News From the End of Life: Poor regimen adherence leads to poor pain care

Addiction fears not the problem

Lack of adherence to pain medication regimens and inadequate analgesic prescriptions are the main reasons cancer patients do not achieve adequate pain relief, according to researchers at the University of California San Francisco (UCSF).

In one of the first studies to observe cancer patients in their homes, researchers at the schools of nursing, medicine, and pharmacy at UCSF studied whether cancer patients were adhering to the around-the-clock and as-needed pain management regimens prescribed by their doctors. The results of the study were published in the Dec. 1 issue of the Journal of Clinical Oncology.

"The old message was that people weren’t taking their pain medication because of fear of addiction," says Christine Miaskowski, RN, PhD, professor and chairwoman of the department of physiological nursing at UCSF. "Our study debunks that explanation, and found that the side effects caused by most opioid analgesics were a key reason why cancer patients did not adhere to their pain medication regimen."

Side effects, such constipation and sedation, deterred patients from taking their pain medications. Patients in the study told researchers that they would rather experience pain than deal with the side effects of the analgesic medications. This finding is unfortunate, because side effects like these can be proactively treated.

According to an accompanying editorial by Jamie von Roenn, MD, professor of medicine at Northwestern University in Chicago, "Lack of adequate knowledge or assessment of pain management by physicians is suggested by the pattern of analgesic prescriptions. Effective pain management requires repeated assessment and adjustments in dosage."

The randomized five-week study included 65 adult oncology patients with baseline pain and evidence of bone metastases. On a daily basis, patients rated their level of pain intensity and recorded their pain medication intake. Adherence rates for opioid analgesics prescribed on around-the-clock and as-needed bases were calculated weekly.

Overall adherence rates ranged from 84.5% to 90.8% for around-the-clock opioid analgesics and 22.2 % to 26.6% for as-needed analgesics. There were no significant changes in adherence rates, pain intensity, or duration of pain during the course of the study.

Federal guidelines recommend that all cancer patients with chronic cancer pain be prescribed an around-the-clock analgesic regimen, as well as a short-acting supplement for breakthrough pain. However, not all patients received both types of medication. In the study, 13.9% of patients were prescribed opioid analgesics on an around-the-clock basis, 56.9% were prescribed opioid analgesics on an as-needed basis, and 29.2% were prescribed both around-the-clock and as-needed analgesics.

"Poor adherence, may, therefore, in part reflect the lack of relief from inadequate analgesic prescriptions," says von Roenn.