound bureaucracy.
Henry N. Blansfield, M.D.
1 Cedarcrest Dr., Danbury, CT 06811To the Editor:
I do not think the problem of pain control will be solved until we face the fact that much of it stems from our puritanical culture. In the recesses of our collective identity, we still embrace the notion that pleasure is bad and suffering is redemptive (no pain, no gain).
John H. Kilwein, Ph.D.
University of Pittsburgh School of Pharmacy, Pittsburgh, PA 15261To the Editor:
The article by Cleeland et al. is at odds with my experience in a community oncology practice. Maybe they should confine their conclusions to physicians who are members of the Eastern Cooperative Oncology Group.
I have never heard of any physicians who restricted opioids “until the patient had less than six months to live” or “even after a course of palliative radiotherapy had failed.” Is it possible that members of the Eastern Cooperative Oncology Group have a bias toward undertreatment of pain (to prolong length of stay)?
Alan N. Goodman, M.D.
600 S. Dixie Hwy., Boca Raton, FL 33432-6096To the Editor:
For decades, sodium phosphate P 32 has been used to palliate the pain of bony metastases. In June 1993, strontium chloride Sr 89 was approved by the Food and Drug Administration for this purpose. About three quarters of patients have had positive responses, and repeated treatment after three months is associated with renewed effectiveness. Neutrophil and platelet decreases are minimal and transient, and no unpleasant effects, such as hair loss, nausea, or vomiting, are reported.
Promising research is now under way with other beta emitters to increase the dose of radiation to the tumor relative to normal bone marrow.
Carol S. Marcus, Ph.D., M.D.
Harbor-UCLA Medical Center, Torrance, CA 90509To the Editor:
The Special Report by Jacox et al. (March 3 issue)1 provides a clear, detailed approach to the initial and subsequent assessment of cancer pain. It also highlights the benefit of a simple approach to the use of drugs, with optimal oral therapy used before parenteral administration or invasive anesthetic or neurosurgical techniques. However, we have some concern about the details of the pharmacologic management advocated. First, the recommended starting dose of morphine (30 mg every three to four hours) is much higher than that normally recommended in Europe, where patients are more commonly started on a regimen of 10 mg every four hours, with a similar dose used as often as necessary for breakthrough pain. The use of controlled-release morphine is not generally recommended until the patient's pain is under control. In situations where it is used, a starting dose of 90 to 100 mg every 12 hours is excessive and is likely to result in adverse effects, including life-threatening respiratory depression. Second, greater emphasis should be placed on the use of regular doses of opioid analgesics in combination with “rescue” doses for breakthrough pain. Third, although physical dependence is commonly seen in patients whose doses of opioids are intentionally or inadvertently reduced, we dispute the statement that tolerance is a common occurrence. Finally, if a change in the nonsteroidal antiinflammatory agent (NSAID) is indicated, we suggest that it should be to an NSAID from a different pharmacologic group.
In addition, the terms “adjuvant analgesic drug” and “adjuvant drug” are not defined and are used synonymously in the article. Methotrimeprazine may be useful in doses that exceed 40 to 80 mg per day and can be administered subcutaneously. The evidence for its analgesic effect is slight. It is commonly used as an antiemetic agent when sedation is desirable. In the context of pain management in patients with cancer, haloperidol is much more commonly used, and it is possible to use a smaller volume for injection.
Both dexamethasone and prednisone are used as adjuvant analgesic drugs (to treat pain) and as adjuvant drugs (to treat other symptoms). There is a major discrepancy in the doses advocated in the guidelines. A dose of 16 to 96 mg of dexamethasone per day is in no way equivalent to a dose of 40 to 80 mg of prednisone per day, on the basis of an assumed equivalence of seven to one.
The role of psychostimulants has yet to be established, and convincing evidence for enhancement of the analgesic effect of opioids has been shown only in single-dose studies in postoperative patients.
1 ReferencesWilliam M. O'Neill, M.B.
E. Joanna Chambers, F.R.C.P.
Marie T. Fallon, M.R.C.G.P.
University of Bristol, Bristol BS2 8ED, United Kingdom1
Jacox A ,Carr DB ,Payne R . New clinical-practice guidelines for the management of pain in patients with cancer. N Engl J Med 1994;330:651-655
Full Text | Web of Science | Medline
To the Editor:
As compared with analgesics and narcotics, radiation therapy has the advantage of treating the underlying disease process causing the cancer pain rather than merely treating the symptoms of the disease. Consequently, radiation therapy can prevent serious oncologic problems, such as spinal cord compression and pathologic bone fractures -- two conditions with sequelae that are difficult and expensive to manage and with clinical outcomes that are often poor.
Although oral analgesics are often the initial treatment of choice for cancer pain, short courses of radiation therapy frequently lead to extended periods of pain relief, during which the need for pain medications that are often habit-forming can be dramatically reduced and sometimes even eliminated. These considerations of the quality of life are of particular importance for patients with a life expectancy that is more than a few months. On the other hand, analgesic and narcotic drugs may be the treatment of choice for patients with end-stage disease who have declined therapeutic interventions or for whom such interventions are deemed medically inappropriate.
William D. Bloomer, M.D.
American College of Radiation Oncology, Oak Brook, IL 60521for the Board of Chancellors
Author/Editor Response
The authors reply:
To the Editor: In responding to our article, Drs. Blansfield and Karnad note potential reasons for the undertreatment of cancer pain. As Dr. Blansfield points out, fear of regulation continues to be reported as a primary reason for the underprescription of opioids1. However, at least some regulatory agencies have taken it on themselves to become educated about the analgesic needs of patients with cancer and other diseases2. Health care professionals need to be active in offering to provide the relevant regulatory agencies with information about the use of opioids in the management of cancer pain and about the high doses of these medications that some patients need. Dr. Karnad agrees with points we raised in our discussion. Assessment and treatment of pain require time and agreed-on standards of practice. Dr. Kilwein suggests that a cultural attitude may also restrict pain relief, although we have no evidence of this attitude in our own studies.
I commend the courage of the Eastern Cooperative Oncology Group in allowing the pain of their patients to be studied. The group is now able to identify specific reasons for undertreatment, and clinical trials of methods to improve pain treatment are under way at centers affiliated with the group. These trials may be of benefit to all patients with pain due to cancer. I will have more confidence in Dr. Goodman's remarks about patients in his practice when he is able to provide data on their level of pain, their functional status, and how their treatment compares with accepted guidelines.
2 ReferencesCharles S. Cleeland, Ph.D.
University of Wisconsin Medical School, Madison, WI 53705Author/Editor Response
In reducing a 257-page document1 to 5 pages, we could not present details; we urge readers to obtain and read the full guidelines. The paragraph on radiation therapy in our Special Report refers to a multipage section in the full document that agrees with and extends the comments of Drs. Marcus and Bloomer on the value of radionuclide and external radiation therapies.
The concern expressed by O'Neill et al. that “the recommended starting dose of morphine (30 mg every three to four hours) is much higher than that normally recommended in Europe” is unfounded. Among the several sources supporting initial doses of 30 to 60 mg of oral morphine for severe cancer pain is the authoritative Oxford Textbook of Palliative Medicine, in a table entitled “Opioid Analgesics Commonly Used for Severe Cancer Pain.”2 That table, the chapter in which it appears, and the entire textbook originate from the department with which O'Neill et al. are affiliated. The text accompanying the table states, “When starting on controlled release morphine the same 24-hour dose should be used.” Accordingly, for an oral morphine dose of 30 mg every 3 to 4 hours (i.e., 180 to 240 mg in 24 hours), the equivalent is 90 to 120 mg of controlled-release morphine every 12 hours -- a range slightly higher than that we presented. If O'Neill et al. believe that their own department's textbook advocates “excessive” morphine doses, we urge them to resolve their differences with their colleagues.
In our Special Report, we wrote that “medications . . . should be administered on an around-the-clock basis, with additional `as needed' doses” and thereby echoed the recommendations of the World Health Organization3 -- as do O'Neill et al. “Adjuvant drug” was defined in the last paragraph of our discussion of pharmacologic management. On this and many other specific pharmacologic matters, there are detailed discussions in the full guidelines1. Table 3 in our Special Report was neither intended nor titled as a list of equivalent drug doses. Only for the opioids does sufficient clinical evidence exist to calculate approximate equianalgesic doses, and we presented those doses in Table 1. To quote again from the Oxford Textbook of Palliative Medicine, for corticosteroids given as adjuvant analgesics, “there are no data by which to judge dose-response relationships [or] relative potencies among drugs.”4 Above all else, “an essential principle in using medications to manage cancer pain is to individualize the regimen to the patient.”1
4 ReferencesAda Jacox, R.N., Ph.D.
Johns Hopkins University School of Nursing, Baltimore, MD 21205Daniel B. Carr, M.D.
Massachusetts General Hospital, Boston, MA 02114Richard Payne, M.D.
M.D. Anderson Cancer Hospital, Houston, TX 770301
Jacox A, Carr DB, Payne R, et al. Management of cancer pain. Clinical practice guideline no. 9. Rockville, Md.: Department of Health and Human Services, 1994. (AHCPR publication no. 94-0592.)
2
Inturrisi CE, Hanks G. Opioid analgesic therapy. In: Doyle D, Hanks GWC, MacDonald N, eds. Oxford textbook of palliative medicine. Oxford, England: Oxford University Press, 1993:170.
3
Cancer pain relief. Geneva: World Health Organization, 1986.
4
Portenoy RK. Adjuvant analgesics in pain management. In: Doyle D, Hanks GWC, MacDonald N, eds. Oxford textbook of palliative medicine. Oxford, England: Oxford University Press, 1993:195.
- Citing Articles (2)
Citing Articles
1
Nijmeh Mohammed Hussein Al-Atiyyat. (2008) Patient-Related Barriers to Effective Cancer Pain Management. Journal of Hospice & Palliative Nursing 10:4, 198-204
CrossRef2
De Salles, Antonio A.F., Johnson, J. Patrick, . (1994) More on the Treatment of Pain. New England Journal of Medicine 331:22, 1528-1528
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