April 11, 2001

There is now a set of treatment guidelines for cancer patients and pain. Read the story.

INTELIHEALTH FEATURE

By Lisa Ellis

Patients, doctors and advocates who have led a movement in the last decade to gain increased attention to the relief of chronic pain now have a new educational tool.

The release of "Cancer Pain: Treatment Guidelines for Patients" provides an easy-to-read summary of the types, causes and treatments of cancer pain; how to manage side effects; common myths and fears about pain medications; and assessment tools to help patients describe their pain to health care workers.

A joint project of the American Cancer Society and a group of 18 cancer hospitals called the National Comprehensive Cancer Network, the guidelines are based on the network's guidelines for doctors, rewritten in lay language.

The project is just the latest development in a movement to improve treatment of pain for all illnesses. Perhaps the most important advance came in January 2001, when the organization that accredits hospitals, nursing homes and other health care institutions began requiring them to follow specific standards on pain assessment and treatment, as well as education of both staff and patients on pain management.

Janet Abrahm, M.D., director of the Pain And Palliative Care Program at Dana-Farber Cancer Institute and Brigham And Women's Hospital in Boston, praised both the accreditation standards and the new patient guidelines as a great help in improving patient care.

"I think it's great that the American Cancer Society is bringing this out of the closet and saying that doctors who are caring for cancer patients do care about your pain and that we want to treat your pain with as much care as we give to treating your cancer," said Dr. Abrahm, a faculty member in the department of medicine at Harvard Medical School.

She urged that oncologists give the guidelines to their patients, many of whom do not realize that nearly all cancer pain can be treated effectively. "I think it's very important that patients and physicians be able to communicate about cancer pain."

According to the American Cancer Society, research shows that one of three patients being treated for cancer and about two-thirds of patients with advanced cancer experience pain, but less than half receive adequate relief for their pain.

Dr. Abrahm, who is author of A Physician's Guide to Pain and Symptom Management in Cancer Patients, said about 90 percent of cancer patients could get their pain relieved by taking medicines delivered either in sustained-release pills or through a skin patch.

If these treatments do not work well, other options are available. The cancer pain guidelines list these possibilities: medicines delivered intravenously, by injection or by an implanted pump; surgery; nerve blocks; heat or cold therapy; massage; hypnosis; acupuncture; and transcutaneous electric nerve stimulation, which uses a mild electrical current applied to the skin at the site of pain.

Although treatment is available, several obstacles have stood in the way of pain relief, according to the cancer pain guidelines:

• Fear of addiction. Although many of the best treatments for cancer pain are narcotics (also called opioids), addiction is very rare, Dr. Abrahm said. "Fewer than one in 10,000 cancer patients who take drugs and were not dependent before will become addicts," she said. Recent advances also allow delivery of medication in long-term, slow-acting form, she said, which allows "a baseline level of pain relief without the peaks and valleys" of pain at some times and grogginess at other times.
• Fear of side effects. "Patients often take less than the prescribed dose of pain medicines because they are concerned about the side effects that may occur," according to the guidelines. "Most side effects, however, can be prevented or relieved." The most typical side effects listed are nausea and constipation.
• Inadequate knowledge. Health care professionals in the past "were not well trained to care for patients with chronic pain" and also were fearful of addiction, the guidelines state.
• Inadequate pain assessment. Patients might try to be tough rather than ask for relief of pain.
• Legal obstacles. When prescribing narcotics, health care professionals sometimes feared action by law-enforcement agencies. "These actions may be exaggerated by professionals and should not be an obstacle to pain relief."

Dr. Abrahm said one of the most helpful aspects of the guidelines is that they could popularize several assessment tools that provide a way for patients and doctors to describe pain objectively. One of the simplest is a number scale, in which zero indicates no pain and 10 represents the most severe pain.

"Cancer patients are used to communicating about the size of their tumors, their weight, their temperature, their blood count," she said, "so they're used to communicating in numbers.

"If we give the pain a number, doctors and patients can work together in a common goal to getting that pain number down to a level that's acceptable to the patient. This all normalizes it and turns it from a complaint to a symptom."

The new health care accreditation standards that took effect in January also should improve treatment of pain, in part because they also insist that pain be evaluated regularly along with other vital signs such as blood pressure, Dr. Abrahm said.

Requiring that patients be asked about pain is important because "often the patients don't complain to the doctors about pain," Dr. Abrahm said. If they tell anyone, she said, it is usually the nurses.

The standards also require that hospitals and other health care institutions educate their own professional employees, patients and their families about pain assessment and management and that they provide a pain-management plan to every patient at the point of discharge.

It's "a little early to tell" how well the new accreditation guidelines have translated into improvements in pain relief for patients, Dr. Abrahm said. "There's been an explosion of new treatments for pain, and I definitely think the medical community is eager to understand more about what they can do."

To do their jobs, " doctors use pain as a clue to diagnosing and treating the underlying disease," she said.

But pain also can be caused by treatments and by advancing disease that is not amenable to treatment. It is therefore important for us to treat pain whenever it occurs, even while we?re trying to determine what has caused it."

To read the guidelines or order a copy, see the Web site of the National Comprehensive Cancer Network.