MEDICAL PRACTICE

Chronic : Treatment Barriers and Strategies for J Am Board Fam Pract: first published as on 1 May 2001. Downloaded from Clinical Practice

Myra Glajchen, DSW

Background: is a clinical challenge for the practicing physician. Lack of knowledge about opioids, negative attitudes toward prescribing opioids, and inadequate pain-assessment skills combine to create major barriers to pain relief. Patient-related barriers, such as lack of communication and un- warranted fears of addiction, further complicate pain assessment and treatment. The health care system itself can hinder pain relief through practical constraints in the community and fear of regulatory scru- tiny by the physician. Methods: Information was gathered by doing a literature search, collating clinical information from practice and additional research findings from national meetings, and reviewing the Bulletin of the American Pain Society. Key search terms included “pain,” “chronic pain,” “,” “pain assessment,” “pain treatment,” and “barriers to pain management.” Results and Conclusions: Concrete steps for the clinician engaged in the treatment of chronic pain include selection and administration of an effective opioid, dose titration, short- vs long-acting opioids, opioid rotation, ongoing assessment, and consideration of patient preferences. In addition, communica- tion, coping behaviors, and pain education play important roles in the pain equation. (J Am Board Fam Pract 2001;14:211–18.)

The prevalence of chronic pain among adults in the For all these reasons, it is essential that primary

United States has been estimated to range from 2% care physicians become knowledgeable in the area http://www.jabfm.org/ to 40% of the general population1–3 and from 45% of pain management. Because pain is such a sub- to 80% among nursing home patients,4 and it has jective experience, influenced by a host of nonmed- been found in up to 75% of patients with advanced ical factors, including age, sex, culture, communi- cancer.5 Because more than 40% to 50% of pa- cation style, and fear of addiction, these tients in routine practice settings fail to achieve demographic and behavioral barriers must be con- sidered in assessment and treatment.9,10 This arti- adequate relief, chronic pain is now considered to on 2 October 2021 by guest. Protected copyright. be a public health problem of major proportions.6 cle presents an overview of the major barriers to Chronic pain can dramatically affect quality of life, chronic pain management, with strategies for over- a multidimensional concept that includes physical, coming them in clinical practice. psychological, spiritual, and social domains.7 Un- remitting pain is associated with anxiety, depres- Methods sion, loss of independence, and interference with Information was gathered by doing a literature search, collating clinical information from practice, work and relationships. The annual cost of chronic as well as additional research findings from national pain, including medical expenses, lost income, and meetings, and referring to the Bulletin of the Amer- lost productivity, is an estimated $100 billion.3,8 ican Pain Society. Key search terms included “pain,” “chronic pain,” “pain management,” “pain assess- ment,” “pain treatment,” and “barriers to pain Submitted, revised, 3 December 2000. From the Institute for Education and Research in Pain management.” and (MG), Department of Pain Medicine and Palliative Care, Beth Israel Medical Center, New York. Address reprint requests to Myra Glajchen, DSW, Institute Barriers to Effective Pain Management for Education and Research in Pain and Palliative Care, Undertreatment of Pain Beth Israel Medical Center, Department of Pain Medicine and Palliative Care, First Avenue at 16th Street, New York, In a recent study of 805 chronic pain sufferers, it NY 10003. was reported that more than 50% found it neces-

Chronic Pain 211 sary to change physicians in their quest for pain Cooperative Oncology Group, and all had patient relief. Specific reasons for changing physicians in- care responsibilities. Approximately three fourths

cluded lack of physicians’ willingness to treat the of the physicians (76%) cited their own sense of low J Am Board Fam Pract: first published as on 1 May 2001. Downloaded from pain aggressively, failure to take the pain seriously, competence in patient assessment as the major bar- and lack of knowledge about pain management.3 In rier to effective pain management. Reluctance to a study of 1,308 outpatients with metastatic can- prescribe opioids was cited by 61% of the respon- cer,11 67% (871) of the patients reported that they dents as the second most important barrier.15 had pain or had taken drugs daily during These clinician-related barriers have been borne the week preceding the study, and 36% (475) had out by subsequent research, and they tend to be pain severe enough to impair their ability to func- compounded in the treatment of nonmalignant tion. Forty-two percent of those with pain were not pain.12 given adequate analgesic therapy. A discrepancy between patient and physician in judging the sever- Patient-Related Barriers ity of the patient’s pain was predictive of inadequate Patient-related barriers include communication, pain management. One third of practitioners re- psychological, and attitudinal issues. In a sample ported that they would wait until the patient had survey of cancer patients receiving services from an less than 6 months to live before starting the max- outpatient social service agency, patients who re- imal tolerated analgesia for severe pain. ported communication problems with their physi- Although opioid use in the treatment of chronic cians had significantly worse pain than those who has gained increasing acceptance did not.18 Several psychological factors can influ- worldwide, the debate continues regarding the use ence pain assessment and treatment, such as anxi- of these in the treatment of chronic non- ety, distress, depression, anger, and dementia, all of malignant pain.2,12,13 A recent review concludes which can complicate assessment by masking symp- that the reluctance to use opioids for noncancer toms. Ward and colleagues19 measured the extent pain treatment has resulted in ineffective relief for to which patients’ attitudes toward pain and opioids a large group of patients. Several researchers have pose barriers to treatment. Fear of addiction, tol- found physician resistance to treating chronic non- erance, and side effects were described by patients http://www.jabfm.org/ malignant pain with opioids. Regulatory concerns, as their most important concerns. Fatalism and the beliefs about the inevitability of tolerance, concern desire to please the clinician were also cited by a about long-term safety and durability of response— majority of respondents. Some patients expressed all combine to reduce the willingness of primary the belief that pain was inevitable, indicating that care physicians to prescribe opioids for chronic they did not expect medication to relieve their pain. 14 nonmalignant pain. In addition, patients associated pain with worsening on 2 October 2021 by guest. Protected copyright. disease. Such concerns can result in patients’ reluc- Clinician Barriers tance to report pain or comply with a regimen that Gaps in knowledge, negative attitudes toward pre- involves opioid medication. scribing opioids, inadequate assessment skills, and timidity in prescribing are barriers that clinicians Health Care System Barriers can unwittingly bring to clinical encounters with The health care system itself can pose barriers to patients.15,16 The problem might begin with the effective pain relief in the form of practical con- low priority given to pain treatment in medical straints. The lack of a neighborhood pharmacy, the schools and residency training programs. When lack of transportation to the physician or pharmacy, asked about their training in pain management, an absence of high doses of opioids at the phar- 88% of physicians reported that their medical macy, and the lack of a home caregiver to assist school education in pain management was poor, with administering drugs pose major obstacles to and 73% reported that residency training was fair pain treatment. Changes in reimbursement policies or poor.15,17 In a study of physician attitudes and impose barriers, especially for older patients whose practice, Von Roenn and associates15 asked physi- Medicare benefits do not pay the costs of outpatient cians to describe barriers to pain relief in their prescription drugs.20 In addition, patients and care- practice settings. The 897 physicians who com- givers might confront increasing co-payments, out- pleted the survey were members of the Eastern of-pocket expenses, limits on the number of pre-

212 JABFP May–June 2001 Vol. 14 No. 3 scriptions filled per month, and limits on refills. Race Finally, fear of regulatory scrutiny for prescribing In the same study, the percentage of patients with

controlled substances has been shown to discourage negative scores was three times higher in commu- J Am Board Fam Pract: first published as on 1 May 2001. Downloaded from physicians from prescribing opioids of sufficient nity clinical oncology programs that treated pre- strength for the patient’s pain, especially for dominantly minority patients, primarily African chronic nonmalignant pain.11 Such fears can result Americans and Hispanics. Minority patients were in the selection of less effective analgesics and, more likely than nonminority patients to have in- ultimately, undertreatment of the patient’s pain. adequate analgesia.11 Bernabei et al,22 in a study of end-of-life pain management and access to care, Demographic Considerations in Assessment found that members of a minority race were among and Treatment the least likely to receive analgesics. In addition, patient relief might be withheld because physicians When assessing and treating chronic pain, the cli- fear drug-seeking and substance-misuse behavior in nician would be wise to consider nonmedical fac- this subset of patients.23 tors, including age, sex, and race.

Age Selecting Effective Treatment for Chronic Pain Older patients with mild to moderate cognitive Guidelines issued by the US Agency for Health impairment often require extra time to assimilate Care Policy and Research (AHCPR) for managing questions, have a limited attention span, and are cancer pain incorporate various treatment modes, easily distracted. When assessing pain in these pa- including the three-step analgesic ladder of the 5 tients, good ambient lighting, amplified hearing World Health Organization. On diagnosis of devices, and visual cues in large print have been chronic pain, step 1 recommends prescribing a found to be effective. In addition, the clinician nonopioid medication with or without an adjuvant should always face the patient directly, speak slowly medication, if necessary. If the pain persists or and clearly, and keep the interview brief. Repeating increases, step 2 recommends prescribing an opioid 2 or rewording questions might be necessary. medication for mild to moderate pain along with a http://www.jabfm.org/ nonopioid medication and an adjuvant medication, if necessary. If the pain continues to persist or Sex increase, step 3 recommends an opioid medication Variations in pain by the sex of the patient are likely for moderate to severe pain along with a nonopioid to represent an interaction of biologic and psycho- medication and an adjuvant medication, if neces- logical components. Some differences in prescrib- 15 sary.

ing by sex, however, might not be patient based. on 2 October 2021 by guest. Protected copyright. Instead, physicians’ opioid-prescribing habits might be affected by gender stereotypes. Mc- Guidelines for Opioid Use Donald21 reviewed the medical records of 101 male “Start low, go slow” is particularly apt for older and 79 female adult appendectomy patients without patients, because they are likely to achieve optimal postoperative complications and found that male pain control from doses lower than those needed by patients received significantly larger initial doses of younger patients. In general, pain is stabilized with opioid analgesics than did female patients (P Ͻ immediate-release preparations; then treatment is .001), but no gender difference was noted in the switched to sustained-release forms, with immedi- total dose of opioid analgesic received in the post- ate-release agents available as needed for break- operative period. McDonald suggested that the dif- through pain. ferences in initial doses of opioid analgesic might be due to gender stereotyping during the initial Dosing Intervals postoperative period, when the patient is still The benefits of long-acting opioids for chronic drowsy and unable to make his or her needs known. pain include continuous pain relief, less peak-and- Similarly, a study by Cleeland et al11 found that in trough effect found with short-acting opioids, less a population of patients with metastatic cancer, sleep disturbance, fewer problems with patient being female was a significant predictor of inade- compliance, and fewer reported side effects.12,24 quate pain management. Opioid analgesics should be administered at regular

Chronic Pain 213 Table 1. Dose Equivalencies.

Medication and Dose Initiation 1st Titration 2nd Titration 3rd Titration J Am Board Fam Pract: first published as on 1 May 2001. Downloaded from Oral morphine, mg/d q 12 h 45–134 135–224 225–314 315–404 Intramuscular or intravenous morphine, mg/d 8–22 23–37 38–52 53–67 Oral oxycodone, mg/d q 8–12 h 22.5–67 67.5–112 112.5–157 157.5–202 Intramuscular or intravenous oxycodone, mg/d 12–33 33.1–56 56.1–78 78.1–101 Oral codeine, mg/d q 3–4 h 150–449 450–749 750–1049 1050–1349 Intramuscular or intravenous codeine, mg/d 104–292 293–487 488–682 683–877 Oral , mg/d q 3–4 h 5.6–16.7 16.8–28 28.1–39.2 39.3–50.5 Transdermal fentanyl, ␮g/h q 72 h 25 50 75 100

From: Duragesic dosage conversion reference guide. Titusville, NJ: Janssen Pharmaceutica, 1997. intervals, not as needed. Avoiding sharp trough Fentanyl is available as a sustained-release opi- levels can reduce overall drug consumption.25 oid analgesic administered through the skin via a transdermal patch. The patch is available in four Titration strengths: 25, 50, 75, and 100 ␮g/h. The initial Titration is the adjustment of medication to main- dose for opioid-naive patients should not exceed 25 tain optimal analgesia in response to patients’ re- ␮g/h, with the dose titrated upward if needed for ports of pain. The titration of an opioid analgesic maximal pain control. Transdermal fentanyl is de- should be made, if needed, 3 days after the initial signed for duration of action of up to 72 hours, dose. Thereafter, dose titrations can be made in although its effective activity might exceed 72 24-hour periods. Opioids have no ceiling effect; hours in older patients. The peak effects of the first therefore, the dose can be increased until the de- dose can take 18 to 24 hours to achieve. In this sired analgesic effect is obtained or until side effects phase, immediate-release analgesics may be admin- become intolerable. Dose equivalencies are listed in istered for breakthrough pain.3,25 http://www.jabfm.org/ Table 1. Oxycodone is available in a sustained-release form, although an immediate-release opioid is usu- Commonly Used Opioids ally necessary for breakthrough pain, as is also the 8,25 The least invasive route of administration should case for sustained-release morphine. A reason- be used first, which generally means an oral or able starting dose for most patients who are opioid-

transdermal route. Some of the most commonly naive is 10 mg every 12 hours. If greater analgesia on 2 October 2021 by guest. Protected copyright. used long-acting preparations are discussed below. is needed, the amount, but not the frequency, of the Morphine is considered the reference standard sustained-release dose may be increased. In con- of opioid analgesics. It is available in sustained- trolled pharmacokinetic studies in older patients, release form and may be given orally or parenter- the clearance of oxycodone appeared to be slightly ally. Sustained-release morphine does not release reduced. morphine continuously during the course of the Methadone is a synthetic opioid derived from dosing interval. For patients whose daily morphine opium. Although methadone has been available for requirements are expected to be 120 mg/d or less, many years, primarily to treat opioid addiction, a the 30-mg tablet strength is recommended for the resurgence of interest has occurred in its analgesic initial titration period. Once a stable dose regimen properties for patients with chronic, nonmalignant is reached, the patient can be converted to the pain and cancer pain. Methadone accumulates with 60-mg or 100-mg tablet strength, titrating upward repeated dosing because of its long half-life of 17 to until adequate analgesia is achieved. The 200-mg 128 hours, and it has enormous interindividual tablet strength is a high-dose tablet indicated for variability in clearance. It is recommended that this the relief of pain in opioid-tolerant patients only. drug be prescribed as needed during initial titration The increased risk of morphine use in older pa- to avoid excessive side effects during the titration tients should be taken into account, especially in period. There are no known active metabolites of patients with severe renal or hepatic impairment.3 methadone, which makes it attractive for patients at

214 JABFP May–June 2001 Vol. 14 No. 3 risk for toxicity associated with metabolite accumu- port.7,27 In addition, caregivers encourage the pa- lation. Other advantages include its low cost, rela- tient to report pain, remind the patient to take

tive potency and long duration of analgesia with medication, and legitimize or question the experi- J Am Board Fam Pract: first published as on 1 May 2001. Downloaded from on-going use, and multiple routes of administra- ence of pain and its treatment. tion.26 Difficulties with methadone use include vast differences in pharmacokinetics among patients, a Recognizing and Treating Side Effects poorly defined equianalgesic potency, and its long When assessing the patient, the clinician should half-life, which can be associated with toxicity, es- always inquire about side effects, develop a plan for pecially among the elderly. If clinicians heed the treating them, and explain the plan to the pa- advice to start low and go slow, however, metha- tient.4,19 If the clinician does not inquire about side done can be used safely and effectively.26 effects or does not initiate prompt treatment, pa- Pharmacokinetic differences exist among opioid tient compliance might be affected. analgesics. When selecting an analgesic, the activity The most common side effect of opioid analge- of metabolites, cytochrome P-450 drug interac- sia in patients with either malignant or nonmalig- tions, side-effect profiles, and potential for dehy- nant pain is constipation.12 Unlike the other com- dration should be reviewed carefully. Before initi- mon opioid side effects, constipation does not ating pain therapy, careful attention should be paid improve with time. A prophylactic bowel regimen to other drugs the patient might be taking. The should be initiated at the start of opioid therapy. patient’s age and degree of renal or hepatic impair- Other common side effects include somnolence, ment are important considerations as well.7 confusion, nausea, and vomiting. Patients usually develop tolerance to these effects within 1 week to Strategies for Clinical Practice 10 days. If side effects become intolerable, relief can be attained through dose titration, adjuvant Clinicians can take several concrete steps to address therapy, or opioid rotation. the factors that influence the assessment and treat- Opioid rotation can be implemented to improve ment of the patient with chronic pain. treatment efficacy, reduce side effects (especially sedation and myoclonus), and reduce tolerance. http://www.jabfm.org/ Conducting Optimal Assessments The clinician should assess pain frequently and at Ongoing Assessment regular intervals, using one of several available brief The chronic pain patient should be monitored fre- self-report questionnaires, including the numerical quently after initiating treatment. The analgesic 0 to 10 scale (in which 0 equals no pain and 10 the efficacy of the chosen opioid therapy, as well as the worst pain imaginable), pain diaries, pain logs, faces level of side effects and the effects on patient func- on 2 October 2021 by guest. Protected copyright. scales, and color scales. A complete listing of these tioning, should be assessed with the aim of attain- tools can be found in the AHCPR guidelines on the ing improvement in the patient’s ability to perform 5 management of cancer pain. activities of daily living. For the patient on a new medication regimen, monthly follow-up is recom- Improving Communication mended. Once the treatment protocol has been To improve communication, the practicing physi- established, follow-up visits can be extended to cian should initiate discussions about pain with the 3-month intervals. In all cases, the patient should patient and the family, reassess pain more fre- be encouraged to contact the physician’s office to quently (perhaps monthly or bimonthly if the pain report on their progress and side effects, if any. is not well controlled), and encourage patients to report changes, both positive and negative, in pain Promoting Coping Behaviors status. Because family caregivers play a key role in To maximize the success of a pain management chronic pain management, they should be included strategy, physicians can assist the patient in report- in assessment and treatment to ensure that they ing pain, taking pain medication exactly as pre- support the treatment plan in the home. Family scribed, increasing activity level, participating in caregivers are required to assess and report pain, fill rehabilitation, and using cognitive behavioral tech- prescriptions, administer medication, manage niques (for example, hypnosis, distraction, biofeed- emergencies, and provide ongoing emotional sup- back, relaxation, and imagery). Patients might ben-

Chronic Pain 215 efit from psychotherapy, a group support, or a The National Federation of State Medical Boards multidisciplinary rehabilitation program. has defined addiction as psychological dependence

on the use of substances for their psychic effects, J Am Board Fam Pract: first published as on 1 May 2001. Downloaded from Ongoing Education characterized by compulsive use despite harm. Tol- Pain practitioners can stay abreast of the latest erance is a form of neuroadaptation to the effects of developments in the area of pain management in a opioid or other medications administered long- variety of ways, including continuing medical edu- term and is manifested by the need for increasing cation conferences, pain journals, and pain Web or more frequent doses of the medication to sites, such as the following: achieve the initial effects of the drug. Tolerance http://www.ampainsoc.org/ can develop both to the analgesic effects of opioids http://www.medsch.wisc.edu/painpolicy/ and to unwanted side effects, such as respiratory http://www.painmed.org/ depression, sedation, and nausea. Tolerance is a http://www.druglibrary.org/schaffer/asap/in- natural and expected outcome of opioid therapy, dex.htm which resolves during treatment and should not be http://www.cancerpainrelief.com/ misconstrued as addiction. Addiction and tolerance http://www.StopPain.org should be distinguished from physical dependence, which refers to the physiologic adaptation of the Considering Patient Preferences body to the presence of an opioid medication re- In a cross-sectional study of patients with late-stage quired to maintain the same level of analgesia. Even cancer receiving either transdermal fentanyl (Du- if physical withdrawal occurs when the opioid med- ragesic) or sustained-release oral morphine (MS ication is abruptly withdrawn, physical dependence Contin, Oramorph SR), investigators found that should not be confused with true addiction.5 patients receiving transdermal fentanyl were more A survey of published data of opioid use in the satisfied overall with their pain medication than treatment of chronic nonmalignant pain revealed were those receiving sustained-release oral mor- little risk of addiction in patients who had no his- phine (P ϭ .035). Fentanyl patients also reported a tory of substance abuse.24 The factors that predis- significantly lower frequency (P Ͻ .002) and impact pose to addiction have not been confirmed, how- http://www.jabfm.org/ (P Ͻ .001) of side effects.28 ever, and there is no proven method of screening An open-label study of transdermal fentanyl was people at risk for addiction. Accordingly, although conducted in patients with chronic low- addiction is unlikely for patients with no history of of 6 months’ duration or longer that was not ade- substance abuse, each behavior has to be addressed quately controlled with short-acting opioids. as it arises in practice.

Transdermal fentanyl significantly reduced pain in- Patients in unremitting pain might exhibit be- on 2 October 2021 by guest. Protected copyright. tensity scores as measured by both a visual analog havioral characteristics suggestive of addiction; scale, which declined from 79.78 to 44.22 (P Ͻ these behaviors, however, should be distinguished .0001), and a numerical , which declined from true aberrant activities. The term pseudoaddic- from 8.02 to 6.02 (P Ͻ .0001). Although the results tion refers to the perception by observers of drug- were less dramatic, transdermal fentanyl therapy seeking behavior by patients who have severe pain. also significantly reduced disability. At the conclu- These behaviors can include drug-seeking behav- sion of the study, 43 patients (86%) reported expe- ior, medications taken in larger amounts than pre- riencing overall benefit from transdermal fentanyl scribed, running out of medications prematurely, in controlling low-back pain, while 7 patients tolerance, and withdrawal symptoms. There is an (14%) did not experience measurable overall ben- emerging consensus that these behaviors are not efit. The 43 patients stated that they would recom- often associated with true addiction but are a result mend transdermal fentanyl to other persons with of serious undertreatment for pain. It is increas- chronic low-back pain.29 ingly believed that pseudoaddictive behavior can be distinguished from true addictive behavior if higher Concern About Addiction and Aberrant Drug- doses of an opioid analgesic result in elimination of Taking Behavior these behaviors.30 Confusion persists regarding the correct meaning Of concern to the physician should be the fol- of addiction, tolerance, and physical dependence. lowing drug-related behaviors: forging or stealing

216 JABFP May–June 2001 Vol. 14 No. 3 prescriptions, selling prescription medications, re- givers of elderly patients. Oncol Nurs Forum 1995; peatedly escalating doses, or obtaining drugs from 22:1211–8. 24 5. Management of cancer pain. Management of Cancer

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