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.     

Pain management in sickle cell disease

The unpredictable, recurrent, intense, and frequently persistent nature of pain associated with sickle cell disease poses a difficult challenge in terms of management. A wide variability exists in the way painful episodes are managed. Variations in practice reflect different views about the suitability of opioids, the efficacy of parenteral administration, and the risk of dependence on opioids. Consequently, the acute and chronic pain associated with sickle cell disease often is undertreated or inappropriately managed. Although medical staff fear that patients might abuse pain medication and become psychologically dependent, patients are more concerned about the side effects associated with analgesics. Some patients may persuade staff to give them more analgesics, engage in clock-watching, and request specific medications or dosages; these patients often are perceived as manipulative or demanding. However, these patients are knowledgeable about their medications and doses that have worked in the past. Requests for specific medications and dosages should not be interpreted as indications of drug-seeking behavior, but clinicians should communicate with these patients, make accurate assessments, and provide adequate doses of opioid analgesics. The American Pain Society recognized that the undertreatment of pain and inappropriate management of pain in sickle cell disease seem to be common. A Clinical Practice Guideline was developed to provide evidence-based recommendations that could potentially improve pain management. The purpose of this report is to describe the pharmacologic strategies used to manage pain associated with sickle cell disease, examine issues and challenges related to pain management as well as concerns and fears related to addiction, and explain the administration of opioids as recommended by the American Pain Society.     

Managing chronic nonmalignant pain: Overcoming obstacles to the use of opioids

Physicians involved in cancer pain management treat thousands of patients with opioids, whose effective analgesia improves overall functioning. Side effects generally are tolerable, and treatment can be maintained with stable doses for long periods. Problems with addiction are infrequent. Many physicians, however, assume that opioids should be used only for chronic malignant pain. Research and clinical experience have demonstrated that opioids can safely and effectively relieve most chronic moderate to severe nonmalignant pain. Fears of addiction, disciplinary action, and adverse effects result in ineffective pain management. With current information on the use of opioids in chronic nonmalignant pain, primary care physicians can overcome these obstacles. Guidelines must clearly define the role of the primary care physician in the proper management of pain and the integration of opioid therapy. Used appropriately, opioids may represent the only source of relief for many patients.     

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.     

Approach to the vaso-occlusive crisis in adults with sickle cell disease

The vaso-occlusive crisis, or sickle cell crisis, is a common painful complication of sickle cell disease in adolescents and adults. Acute episodes of severe pain (crises) are the primary reason that these patients seek medical care in hospital emergency departments. Frequently, however, the pain is incompletely treated. Despite advances in pain management, physicians are often reluctant to give patients adequate dosages of narcotic analgesics because of concerns about addiction, tolerance and side effects. It is important to recognize a pain crisis early, correct the inciting causes, control pain, maintain euvolemia and, when necessary, administer adequate hemoglobin to decrease the hemoglobin S level. The family physician and the hematologist must work together to treat acute pain episodes promptly and effectively, manage the long-term sequelae of chronic pain and prevent future vaso-occlusive crises.     

Assessment of physiatrists' knowledge and perspectives on the use of opioids: review of basic concepts for managing chronic pain.

Previous studies of physicians have elucidated knowledge gaps and misconceptions about the use of opioids for the treatment of chronic pain. The recent approval of a pain management subspecialty certification for physiatrists will create higher expectations of the field regarding the treatment of chronic pain. Five hundred randomly chosen physiatrists were surveyed with a 50.6% response rate. Ninety-eight percent of respondents treat patients with chronic noncancer pain diagnoses, and 37% occasionally treat patients with cancer-related pain. Seventy percent of respondents underestimated the percentage of patients with cancer-related pain that could experience relief with oral analgesics. Only 17% underestimated the percentage of advanced cancer patients that experience significant pain. Eight percent of respondents incorrectly answered that a patient, regardless of diagnosis, would become addicted to opioids by taking an opioid daily. Only 25% identified the correct definition of addiction. Questions regarding side effects revealed that 10% of respondents incorrectly believed that opioid-induced respiratory depression is common in patients whose oral morphine dose exceeds 100 mg per day. Eighty percent of respondents preferred long-acting preparations, and 92% preferred set dosing schedules for the treatment of chronic pain. Rapidly evolving concepts regarding the implementation of pharmacologic regimens for chronic pain diagnoses require health care professionals who are trained to administer these treatments. Overall, the survey results are encouraging regarding physiatrists' knowledge about the use of opioids to treat patients with chronic pain.     

Cancer pain assessment and management recommendations by hospice nurses. University of Kentucky, Lexington, Kentucky.

Pain is often the most prevalent symptom among cancer patients referred to hospice or palliative care programs. This study was designed to use performance-based testing to evaluate the skills of hospice nurses in assessing the severe pain of a cancer patient and the pain management recommendations they would present to the patient's primary care physician. Twenty-seven hospice nurses (ranging in experience from 1 month to 10 years) were presented with the same standardized patient with cancer pain. In Part A (7 minutes), one of the investigators checked for predetermined behaviors as the nurses performed the clinical pain assessment. In Part B (7 minutes), the nurses answered questions regarding their recommendations for pain management for the patient seen in Part A. In the admission pain assessment, hospice nurses did well in assessing pain intensity (85%), pain location (70%), and pain-relieving factors (59%). However, only 48% of the nurses adequately assessed the pain onset, and only 44% adequately assessed other symptoms the patient might be experiencing. In Part B, 96% of the nurses recommended opioids, 96% recommended the oral route of administration, and 82% recommended regular dosing of the opioids. Fifty-six percent of nurses included a breakthrough medication in their analgesic recommendations. All of the hospice nurses treated the patient's fear of addiction in an appropriate manner, and 93% of the nurses recommended increasing the patient's opioid dosage to treat the persisting pain problem. There were no significant differences among nurses with regard to length of time as a hospice nurse or hospice certification on any of the items in either Part A or Part B. Most practicing hospice nurses were judged to be competent in the assessment and management of the severe pain of the standardized cancer patient, although some deficits were noted. Regular oral opioids were the analgesics of choice. Co-analgesics were rarely recommended.     

Long-acting opioids for chronic pain: pharmacotherapeutic opportunities to enhance compliance, quality of life, and analgesia

Effective management of chronic pain has become an increasingly critical issue in health care. Opioid agonists are among the most effective analgesics available for reducing pain perception; however, their chronic use is controversial. This is primarily due to regulatory barriers, misunderstandings about pain management among primary caregivers, fear of adverse side effects, and misconceptions about the potential risks of addiction. Short-acting opioids provide effective analgesia for acute pain but should be avoided as primary analgesics for chronic pain management. Long-acting opioids have greater utility than short-acting opioids in treating chronic pain in patients with consistent pain levels. Results of studies show that improved quality of life is directly related to the use of long-acting opioids in patients with chronic pain of both cancer and noncancer etiology. Short-acting opioids may be used during the initial dose titration period of long-acting formulations and as rescue medication for episodes of breakthrough pain. Clinical experience reveals that selection of an effective pain regimen for the patient with chronic pain, combined with aggressive management of side effects, leads to improved overall functioning and quality of life.     

Pediatric nurses' knowledge and attitudes survey regarding pain

PURPOSE: The purpose of this study is to determine pediatric nurses' current attitudes and knowledge regarding pain. METHOD: The Pediatric Nurses' Knowledge and Attitudes Regarding Pain Survey was completed by a convenience sample of 274 nurses at a large children's medical center. RESULTS: Sixty-six percent of the questions were answered correctly. Nurses with their master's degree scored significantly higher (75%). Hematology/oncology nurses (76%), nurses from the intensive care unit (71%), and emergency room nurses (70%) scored significantly higher than nurses from other patient care units. CONCLUSIONS: Pain management knowledge deficiencies were identified, including assessment; pharmacologic management with opioids, nonopioids, and adjuvant medications; risks of addiction; risks of respiratory depression; nonpharmacologic pain interventions; and the treatment of procedural pain, surgical pain, and cancer pain.     

Nurse case management program of chronic pain patients treated with methadone.

Methadone treatment in chronic pain patients is still limited owing to misconceptions about addiction, safety, and its unique pharmacokinetic and pharmacodynamic properties. Nevertheless, patients with chronic noncancer pain are frequently treated with methadone at our Pain Centre either as the first opioid of choice, for specific pain conditions, or as a second-line opioid in patients developing tolerance or intractable side effects with other opioids. The aim of this study was to examine whether a nurse case management program of chronic pain patients treated with methadone is feasible and safe in trying to improve patients' care in an ambulatory setting. This program consisted of three phases: initial primary education session, telephone follow-up during methadone titration, and a subsequent maintenance period. The nurse case manager functioned autonomously and when required reported to and consulted the physician. The study included 75 subjects and was done over a nine-month period by completing follow-up questionnaires for every call. Of a total of 194 recorded calls, 41% were unscheduled. Forty-four percent of phone calls resulted in a methadone increase and 11% led to a decrease or cessation of methadone. No patients developed serious morbidity or mortality. Fifty-seven percent of patients were either satisfied or very satisfied with their treatment. A nurse-led case management program of methadone in chronic pain patients can improve patient care in an ambulatory setting.     

"I feel uncomfortable 'calling a patient out'": educational needs of palliative medicine fellows in managing opioid misuse

ContextDuring the past 10 years, advocates of palliative care have sought to be included earlier in the course of patients’ illnesses. Palliative care providers may thus be more likely to care for patients who misuse and abuse opioids.ObjectivesTo assess whether hospice and palliative medicine (HPM) fellows see patients at risk for opioid misuse and how competent they perceive themselves to be to treat pain in these patients.MethodsAn electronic survey was distributed to 102 HPM fellows. The survey included questions assessing self-perceived competency in care for patients who misuse opioids. Responses were rated using a Likert scale of one to seven, where one = strongly agree and seven = strongly disagree; any number greater than two was considered to be nonagreement.ResultsFifty-seven (56%) fellows from 34 programs responded to the survey. In the previous two weeks, 77.2% of respondents had seen at least one patient with a substance use disorder (SUD) and 43.9% had treated a patient whom they were concerned was misusing opioids. Half (47.2%) of respondents stated that they have a working knowledge of addiction, 41.4% agreed their training has prepared them to manage opioid misuse, and 36.8% felt they knew how to differentiate pain from addiction. Only 21.1% were satisfied with how they treat symptoms in this population. Fellowship training in opioid misuse was associated with increased satisfaction.ConclusionHPM fellows regularly see patients who are at risk for opioid misuse and feel unprepared to treat pain in these patients. There is a need for more education of fellows in this area.     

Addiction to opioids in chronic pain patients: a literature review.

Opioids have proven very useful for treatment of acute pain and cancer pain, and in the developed countries opioids are increasingly used for treatment of chronic non-malignant pain patients as well. This literature review aims at giving an overview of definitions, mechanisms, diagnostic criteria, incidence and prevalence of addiction in opioid treated pain patients, screening tools for assessing opioid addiction in chronic pain patients and recommendations regarding addiction problems in national and international guidelines for opioid treatment in cancer patients and chronic non-malignant pain patients. The review indicates that the prevalence of addiction varied from 0% up to 50% in chronic non-malignant pain patients, and from 0% to 7.7% in cancer patients depending of the subpopulation studied and the criteria used. The risk of addiction has to be considered when initiating long-term opioid treatment as addiction may result in poor pain control. Several screening tools were identified, but only a few were thoroughly validated with respect to validity and reliability. Most of the identified guidelines mention addiction as a potential problem. The guidelines in cancer pain management are concerned with the fact that pain may be under treated because of fear of addiction, and the guidelines in management of non-malignant pain patients include warnings of addiction. According to the literature, it seems appropriate and necessary to be aware of the problems associated with addiction during long-term opioid treatment, and specialised treatment facilities for pain management or addiction medicine should be consulted in these cases.     

Opioid treatment of chronic pain in patients with addiction

Patients with a history of drug or alcohol addiction may present to physicians with pain complaints. The medical literature is weak on the treatment of pain with opioids in patients in recovery or active addiction. This is because inconsistent criteria were used to define addiction and the types of chronic pain. There are clear differences between physical dependence, tolerance, and addiction. Addiction is different from pseudoaddiction and must be determined by the patient's behavior after appropriate pain management. Long-acting opioids are often the medications of choice for moderate to severe pain control. Short-acting opioids can be used for breakthrough pain. There are many other medications that can enhance pain control as adjunctive analgesics. Drug-seeking behavior may be seen with either active addiction or pseudoaddiction, or as part of deviant behavior such as drug diversion. A way to distinguish between these conditions is by giving the patient appropriate pain medication and observing the pattern of behavior to determine which is causing the drug-seeking behavior. Safe prescribing of medications with abuse potential includes use of a medication agreement, setting goals with the patient, giving appropriate amounts of pain medication, monitoring with pill counts and drug screens, and careful documentation. Even patients with a history of addiction can benefit from opioid pain medications if monitored appropriately.     

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.     

Pain and addiction: an urgent need for change in nursing education.

Lack of education of health care professionals, including nurses, is frequently cited as a major reason for undertreatment of patients with pain. A reason for undertreatment of pain with opioid analgesics is the irrational fear of creating opioid addiction. To characterize the information nurses receive in their basic education that could contribute to misinformation about this issue, the authors reviewed 14 nursing textbooks, published since 1985, including 8 pharmacology texts and 6 medical surgical texts. An analysis of content revealed that only one textbook correctly stated the definition of opioid addiction and its likelihood following use of opioid analgesics for pain control. Almost all of the texts used confusing terminology, and some erroneously promoted the fear of addiction when opioids are used for pain relief. A simple solution to this problem is to encourage nursing educators to use the American Pain Society publication "Guidelines for Analgesic Use" until textbooks have the opportunity to incorporate correct information.     

Evolution of Opioids Reimbursement since 2004 from the National Database of the General Health Insurance System

Objective. This study aims at evaluating trends in the consumption of opioids over the last years to assess the impact of public health measures on the management of pain and opiate addiction in France. Methods. The evolution of opioids consumption was analysed by using the national database of the General Health Insurance System in France between 2004 and 2008. Results. During the study period, the reimbursed quantities of opioids used for pain management have increased by 13%, except for dextropropoxyphene that has decreased by 9%. The reimbursed quantities of opioids used for substitution maintenance treatments for opioid dependence have increased by 34%, with a 116% increase for methadone. Conclusion. This study suggests that consumption of opioids is globally increasing in France and reveals discrepancies concerning the evolution of the different drugs. It allows to analyse switches of consumption between different opioids and constitutes the first step for further studies targetting signals of diversion and abuse.