The prescription of opioid analgesics to terminal cancer patients: Impact of physicians' general attitudes and contextual factors

[Questionnaire made to understand the opioid analgesics prescription habits in the community of Madrid (Spain)]

OBJECTIVE

Pain is the fearest and disabling symptom for cancer patients. The cornerstone of treatment is opioid analgesics. The objective of this research was to relate the opioid consumption existing in the Community of Madrid (CM) with the prescription habits expressed by the Primary Care (PrC) and Palliative Care (PalC) physicians.

DESIGN

An opioid prescription habits questionnaire was designed. Sampling was consecutive non-probability. SITE: PrC and specific PalC resources in the CM.

PARTICIPANTS

The study population included all the family doctors who worked in PrC in the Madrid Public Health Service and all the physicians who worked in some specific PalC resources, both home-based teams and supportive hospital teams in the CM of the public and private/concerted health network services.

MAIN MEASUREMENTS

We asked about the strong and weak opioids most used in moderate-severe oncological and non-oncological pain, the preferred administration route, the safety in the use of opioids in the treatment of pain and the preferred clinical practice guidelines.

RESULTS

The questionnaire was answered by 840 PrC physicians (20%) and 56 PalC physicians (45%). For the treatment of moderate-severe cancer pain in both groups of professionals, the first choice was morphine; however, in non-cancer pain for PrC it was fentanyl and morphine for PalC professionals. Regarding the route of administration, 70% of family doctors and 87% of PalC physicians stated that the oral route was the first choice, compared to 27% in PrC and 5% in PalC who preferred the transdermal route. The PrC physicians rated their ability to use opioids as average (4-7/10), while the palliativists considered it as high (8-10/10). In PrC, they declared that they knew, above all, the European Association for Palliative Care (EAPC) and National Institute for Health and Care Excellence (NICE) guidelines, although the largest number answered that they trusted their experience. PalC physicians preferred to use the EAPC guide.

CONCLUSIONS

There is a clear disagreement between the actual consumption of opioids and the prescribing habits manifested by family doctors, as well as a false certainty in prescribing these drugs.

Medical oncologists' attitudes and practice in cancer pain management: a national survey

PURPOSE

To evaluate the attitudes, knowledge, and practices of US medical oncologists that are related to management of cancer pain.

METHODS

An anonymous survey was mailed to a geographically representative sample of medical oncologists randomly selected from the American Medical Association's Physician Master File.

RESULTS

From a total of 2,000 oncologists, 354 responded to the original questionnaire and 256 responded to one of two subsequent shortened versions (overall response rate, 32%). Responders were demographically similar to all US medical oncologists. Using numeric rating scales of 0 to 10, oncologists rated their specialty highly for the ability to manage cancer pain (median, 7; interquartile range [IQR], 6 to 8) but rated their peers as more conservative prescribers than themselves (median, 3; IQR, 2 to 5). The quality of pain management training during medical school and residency was rated as 3 (IQR, 1 to 5) and 5 (IQR, 3 to 7), respectively. The most important barriers to pain management were poor assessment (median, 6; IQR, 4 to 7) and patient reluctance to take opioids (median, 6; IQR, 5 to 7) or report pain (median, 6; IQR, 4 to 7). Other barriers included physician reluctance to prescribe opioids (median, 5; IQR, 3 to 7) and perceived excessive regulation (median, 4; IQR, 2 to 7). In response to two vignettes describing challenging clinical scenarios, 60% and 87%, respectively, endorsed treatment decisions that would be considered unacceptable by pain specialists. Frequent referrals to pain or palliative care specialists were reported by only 14% and 16%, respectively.

CONCLUSION

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.

The coordination of primary and oncology specialty care at the end of life

The end of life is a time in which both the intensity of cancer patients' needs and the complexity of care increase, heightening the need for effective care coordination between oncology and primary care physicians. However, little is known about the extent to which such coordination occurs or the ways in which it is achieved. We review existing evidence on current practice patterns, patient and physician preferences regarding involvement of oncology and primary care physicians in end-of-life care, and the potential impact of care coordination on the quality of care and health outcomes. Data are lacking on the extent to which end-of-life care is coordinated between oncology and primary care physicians. Patients appear to prefer the continued involvement of both types of physicians, and preliminary evidence suggests that coordinated care improves health outcomes. However, more work needs to be done to corroborate these findings, and many unanswered questions remain.

Delivering research in end-of-life care: problems, pitfalls and future priorities

In this paper we review the challenges facing the delivery of research in end-of-life care in the UK and internationally as health policies begin to focus on improving care. These include the problems of terminology in this field of enquiry and the lack of emphasis on clinical studies relating to the medical aspects of end-of-life care, including research into pain and other symptoms. Future priorities are discussed that include the pressing need to build research capacity, making better use of existing intelligence, and to progress in incremental steps as part of sustained programmes of research.

Dying in an acute hospital setting: the challenges and solutions

More than half of all UK deaths occur in hospital, yet evidence suggests that the quality of inpatient end of life care is suboptimal at best. Over half of all NHS complaints pertain to problems with care in the dying phase, particularly with regard to poor communication. This is a hugely topical area following the recent publication of the Department of Health's End of Life Care Strategy. With reference to current literature, we seek to investigate the challenges associated with providing 'a good death' in hospital and construct a framework of strategies for improvement; including communication skills training, use of integrated care pathways, advance planning, educational initiatives and the role of the palliative care team.

Barriers to pain management in the rehabilitation of the surgical oncology patient

Virtually every surgical oncology patient faces pain, and it can become a major barrier to rehabilitation and quality of life. Pain must be assessed as to its severity, etiology (somatic, visceral, or neuropathic), causation (directly from malignancy or from treatment side effects), and its impact on daily function. Treatments can include physical modalities, exercise, opioids, adjuvant medications, and interventional techniques. Barriers to treatment may include side effects, finances, and attitudes. New technologies in medication delivery systems, intrathecal pumps, injections, and surgery have greatly strengthened the armamentarium available to manage pain.