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Cancer pain can be managed.

Its time that Americans demanded the right to be free from needless agony.

TO MANY PEOPLE, the most frightening words imaginable are "It is malignant." The phrase conjures up a nightmare of unendurable pain, more frightening than the thought of death itself Pain remains one of the most debilitating effects and undertreated aspects of cancer. Many patients feel they must choose between two evils--unrelieved agony or dependency on dangerous, addicting drugs. Often, physicians fail to provide adequate pain relief for sufferers.

Pain sometimes is the first symptom of cancer, though some patients may live for years with virtually none at all. Over all, pain eventually becomes a problem for 65-85% of patients.

Even in cancer's most advanced stages, however, the pain of up to 95% of patients can be treated effectively with drugs that reduce its cause or intensity. For the remainder, neurosurgical procedures can eliminate even the most seemingly incurable pain. Most cancer patients, believing that pain can not be treated without paying a terrible price, will suffer--needlessly--in silence.

Short-term, acute pain is nature's way of calling attention to a physical ailment. As with a sprain or a serious infection, early cancer may cause tissue damage, creating chemical changes, which are sensed by nearby nerve endings. Signals travel along the nerves to the brain, where pain is "felt." Pain from tissue damage can be controlled at the source, with inflammation-fighting medications such as aspirin and ibuprofen.

A cancer's chronic, deepening pain originates in nerves, rather than nerve-endings. A growing tumor may pinch a nerve, or an inoperable tumor may squeeze internal organs. These conditions can occur fairly early and remain as long as the cancer is present.

Nerves generally can not be kept from delivering pain messages to the brain, but the brain can be kept from receiving these messages. Without understanding the neurochemistry involved, physicians from ancient times have employed drugs to treat pain. The oldest of these compounds is opium. Its active component, morphine, has the same effect on pain as the brain's natural pain blockers, the endorphins. Today's best drugs for severe cancer pain relief all are derived from opium or synthetically modeled on morphine. Fentanyl, codeine, methadone, and several other drugs make up the opioid family of drugs, perhaps the most merciful and effective known to medicine.

Physicians who understand these drugs know that alleviating pain is not a mystery. There is no good reason why pain treatment should not start when pain begins. With cancer patients living longer as treatment improves, I would argue that physicians who extend a patient's life should hold themselves responsible for not extending pain as well. Too few physicians recognize this responsibility, and too many patients live in pain. For instance, an Eastern Cooperative Oncology Group physician survey noted that many patients are reluctant to take their pain medication or even to report their pain. Eighty-five percent of the physicians surveyed felt that patients are undermedicated for cancer pain. There are three major reasons why pain is not treated effectively: * Physicians are not taught to treat it. * Misunderstandings and myths limit the utilization of the most effective and best-researched medications. * Public health policy and the insurance industry can limit access to these medications.

At Fox Chase Cancer Center, a patient with a very painful knee was found to have an infectious form of arthritis. All the right procedures were performed and he received the correct antibiotics. Three days later, however, the resident in charge suggested putting the leg in a cast, because the slightest movement hurt the patient unbearably.

"Well, what pain medication is he getting?," I asked. "We are not giving him anything," replied the resident. This young physician could diagnose and treat disease, but was at a loss when confronted with pain. It was not his fault. Medical schools and accrediting authorities have not given pain a proper place in the curriculum and on board certification examinations.

Although pain is all too real to the patient, it remains invisible to caregivers. Physicians and institutions lack methods for monitoring and recording it. In most hospitals, a patient's bowel movements are documented, but the bedside chart has no space for noting pain. Furthermore, since it can not be measured objectively, like blood pressure, hospital personnel need training to obtain accurate information directly from patients. It is not surprising that pain is undertreated.

As cancer treatment has improved, the art of treating pain has become secondary. Today, with more than half of patients being cured, "beating the cancer" is the main concern. Patients fear that mentioning pain would brand them "bad patients" and think they must choose between optimum treatment and temporary relief from pain that is bound to return.

In addition, the epidemic of drug abuse has generated the idea that opioids are too dangerous to use, even to relieve pain. The word "narcotics" has a sensational aura, associated with criminal behavior, degradation, and death. Many patients taking opioids to relieve cancer pain fear addiction to the drug, but studies have proven this rarely occurs in the clinical setting. A patient may become tolerant to an opioid analgesic, which means increasingly higher doses of the drug may be needed to produce the desired analgesic effect. However, tolerance occurs very slowly in cancer patients and easily is managed by the health care team. Tolerance may be overcome by first increasing the dose and then, if necessary, changing the type of opioid.

In contrast, psychological craving or addiction is rare. The Boston Collaborative Drug Surveillance Program found that, of 11,882 hospitalized patients who received at least one opioid, there only were four (0.03%) cases of addiction in those with no history of addiction. Concern about physical dependence should not deter physicians from using adequate amounts of opioids in the management of severe pain when such use is indicated. Nor should it keep patients from taking their appropriately prescribed opioid analgesics.

The World Health Organization (WHO) recommends a "stepladder" strategy to manage pain effectively. Mild to moderate pain is treated best with simple medications. Aspirin, ibuprofen, and other non-steroidal anti-inflammatory drugs (NSAIDS) act on the mild to moderate pain caused by tissue damage. NSAIDS prevent local nerve endings from sensing pain and, when given with weak opioids, such as codeine, the combination will deaden even moderate pain.

When a patient advances to severe or chronic pain, WHO recommends opioids that block the perception of pain signals at the receiving end, in the brain. Like all medications, opioids should be used carefully. A thrill-seeking addict can stop breathing and die after a sudden, unaccustomed large dose. Medically supervised patients--acclimatized to regular, pain-controlling doses--usually run no such risk, nor do they become addicted. More research is needed on the mechanisms of addiction, and psychological, social, and perhaps genetic factors may be involved. However, the statistics show that former cancer patients who have taken opioids for pain do not start abusing drugs any more often than people who never have had cancer. Patients who take opioids for pain no longer need or want them once it goes away.

Public policies cause needless pain

Laws reflect exaggerated concerns about drug addiction by cancer patients. Fears of litigation and the whims of insurers contribute to a non-medical climate that virtually guarantees the undertreatment of cancer pain.

In a number of states, a triplicate prescription form must be used for any drug with the faintest potential for abuse. Statistics show that, when this procedure was introduced, prescriptions for opioids dropped by 50%. Fearing some small clerical error might jeopardize their license, cautious doctors may not prescribe opioids their patients need.

Patients must negotiate a maze of restrictions. Prescriptions for opioids are nonrenewable and often must be picked up personally at the physician's office. Pharmacies can not accept telephoned prescriptions, and, since retailers in some neighborhoods fear that stocking opioids may invite criminal break-ins, the patient may have to journey some distance to have the prescription filled.

Insurance companies present another obstacle. Reimbursement for medication used at home is inconsistent. Insurance may cover the home use of a $600 miniature pump to administer opioids into the patient's vein, but not $50 worth of analgesic tablets that could control the pain with greater simplicity and independence. Patients paying out of pocket for an array of drugs may tough out their pain for fear of leaving their families penniless.

Formerly, patients in severe pain had to be hospitalized, but today's treatment is much more convenient. After some training, patients easily can manage their own pain from day to day, just as people with diabetes routinely use insulin.

Ideally, pain control medication should imitate the smooth action of natural endorphins, avoiding peaks and valleys of drug concentrations in the bloodstream. The correct dosage is whatever the pain requires. If pain worsens, the physician will increase the dose, meeting the patient's need, not following a rigid routine. If the cause can be corrected, pain subsides and the doses are tapered or the drug is discontinued. With the patient's body chemistry setting the pace, no withdrawal symptoms occur. Should the cause persist, continued regular use of the opioid analgesics can assure safe and effective pain prevention.

Years ago, opioids only could be injected at timed intervals in the hospital setting. This was problematic, since it was difficult to prevent the fluctuations of pain.

Another method to manage pain was a slow intravenous infusion of morphine through a hollow needle into a vein. It is effective, but the procedure is invasive and the needles can transmit blood-borne infections.

High-technology brought improvements, beginning with a miniature pump to infuse opioids continuously through a needle inserted into a vein. The pump is taped to the body; smaller models are implanted under the skin. The newest versions administer opioids directly into the cerebrospinal fluid, where minute amounts give enormous pain relief to patients who, for one reason or another, can not take the drugs by conventional routes. These devices are expensive, however.

A new delivery system was introduced recently when the synthetic opioid, fentanyl, became available in a patch worn like an adhesive bandage. The drug permeates the skin into the bloodstream at a constant rate. The Duragesic transdermal system patch comes in several sizes containing different amounts of fentanyl. Every three days, the patient applies a fresh set of patches.

The patch provides 72 hours of continuous delivery of pain medication and easily can be applied by the patient. Duragesic maintains relatively steady levels of medication in the bloodstream, minimizing fluctuations of pain control, a potential problem with short-acting oral medication.

The patch is available in different strengths so that it can be prescribed for patients taking lower doses of opioids early in their disease or for those in the later stages of cancer who may need higher doses. The adverse effects of Duragesic noted in clinical trials are similar to other opioids and include nausea and hypoventilation (depressed breathing), the latter occurring in less than two percent of cancer patients.

Opioid pills and liquid concentrates are other alternatives that can control pain and are a less-invasive method of delivering relief. However, some patients can not tolerate pills, due to nausea, or if the cancer has affected the gastrointestinal tract. Patches may be a good alternative. Pills or suppositories must be used in conjunction with patches to stop "breakthrough" or "incident" pain that results from extra activity or advancing cancer.

Patients must be trained to take charge of their pain medication. They even need to be taught to discuss pain. At Fox, a medical team teaches them to differentiate between "sharp" and "dull" pain and to rate its intensity, as they are instructed in using their scheduled and supplementary medications. Patients maintain a daily log of their episodes of pain and the medication they take.

In 1987, under the auspices of the World Health Organization, the Wisconsin Pain Initiative was set up as a demonstration project to explore methods of improving cancer pain treatment in the community. Another nine states have set up similar programs, showing that this goal is attainable and cost-effective.

With the intelligent use of existing safe and effective drugs, cancer no longer would be synonymous with agony, and some costly aspects of health care could be simplified. A nationwide initiative to eliminate cancer pain would not solve all our health care problems, but it would be a practical beginning. It also is an ethical imperative, so long as cancer patients live in pain that defies justification. Isn't it time to consider adding one more right to the traditional American freedoms--freedom from needless pain?
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Author:Levy, Michael
Publication:USA Today (Magazine)
Date:May 1, 1993
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