Control of Pain Gains Priority in Cancer Treatment Centers : Medicine: More and more doctors are paying attention to patients’ discomfort. Myths about morphine are being overcome.
BOSTON — A young anesthesiologist outlined the first problem: A deceptively healthy looking man had inoperable cancer. At this stage of his disease, he could have been leading a reasonably active life.
But there was a complication: A tumor on his spine was making him miserable.
Narcotic painkillers might not be strong enough to control the pain, and as the disease spread, it surely would get worse.
“It looks like impending disaster,” the doctor said. Any suggestions?
Neurosurgery, someone offered. Steroids, another said.
For 10 minutes, the doctor gathers ideas. Then the discussion moves on: A policeman cannot bring himself to use narcotics for his own cancer pain. A woman with cancer that had spread to her bones can barely move, and her desolate husband is talking about killing them both.
These are the weekly cancer pain rounds, a Thursday noon gathering in a cramped conference room deep in Massachusetts General Hospital. Fifteen doctors, nurses, social workers and a priest work their way down the list, deciding on counseling, hospice care and various ways of delivering powerful narcotics to ease the ravages of cancer.
Yet however grim the discussion, there is an underlying assumption that even these most difficult cases can be relieved with the right combination of medicine, technology and compassion.
A new realization seems to be sinking in at hospitals across the United States: Dying from cancer need not necessarily mean dying in pain.
“I don’t know why this has, all of a sudden, picked up steam, but it is long overdue,” said Dr. Stuart Grossman of Johns Hopkins University.
Each year, hundreds of thousands of Americans with cancer die in severe pain. Research suggests that 50% to 70% of people with cancer pain do not get adequate relief. Fear of a lingering, painful death is what makes cancer one of the most dreaded of all diseases.
Experts now agree that this suffering is almost always unnecessary. At least 90% of cancer patients should be able to live out their days relatively pain-free.
The reason for past failure is almost always the same. Medical professionals either ignore pain entirely or, more often, prescribe woefully inadequate doses of narcotics.
Of course, this does not mean that doctors and nurses are sadists. The inadequate care more likely results from poor education, fear of using narcotic painkillers and a simple lack of priority for pain.
Pain control is barely touched upon in medical school. Doctors are taught to view their job as curing disease, not controlling symptoms. The duty of a cancer specialist is clear--to reduce tumors--but pain is no one’s responsibility.
Until recently, no one in the hospital except the patient considered pain to be very important. Since it cannot be easily measured, such as temperature or blood pressure, it is not even noted on medical charts.
Dr. Daniel Carr, head of Massachusetts General’s pain center, said that when researchers design experiments on rats, they must say whether the animals will be in pain or discomfort. If so, how will the pain be assessed? Who will take care of it? And if that person is away, who will take his place?
“That’s OK. I’m not anti-rat,” said Carr, “but contrast that to what is required for your grandmother: It’s zero.”
But there are signs that neglect and incompetence in this area of cancer patient care are beginning to be corrected. At least, it is being talked about.
For instance, Carr is co-chairman of a committee that is writing federal guidelines for treating cancer pain for the Agency for Health Care Policy and Research.
The American Cancer Society and the American Society of Clinical Oncology recently added cancer pain to their top priorities.
The Oncology Nursing Society has put out a strongly worded 46-page position paper on cancer pain, calling it a major responsibility of the profession.
And for the first time, doctors and nurses risk being held legally responsible for inadequate attention to pain. In a lawsuit in North Carolina in 1990, a jury ordered a nursing home to pay $15 million to the family of a man who died in agony with prostate cancer. According to testimony, nurses drastically cut back his narcotic painkillers and gave him headache medicine instead.
“There is a growing realization that most people with cancer don’t have to suffer,” said Dr. Charles Berde of Children’s Hospital in Boston. “It is not an inevitable part of having cancer.”
Yet these messages have only recently begun to filter down to the bedsides of the dying, where family doctors and nurses decide how much pain relief is enough.
“We continue to see patients who have horrible stories to tell,” said Vivian Sheidler, a cancer nurse at Johns Hopkins. “There is still significant room for improvement.”
Several experts said a few changes could help make good pain control a routine part of competent care for cancer. Among them:
Doctors should regularly ask patients about pain. Many do not.
* Patients’ pain should be graded according to simple pain assessment scales. Pain should be noted in patients’ charts, as are the vital signs.
* Hospital quality assessment panels should regularly review patients’ pain control, just as they do infections and other complications.
* Pain control should be taught in medical schools.
* Questions about pain treatment should be included on exams taken by doctors who want to be certified as specialists in various fields that take care of cancer patients.
Most cancer pain can be controlled with just one medicine--morphine. It can be taken in pill form, including sustained-release varieties that eliminate the need for frequent pill popping, as well as in skin patches, suppositories and pumps that release an injection whenever the patient needs it.
Yet for reasons ranging from ignorance to irrational fear, this medicine is often not given in powerful enough doses to stop the pain.
“If there is any one major reason for undercontrol of cancer pain, it’s underdosing of opioid analgesics (morphine),” said Dr. Michael Levy of the Fox Chase Cancer Center in Philadelphia.
Proper use of morphine is confused by myths. Perhaps the most powerful, both for doctors and patients, is the fear of addiction.
“You would be surprised how many physicians are concerned they will make the patient a drug addict,” said Dr. Carol Warfield of Boston’s Beth Israel Hospital. “They feel they should not use drugs that are addictive in any situation. It doesn’t make any sense.”
Pain experts say addiction should be the least concern of someone dying of cancer. It is extremely rare, anyway, occurring in perhaps one in 10,000 cases. If someone does become physically dependent, the feelings of headache, nausea and shakiness can be avoided by gradual withdrawal of the drug over five to 10 days.
Morphine’s side effects, another common concern of doctors, can also be dealt with. The most common are nausea and constipation, which can be treated with anti-nausea drugs, high-fiber diet and laxatives. Drowsiness is common when the pain medicine is started, but usually goes away over time.
Patients, too, often resist taking morphine because they fear addiction and feel guilty about enjoying the effects of narcotics. Others don’t want to complain or waste their brief time with their doctors talking about pain. Some also are reluctant to admit they have increasing pain because it means their disease is getting worse.
Doctors and nurses frequently worry that if they give patients enough morphine to ease their pain in the early stages of cancer, they might build up a tolerance so it will be less effective when the pain becomes severe. Experts say that doctors can safely overcome tolerance by gradually increasing the doses as pain increases.
Another difficulty is choosing the right dose. The amount of medicine necessary to relieve pain is likely to vary dramatically from person to person.
“In some patients, two milligrams of morphine is too much. In others, 200 is not enough. You don’t just give a dose and walk away. You adjust the dose for the desired balance between side effects and pain relief,” said Berde.
Doctors also worry about drawing the attention of drug police if they prescribe opiates for people with cancer.
Several states now require triplicate forms for morphine prescriptions--and one form goes to the state drug enforcement agency. Surveys show that prescriptions for powerful painkillers decline 50% under such laws, and doctors substitute less effective medicines.
“There is no question that narcotic addiction on the streets is a major problem, but for a person experiencing pain, narcotics are the best painkillers we know of,” said Dr. Richard Blonsky, president-elect of the American Academy of Pain Medicine.
“A lot of doctors fear that if they write too many prescriptions, Big Brother will get after them.”
