Poor adherence to pain medication regimen, insufficient prescriptions, key factors in ineffective cancer pain management

November 30, 2001

Lack of adherence to pain medication regimens and inadequate analgesic prescriptions are the main reasons cancer patients do not achieve adequate pain relief, a new study finds.

In one of the first studies to observe cancer patients in their homes, researchers at the Schools of Nursing, Medicine, and Pharmacy at the University of California at San Francisco aimed to determine whether cancer patients were adhering to the around-the-clock and as-needed pain management regimens prescribed by their doctors.

"The old message was people weren't taking their pain medication because of fear of addiction," said Christine Miaskowski, RN, PhD, Professor and Chair of the Department of Physiological Nursing at UCSF. "Our study debunks that explanation, and found that the side effects caused by most opioid analgesics were a key reason why cancer patients did not adhere to their pain medication regimen."

Side effects, such constipation and sedation, deterred patients from taking their pain medication. Patients in the study told researchers that they would rather experience pain than deal with the side effects of the analgesic medications. This finding is unfortunate, because side effects like these can be proactively treated.

According to an accompanying editorial in the Journal of Clinical Oncology by Jamie von Roenn, MD, Professor of Medicine at Northwestern University, "Lack of adequate knowledge or assessment of pain management by physicians is suggested by the pattern of analgesic prescriptions. Effective pain management requires repeated assessment and adjustments in dosage."

The randomized five-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.

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.

Federal guidelines recommend that all cancer patients with chronic cancer pain be prescribed an around-the-clock analgesic regimen, as well as a short-acting supplement for breakthrough pain. However, not all patients received both types of medication. In the study, 13.9 percent of patients were prescribed opioid analgesics on an around-the-clock basis, 56.9 percent were prescribed opioid analgesics on an as-needed basis, and 29.2 percent were prescribed both around-the-clock and as-needed analgesics. "Poor adherence, may, therefore, in part reflect the lack of relief from inadequate analgesic prescriptions," said Dr. von Roenn. In an effort to improve physicians' knowledge of pain management, medical societies and universities have begun to integrate pain and symptom management into their educational activities.

Dr. Miaskowski also stressed the need for patients talk to their physicians about the management of side effects.
"Lack of Adherence With Analgesic Regimen: A Significant Barrier to Effective Cancer Pain Management." Christine Miaskowski, RN, PhD, et al.; Schools of Nursing, Medicine and Pharmacy, University of California, San Francisco, CA. Vol 19, No 23 (December 1) 2001, pp: 4275-4279.

The Journal of Clinical Oncology is the semi-monthly peer-reviewed journal of the American Society of Clinical Oncology (ASCO), the world's leading professional society representing physicians who treat people with cancer.

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