Cancer pain: knowledge and attitudes of physicians in Israel

The effectiveness of cancer pain therapy is influenced by the attitudes and knowledge of the treating physicians. As part of a quality improvement project in the management of cancer pain, a survey of 236 medical practitioners was conducted. One hundred seventy-six respondents (74.5%) completed the survey. Fifty-two percent treated patients with cancer pain several times a week or more. Whereas 57.7% of physicians stated that 76-100% of patients could achieve a satisfactory outcome from analgesic therapy, only 17.2% of respondents reported that > 75% actually achieve a satisfactory outcome in their own experience. Unsatisfactory outcome was ascribed to inadequate pain relief (59.7%), or excessive central nervous system (CNS) side effects (43.3%). According to the responding physicians, the major barriers to effective relief include inadequate assessment of the pain and pain relief (65.3%), inadequate knowledge of pain therapy (57.9%), and physician reluctance to prescribe opioids (49.1%). Questions evaluating physician knowledge identified widely prevalent knowledge deficits in pain physiology, risk of addiction, use of adjuvant analgesics, opioid dosing, and treatment of side effects. Specialists in oncology tended to evaluate their knowledge more highly than others (P < 0.05). Despite this, there was no significant knowledge difference between oncologists and noncancer specialists. The data highlight some of the barriers to the successful management of cancer pain in Israel, the prevalence of knowledge deficits, and the common disparity between clinicians' self-assessment of clinical competence and their ability to respond correctly to questions on the management of cancer pain.     

Opioids,Chronic Pain,and Addiction in Primary Care

Research has largely ignored the systematic examination of physicians' attitudes towards providing care for patients with chronic noncancer pain. The objective of this study was to identify barriers and facilitators to opioid treatment of chronic noncancer pain patients by office-based medical providers. We used a qualitative study design using individual and group interviews. Participants were 23 office-based physicians in New England. Interviews were audiotaped, transcribed, and systematically coded by a multidisciplinary team using the constant comparative method. Physician barriers included absence of objective or physiological measures of pain; lack of expertise in the treatment of chronic pain and coexisting disorders, including addiction; lack of interest in pain management; patients' aberrant behaviors; and physicians' attitudes toward prescribing opioid analgesics. Physician facilitators included promoting continuity of patient care and the use of opioid agreements. Physicians' perceptions of patient-related barriers included lack of physician responsiveness to patients' pain reports, negative attitudes toward opioid analgesics, concerns about cost, and patients' low motivation for pain treatment. Perceived logistical barriers included lack of appropriate pain management and addiction referral options, limited information regarding diagnostic workup, limited insurance coverage for pain management services, limited ancillary support for physicians, and insufficient time. Addressing these barriers to pain treatment will be crucial to improving pain management service delivery.     

Pediatric cancer pain management practices and attitudes in China

Children with cancer often receive less adequate pain management than adults. This survey was designed to examine current practices, knowledge, and attitudes pertaining to pediatric pain management in China. Based on the choice of opioid use and self-identification as having a conservative or liberal approach to pain management, we identified two clusters. Members of cluster 1 (60%) had more conservative attitudes and did not perceive that young children experienced pain. Members of cluster 2 (40%) had more liberal attitudes. Four factors predicted conservative membership: never having prescribed opioids for cancer pain (OR=2.67, CI=1.11-6.45), use of placebos for pain management (OR=2.32, CI=1.05-5.08), belief that the adequacy of pain management was fair or good (OR=2.10, CI=1.31-3.37), and belief that children are less sensitive to pain (OR=1.96, CI=1.02-3.76). The top barriers to optimal pediatric pain management were identified as fear of opioid addiction and inadequate knowledge of pain management.     

Physicians' knowledge and attitudes toward the use of analgesics for cancer pain management: a survey of two medical centers in Taiwan

The purposes of this study were to examine the attitudes of physicians regarding the optimal use of analgesics for cancer pain management (CPM), to evaluate their knowledge and attitudes toward opioid prescribing, and to comprehend their perceptions of the barriers to optimal CPM. A survey was conducted on 356 physicians with cancer patient care responsibilities practicing in two medical centers in Taiwan. A total of 204 (57%) physicians responded, including internists (28%), surgeons (27%), oncologists (11%), anesthesiologists (10%), and other specialties (24%). The majority of physicians displayed significantly inadequate knowledge and negative attitudes toward the optimal use of analgesics and opioid prescribing. Multivariate analyses showed that the following six categories of physicians would be inclined to have inadequate knowledge of opioid prescribing: 1) those with perception of good medical school training in CPM, 2) those with perception of poor residency or fellowship training in CPM, 3) those with a medical specialty in surgery, medicine, or oncology (vs. anesthesiology), 4) those with limited clinical experience in cancer patient care (number of patients less than 30), 5) those with a limited aim of pain relief, and 6) those with an underestimation of analgesic effect. Additionally, physicians with inadequate knowledge of opioid prescribing and with hesitation to intervene earlier with maximal dose of analgesia would be inclined to have reluctant attitudes toward opioid prescribing. The most important barriers to optimal CPM identified by physicians themselves were physician-related problems, such as inadequate guidance from a pain specialist, inadequate knowledge of CPM, and inadequate pain assessment. The results of this study suggest that active analgesic education programs are urgently needed in Taiwan.     

Opioid Use in the Philippines – 20 years after the introduction of the WHO analgesic ladder

AimTo find out if the opioid usage has improved in the Philippines 20 years after the introduction of the WHO analgesic ladder.BackgroundTwenty years after the introduction of the WHO analgesic ladder in the Philippines, usage of morphine for cancer pain relief is still low. Barriers to opioid prescribing persist because of factors attributable to physicians, patients, families and constraints imposed by government regulatory bodies.MethodsA survey of 211 physicians on a purposive sampling representing various regions in the country was done. Respondents included anesthesiologists, surgeons, oncologists, and palliative care specialists, who were expected to prescribe opioids in their practice. A 20-item multiple-choice questionnaire was developed to explore possible barriers to opioid prescribing.ResultsThere is a very good awareness of the WHO analgesic ladder (72%) as well as the availability of opioids in their areas of practice (89.57%). Monitoring of pain as the “fifth vital sign” is adhered to by 68.25% of the respondents. There was only 60.66% compliance regarding availment of a narcotics license among respondent physicians. Various reasons were identified as to why they failed to get a narcotics license.ConclusionsThere was adequate knowledge about the WHO analgesic ladder among the respondents. There is a perceived resistance to prescribe strong opioids like morphine making the step 2 of the ladder as a comfort zone by the physicians who tend to “overstay” in this step. Government regulatory policies have affected the physicians' attitudes concerning narcotics license application. There is a very slow, though steady increase in morphine and oxycodone usage in the country. Barriers to opioid use in cancer pain management still persist twenty years after the introduction of the WHO analgesic ladder.     

Physicians' attitude and practices in sickle cell disease pain management

Many physicians believe that patients with sickle cell disease (SCD) are more likely to become addicted to pain medication than are other patient populations. This study hypothesizes that physicians' attitudes towards addiction in patients with SCD affects pain management practices. The Physician Attitudes Survey was sent to 286 physicians at seven National Institutes of Health-funded university-based comprehensive sickle cell centres. The survey assessed demographic information; and physician's attitudes toward and knowledge of pain, pain treatment, and drug addiction and abuse. Significant Pearson product-moment correlations were found between attitudes towards pain and beliefs regarding addiction to prescribed opioids. Physicians reported varied pain management strategies, however, many believe that attitudes toward addiction and to patients in pain crises may result in undertreatment of pain. These results indicate that physicians might benefit from additional education regarding sickle cell disease, addiction to pain medication, the pharmacology of opioids, and the assessment and treatment of pain.     

Determinants of nurses' intention to administer opioids for pain relief

Abstract A statewide cross-sectional survey was conducted in Australia to identify the determinants of registered nurses' intention to administer opioids to patients with pain. Attitudes, subjective norms and perceived control, the key determinants of the Theory of Planned Behavior, were found to independently predict nurses' intention to administer opioids to these patients. Perceived control was the strongest predictor. Nurses reported positive overall attitudes towards opioids and their use in pain management. However, many negative attitudes were identified; for example, administering the least amount of opioid and encouraging patients to have non-opioids rather than opioids for pain relief. The findings related to specific attitudes and normative pressures provide insight into registered nurses' management of pain for hospitalized patients and the direction for educational interventions to improve registered nurses' administration of opioids for pain management.     

Developments in the treatment of cancer pain in Finland: the third nation-wide survey

This survey was designed to investigate the current status of the management of cancer pain in Finland. In 1995 a questionnaire was randomly sent to 5% (n=546) of Finnish physicians, excluding specialists not expected to treat cancer patients. Two previous surveys, using the same questionnaire, were conducted in 1985 and 1990 by Vainio. The response rate was 53%. Seventy-nine percent of the respondents treated one or less than one cancer patient a week. Sixty-seven percent of them assessed the severity of cancer pain in their patients as being at least moderate. In 10 years, the proportion of physicians suggesting the WHO analgesic ladder principle to their ‘typical cancer patient' had increased from 12% to 28%. At the same time, the suggestions of ‘analgesic' without definition had decreased from 48% to 6%. Three simulated patient cases were presented. The mean daily dose of opioids suggested for severe terminal cancer pain corresponded to 72 (18–300) mg of intramuscular morphine in 1995, being only 39 (1–77) mg in 1985 for the same simulated patient case. Continuous infusion of opioid was recommended by 59% of the respondents. Non-steroidal anti-inflammatory drugs as the treatment of choice for bone metastases pain in a patient with breast cancer, was recommended by 68% of the respondents. In the case of local severe pain due to recurrent rectal cancer, 63% of the physicians suggested anaesthetic intervention. Insufficient pain relief and lack of experience were the most common difficulties in pain management. Only one-third of the physicians thought that they had enough time and ability to give sufficient psychological support to their patients.     

Current status of pain management in China: an overview

China is a large country with a huge population.It is estimated that 1.8 million patients suffer initially from cancer and 1.4 million patients die from it each year in Mainland China. Cancer ranks as the primary reason for death among the common diseases in cities and the second in rural areas.The management of pain is still a critical issue in the care of patients both with cancer and non-cancer pain. A national survey suggested that the fear of addicting patients was still a major barrier for medical professionals in prescribing opioid analgesics. The major reasons for poor management or negative factors of pain relief came from patients' own reasons including their over-concern about addiction to opioid analgesics, their reluctance to report pain and their resistance to use opioid analgesics. Oral long-acting opioids are the most commonly used drugs for third ladder pain management. With policy support from the government, the consumption of morphine for medical purposes has increased significantly for the first time in recent Chinese history as this new cancer pain relief policy has been developed in the country. As a result, the three-step analgesic ladder of the World Health Organization (WHO) has been gradually accepted by medical personnel and patients.Although pain management has been improved since the WHO's strategy of the three-step approach was implemented in China, variations still exist in different regions of the Mainland. Currently the three main aspects of work on pain measurement are going to be undertaken including (1) continuous support from government policy; (2) consistent education and training; and (3) better availability of drugs for medical use throughout the whole country.     

State medical board members' beliefs about pain, addiction, and diversion and abuse: a changing regulatory environment.

Three national surveys were conducted in 1991, 1997, and 2004 to evaluate state medical board members' knowledge and attitudes about prescribing opioid analgesics for pain management. Topics addressed include perceived legality of prolonged opioid prescribing, characteristics of addiction, prevalence of medication abuse and diversion, and perceived importance and influence of medical board policy. Questions were added in 2004 to determine board members' views about law enforcement involvement in physician investigations and prosecutions. This study assesses medical regulators' current beliefs and compares the 2004 responses with previous responses to determine how knowledge and attitudes about prescribing opioids have changed in recent years. Survey results show that board members have a greater understanding of pain management issues, particularly regarding characteristics of addiction and the legality of prolonged opioid prescribing for chronic noncancer pain. During the last 15 years, there has been substantial regulatory policy development, with medical boards adopting regulations, guidelines, or policy statements to provide guidance to licensees about using opioids to treat pain. However, many board members believe that federal and state law enforcement agencies have increased criminal investigations and prosecutions of physicians. We discuss appropriate regulatory and law enforcement responses to opioid prescribing violations, and suggest crucial next steps. PERSPECTIVE: The authors examine the evolution of state medical board members' knowledge and attitudes about prescribing opioid analgesics to treat chronic pain, demonstrate that medical regulators believe that there have been increased criminal investigations and prosecutions of physicians for their prescribing practices, and suggest ways to avoid unwarranted criminal prosecutions.     

Knowledge and Attitudes of Health-Care Providers Toward Cancer Pain Management: A Comparison of Physicians, Nurses, and Pharmacists in the State of New Hampshire

The knowledge and attitudes toward cancer pain management of physicians, nurses, and pharmacists in the state of New Hampshire were examined through the use of a statewide survey. Many of the providers who completed the survey, and thus indicated that they treated patients with cancer pain on a regular basis, were not pain or oncology specialists. Most of these providers were quite well informed about the fundamentals of cancer pain management. Approximately 90% of providers in all three groups were not concerned about addiction among cancer patients. Yet, there was a small percentage of providers who responded in less than optimal ways to items dealing with opioid pharmacology, pain assessment, and the importance of pain relief. Comparison of responses among provider groups indicated that nurses were the most knowledgeable and pharmacists the least knowledgeable about pain assessment. Physicians were the most knowledgeable regarding opioid pharmacology but seemed the least committed to providing optimal pain relief. Further analysis identified a small group of physicians that included a disproportionately high percentage of family practitioners and surgeons who consistently responded in less than optimal ways to items dealing with the importance of pain relief. The results of this study indicate a continuing need for broad-based educational programs in cancer pain management and for new initiatives focused on practitioners who see relatively few cancer patients and may have difficulty accessing traditional educational programs.     

An Italian survey on the attitudes in treating breakthrough cancer pain in hospice

As recognition and treatment of breakthrough cancer pain (BcP) depend on the education and knowledge of palliative care physicians, it is important to systematically explore the attitudes of palliative care physicians in hospices or palliative care units. The aim of this study was to assess the knowledge and attitudes of hospice physicians in Italy regarding BcP and its treatment. All hospices existing in Italy were interviewed to gather information about provision of BP medication, drugs of choice, preferred route of administration, methods to choose the dose, and choice of BcP medication based on opioid administered for background analgesia. Of 158 hospices registered, 122 centers agreed with the interview (77.2%). Morphine was more frequently used, either orally or parenterally. In some hospices, oral transmucosal fentanyl (OTFC) was unavailable. Most physicians provided doses of opioids proportional to the opioid basal regimen, independently of the preferred opioid or the route of administration. The choice of dose titration was equally used in patients who were prescribed OTFC or parenteral morphine. The choice of breakthrough medication on the basis of opioid basal regimen was equally distributed. These findings suggest the need for improved education on behalf of physicians on the assessment and treatment of BcP, particularly in a potentially specialized setting, such as palliative care units. The choice of BcP medications should be based on the best cost-efficacy ratio rather than solely on economical considerations.     

Physician attitudes toward opioid prescribing for patients with persistent noncancer pain

OBJECTIVES: Physicians frequently express dissatisfaction about caring for patients with chronic pain and frequently report that inadequate training and concern about addiction are impediments to prescribing opioids. Elderly patients with chronic pain may be at increased risk of experiencing uncontrolled pain and this patient population is increasingly being cared for by geriatricians rather than internists. We sought to determine if there is a differential impact on internists and geriatricians of the factors that adversely affect attitudes toward opioid prescribing. METHODS: Anonymous survey of geriatric and internal medicine physicians at a large urban academic medical center about their beliefs and behaviors regarding opioid prescribing. RESULTS: One hundred thirty-two of 187 physicians completed the survey for an overall response rate of 71%. Controlling for level of training, internists were more likely to be concerned about illegal diversion (adjusted odds ratio=10.0, P=0.004), were more concerned about causing addiction (38% vs. 0%, P<0.001), and were more likely to be concerned about their inability to prescribe the correct opioid dose (adjusted odds ratio=11.1, P=0.020). DISCUSSION: Factors shown to have an adverse affect on opioid prescribing disproportionately impact on the attitudes of internists compared with geriatricians. Further research is needed to determine if there is also a differential impact on how internists care for their elderly patients with chronic pain.     

Pain Management in Patients with Cancer: Focus on Opioid Analgesics

Cancer pain is generally treated with pharmacological measures, relying on using opioids alone or in combination with adjuvant analgesics. Weak opioids are used for mild-to-moderate pain as monotherapy or in a combination with nonopioids. For patients with moderate-to-severe pain, strong opioids are recommended as initial therapy rather than beginning treatment with weak opioids. Adjunctive therapy plays an important role in the treatment of cancer pain not fully responsive to opioids administered alone (ie, neuropathic, bone, and visceral colicky pain). Supportive drugs should be used wisely to prevent and treat opioids’ adverse effects. Understanding the pharmacokinetics, pharmacodynamics, interactions, and cautions with commonly used opioids can help determine appropriate opioid selection for individual cancer patients.     

Knowledge and attitudes regarding cancer pain management among oncology nurses in China

ObjectiveThere are limited studies examining knowledge and attitudes among Chinese oncology nurses regarding cancer pain management.MethodsWe conducted a cross-sectional survey among oncology nurses from 26 hospitals in China. The nurses completed the Knowledge and Attitudes Survey Regarding Pain (KASRP) questionnaire. Multivariate models were used to identify factors associated with nurses’ KASRP score.ResultsA total of 982 nurses completed the KASRP (mean score = 21.56 ± 4.00), and 8 (0.81%) nurses had a passing score. The results of multivariate regression indicated that clinical rank and experience in cancer pain management were associated with good knowledge and attitudes regarding cancer pain management.ConclusionThe Chinese nurses in our study did not have adequate knowledge of or positive attitudes related to cancer pain management. Clinical rank and experience caring for patients with cancer could be used to help identify nurses with inadequate knowledge and attitudes regarding treating cancer pain.     

Overcoming the barriers in pain control: an update of pain management in China

China is a country with a long history of treating pain as a disease entity. However, the current status of pain relief is not optimal. Major barriers to pain management include historical reasons, differences between Chinese philosophy and Western countries, government policies of pain relief and drug availability, patients' fear of addiction and side effects, and professionals' lack of knowledge on pain control. Following the release of the 3-step analgesic ladder guideline for cancer pain relief in 1991, the government has made many approaches to encourage the treatment of cancer pain including adjustment of the national narcotics control policy, approval of new opioid analgesics for sale and distribution, increase of opioids manufacturing volumes, and streamlined procedures for hospitals to obtain sufficient opioids. At the same time, the government has made a lot of efforts in education and training medical professionals on pain control. In 2005, a clinical practice guideline for the management of chronic non-cancer pain was published. Utilization of potent opioids in non-malignant pain patients is described in detail. In addition, invasive interventions have also been introduced in chronic pain control. Although great improvements have been made during the past few years, three main aspects of improving pain control in China still remain to be undertaken, including (1) consistent training and education for health care workers to minimize the variation between cities and rural areas; (2) government support and development of an insurance system to minimize the economic burden of pain patients; (3) development new analgesic drugs with less side effects and new mechanisms of action.     

A Canadian survey of issues in cancer pain management

We report the analysis of a cancer management survey mailed to a representative group of health professionals in 1994. The goals of the study were to gather information on cancer pain treatment practices, and to obtain health professional views on obstacles to ideal pain management. The survey, designed by a working party of pharmacists, nurses and physicians, was distributed to 14,628 physicians. A total of 2,686 physicians responded to the survey, including 39% of medical or radiation oncologists, and 18.19% of physicians who listed their primary interest as Family Medicine. Reflecting the modest emphasis placed on palliative care and cancer pain management in the current Canadian milieu, 67% of physicians rated their past teaching experience as only “fair” or “poor.” Lack of exposure to pain education was reflected in the response to a series of hypothetical case scenarios exploring physician choices in managing severe cancer pain. For example, in the initial management of a cancer patient with severe pain, 50% of physicians would not use a strong opioid in the absence of other contraindications to opioid use. A wide variety of analgesics and non-pharmacologic techniques is available to Canadian physicians to assist patients with pain. Few physicians identified the unavailability of analgesics or analgesic techniques as limiting factors in pain management. We condude that greater emphasis should be placed on pain education in our training programmes. We suggest that further surveys of this type, sponsored by our provincial colleges and medical organizations, can provide feedback which will enhance the adherence by Canadian physicians to published guidelines for pain management.     

Controlled substances and pain management: changes in knowledge and attitudes of state medical regulators

Physicians report that concern about regulatory investigation negatively influences their prescribing of opioid analgesics. The views of medical regulators about the legality of prescribing controlled substances for pain management were studied in 1991. However, little is known about whether these views have changed in light of increased emphasis on pain management and educational programs for state medical boards. Two studies that examined this issue are described. In Study 1, a 1997 survey of state medical board members was compared to results obtained in 1991 to evaluate differences in knowledge and perceptions about opioid analgesics. Important changes were observed over time, particularly regarding characteristics of "addiction" and the legality of prolonged prescribing of opioids. For Study 2, a longitudinal survey was conducted of medical board members who participated in five workshops about pain management and regulatory policy. Results revealed significant and sustained changes in attitudes about the incidence of iatrogenic addiction when using opioids to treat pain, the analgesic and side-effect properties of opioids, and the perceived legality of prescribing opioids. Recommendations for reducing concerns about regulatory scrutiny are presented, including the need for a more intensive education program, increasing the rate of adoption of new state medical board policies, and improving communication between regulators and clinicians.