Drug Therapy Is Cornerstone of Pain Management

By Rodgers, Katie | Drug Topics, June 13, 1994 | Go to article overview

Drug Therapy Is Cornerstone of Pain Management


Rodgers, Katie, Drug Topics


Cancer patients who suffer from pain should talk about it, health-care professionals should believe them and respect their complaints, and those patients should be treated with adequate amounts of medication, even if an "adequate amount" is a very high dose of a narcotic analgesic. In a nutshell, that's the take-away message from the recently released Agency for Health Care Policy & Research guidelines "Management of Cancer Pain: Adults."

Most patients with advanced cancer experience moderate to severe pain that is often undertreated. Inadequate treatment of cancer pain represents a major public health concern, since, in about 90% of cancer patients, pain can be controlled with currently available medications.

"There's an aura that [opioids] are bad drugs. They're associated with drug abuse, and the street image is what people most often think of, and they're reluctant to use them. There's a great fear that patients will become 'addicted' to these drugs," C. Stratton Hill Jr., M.D., told an audience at a recent satellite video conference entitled "An Imperative to Improve Cancer Pain Treatment: The AHCPR Guidelines." The conference, sponsored by the American Pain Society through an educational grant from Janssen Pharmaceutica, was attended by more than 3,000 health-care professionals in 10 cities across the country and was moderated by ABC news correspondent, Morton Dean.

Hill, who is professor of medicine in the Department of Neuro-oncology at the University of Texas, M. D. Anderson Cancer Center in Houston, cited government regulation as another impediment to adequate treatment of cancer pain. "There are many health-care professionals out there who have a perceived or a real fear that they'll be sanctioned by regulatory agencies to interfere with their prescribing to the point of losing their license," Hill said.

Panel member Robert T. Angarola, J.D., a Washington lawyer who specializes in food and drug law, agreed. "Cancer patients in pain have been victimized by the overzealous regulations that negatively affect the availability of needed drugs," he declared. Angarola, director of the United States Cancer Pain Relief Committee and the Institute for Behavior & Health, encouraged health-care providers to become politically active in breaking down the regulatory barriers that prevent patients in pain from receiving adequate treatment.

To clear up some of the misconceptions about opioid use, the AHCPR guidelines clearly differentiate between "addiction" and "tolerance." "The guidelines say that opioid tolerance and physical dependence are to be expected. They're normal pharmacological events, they're expected with long-term treatment, and they're not to be confused with addiction," Hill said. "An addict is one who habituates the use of a drug so as to endanger public health and safety, or one who has lost control over opioid use," he continued.

For the treatment of cancer pain, the AHCPR panel adopted the World Health Organization's analgesic ladder. This three-step approach recommends the use of aspirin, acetaminophen, or NSAIDs for patients with mild to moderate pain. If pain persists or increases, an opioid is added, and if the pain continues or becomes moderate or severe, the dose of the opioid should be increased or the drug should be substituted with a stronger opioid. The analgesic ladder also allows for the use of adjuvant drugs that, when combined with an opioid or a nonopioid, either improve analgesia or treat the side effects. Kathleen M. Foley, M.D., chief of the pain service and attending neurologist at Memorial Sloan-Kettering Cancer Hospital in New York City, explained that the analgesic ladder, along with assessment of the type of pain and the intensity of the pain, determine the choice of treatment.

Foley remarked that, for patients with intense pain, it may not be appropriate to start at the bottom of the ladder with a mild analgesic, and an opioid may be required. …

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