Insufficient prescriptions and poor adherence are key factors in poor cancer pain management

November 29, 2001

Many cancer patients are not achieving adequate pain relief because they do not adhere to pain medication regimens and do not receive adequate pain medication prescriptions, according to a new UCSF study.

In one of the first studies to observe cancer patients using long-term pain management regimens in their homes, researchers in the UCSF schools of Nursing, Medicine and Pharmacy found that many cancer patients were not taking around-the-clock and as-needed pain medicines as prescribed by their physicians. The study appears in the December issue of the Journal of Clinical Oncology.

Over the five weeks of the study, overall adherence rates ranged from 84.5 to 90.8 percent for around the clock opioid analgesics and 22.2 to 26.6 percent for as-needed analgesics. There were no significant changes in adherence rates, pain intensity or duration of pain during the course of the study.

Most patients cited adverse side effects (such as constipation) as the reason for their lack of adherence, said Chris Miaskowksi, PhD, professor and chair of the UCSF department of physiological nursing and lead author on the study. "The old message was people weren't taking their pain medication because of fear of addiction. Our study debunks that explanation and reinforces the need for patients to talk to their physicians about he management of side effects, " said Miaskowski. She explained that physicians can often reduce constipation side effects, for example, by prescribing laxatives.

Researchers noted that current practice guidelines for cancer pain management recommend that patients with chronic cancer pain (like pain from bone metastases) receive a long-acting opioid analgesic for their constant pain and a short-acting opioid on an as-needed basis for breakthrough pain.

However, only 29.2 percent of patients in this study (which focused on oncology patients with baseline pain and evidence of bone metastases) received both kinds of medication. Just over 13 percent were prescribed only opioid analgesics on an around-the clock basis and nearly 57 percent were prescribed only opioid analgesics on an as-needed basis.

"This suggests that more aggressive pain management strategies might be in order for cancer patients," said Miaskowski. In addition, she explained that effective pain management requires repeated assessment and dosage adjustment.

"Health providers need to consistently ask patients if they are taking their medication and if it is working. If necessary, providers need to appropriately adjust prescriptions to make them more effective." she said.

The randomized six-week study included 65 adult oncology patients with baseline pain and evidence of bone metastases. On a daily basis, patients rated their level of pain intensity and recorded their pain medication intake. Adherence rates for opioid analgesics prescribed on an around-the-clock and an as-needed basis were calculated weekly.
Co-researchers on this study include: Marylin J. Dodd, PhD, professor and associate dean in the UCSF School of Nursing; Claudia West, RN, professor in the UCSF department physiological nursing; Steven M. Paul, PhD, senior statistician in the UCSF School of Nursing; Debu Tripathy, MD, UCSF associate professor of hematology and oncology; Peter Koo, PharmD, pain management specialist in UCSF pharmaceutical services; and Karen Schumacher, PhD, assistant professor in the University of Pennsylvania School of Nursing.

This study was supported by a grant from the National Cancer Institute. Additional support was provided through grants from Janssen Pharmaceutica and Purdue Pharma LP.

University of California - San Francisco

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