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Impediments to opioid use

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IMPEDIMENTS OF PAIN THERAPY - LESSONS FROM THE CANCER PAIN INITATIVE MECKLENBURG-VORPOMMERN

WolfDiemer. Th Theurer*, H. Wendlandt*, M Wendt*, Dept of Anaesthesiology and Intensive Care, Pain Service, Emst-Montz-Amdt-Univ Hospital, D-17487 Greifswald, Germany

Aim of Investigation. Cancer pain initiative Mecklenburg-Vorpomrnem (MV) is a joint demonstration project of the medical board MV and the pain service, sponsored by the Federal Minister of Health It runs 1996-99 to improve outpatient cancer pain therapy and palliative treatment in cooperation with general practitioners (gp's) and district nurses

Methods. A survey in 500 physicians was conducted 1997 (and 1999) in two regions. Mecklenburg and Vorpommem Quality management interventions in three counties of Vorpommem include information for professionals, patients, relatives about cancer pain therapy and palliative medicine, four quality circles (participants' 40 physicians, 12 nurses, exchange of experiences in interdisciplinary working groups), a palliative-care team (pet) supports the health care professionals in cancer pain therapy and palliative medicine in the outpatients, documentation of pain treatment

Results 50,6% of the questionnaires were returned 50% of the gp's know the WHO-ladder and 75,5% have prescription forms for strong opioids In more than half of the patients the gp's wish to have a multidisciplmary cooperation to treat difficult pain patients The pet achieved over 2150 contacts to more than 210 patients to optimize the pain therapy. In 46% of the patients an increase of opioid dose could solve the problems, in 16% a change was made from parenteral to noninvasive treatment and in 14% a step up in the WHO-ladder was necessary

Conclusion. A pet is able to improve cancer pain therapy and to avoid admission to the hospital The additional interventions are suitable to implement WHO-guidelmes Negotiations were started to continue this work after the end of the demonstration project in December 1999

Acknowledgments supported by Fed Minister of Health Grant FB 2-43332-50/12

DOES FEAR ABOUT "DRUG ADDICTION" INFLUENCE GERMAN PHYSICIANS TREATING PAIN IN CANCER PATIENTS?

G G Hanekop, M T Bautz*. A Miesner*, M Kriegler*, U Stemmetz*, A. Him*, A Strube, F B M Ensmk*,DeptofAnes-thesiology, Emergency-Medicine and Intensive-Care, Georg-August-Univ, Robert-Koch-Strasse 40, D-37075 Goettingen, Germany

Aim of Investigation Cancer pain treatment is considered to be insufficient worldwide According to Twycross (1982) this is at least partly due to the influence of so called "opioid-myths", with fear of inducing drug addiction being one of the most important myths We tried to evaluate the knowledge and attitudes on cancer pain treatment among physicians in Lower-Saxony, thereby investigating some of these myths

Methods In order to improve the current situation of palliative ; medicine a project called "SUPPORT" (http://come.to/SUPPORT) E was initiated with approval by the local ethics committee Before starting the interventions a pre-survey was earned out in 1997 A questionnaire consisting of more than 50 items was sent out to a representative random sample of 400 practicing physicians, which was returned by 267 (67%) In a special section of the questionnaire on attitudes and knowledge about drug addiction physicians had to respond on a 6-pomt scale (1 = fully agree . 6 = fully disagree) to the statement ,,As there is a risk of developing drug addiction, one has to be very careful when prescribing opioids " On the other hand physicians were asked to estimate the incidence of drug addiction induced by use of strong opioids

Results Two thirds of the responders indicated, that they do not agree with the given statement (1=6 7%, 2=9 7%, 3=11 6%, 4 = 8 2%, 5=21 0%, 6 = 36 7%, missing = 6 0%) However, only about half of the answering physicians estimated correctly the true incidence of drug addiction (incidence <1% = 49 2%, 1-20% = 13 5%, 21 -40% = 4 4%, 41 -60% = 5.2%, 61 -80% = 0 8%, 81 -99% = 0 4%, 100% = 4 0%, missing = 22 6%)

Conclusions The fear about drug addiction seems to have no substantial influence on the attitudes of physicians treating cancer patients in Lower-Saxony with respect to their pain treatment behavior However, the physicians in this sample tend to overestimate the true risk ofopioid induced drug addiction These incorrect beliefs might interfere with adequate prescription rates of opioids Reference Twycross, R (1982) Acta Anaesthesiol Scand 74(Suppl) 83-90

Acknowledgment Sponsored by the German Ministry of Health (BMG) with federal grant number FB 2-43332-50/11.

THE INFLUENCE OF "OPIOID-MYTHS" ON THE ATTITUDES OF GERMAN PHYSICIANS TREATING PAIN IN CANCER PATIENTS.

F B M. Ensmk*. M T. Bautz*. W Weyland, A Albrecht*,I Benken*, D Beck*, A Miesner*, G G Hanekop, Dept of Anesthe-siology, Emergency-Medicine and Intensive-Care, Georg-August-Univ, Robert-Koch-Strasse 40, D-37075 Goettingen, Germany

Aim of Investigation Cancer pain treatment is considered to be insufficient worldwide According to Twycross (1982) this is at least partly due to the influence of so called ,,opioid-myths" We tried to evaluate the knowledge and attitudes on cancer pain treatment among physicians in Lower-Saxony, thereby investigating the myth that prescription of morphine invariably indicates no chance for curing the disease

Methods In order to improve the current situation of palliative medicine a project called ..SUPPORT" (http //come to/SUPPORT) was initiated with approval by the local ethics committee Before starting the interventions a pre-survey was earned out in 1997 A questionnaire consisting of more than 50 items was sent out to a representative random sample of 400 practicing physicians, which was returned by 267 (67%) They had to respond on a 6-point scale (1 = fully agree 6 = fully disagree) to the following two statements ,,Prescnption of strong opioids indicates that the only remaining choice is palliative care as there is no chance of cure " (Statement A) and ,,Strong opioids are an indispensable choice of treatment for cancer pain" (Statement B)

Results More than two thirds of the responders indicated, that they do not agree with Statement A (1=5 6%, 2=5 6%, 3=12 7%, 4 = 13 5%, 5=13 1%, 6 = 42 7%, missing = 6 7%), whereas the ma-jonty of responders does agree with Statement B (1 = 74 5%, 2 = 9 7%, 3=5 2%, 4 = 1 5%, 5=0 8%, 6 = 1.9%, missing = 6 4%)

Conclusions In the sample under investigation it is well accepted that strong opioids should be prescnbed whenever they are needed Furthermore, the data suggest that there is no adverse influence of the aforementioned myth on the use of morphine under these circumstances. However, it seems that the official consumption rates of strong opioids in Germany do not correspond well to these self-reported attitudes In fact these official figures suggest that opioid prescription for cancer pain is still insufficient Reference' Twycross, R (1982) Acta Anaesthesiol Scand 74(Suppl): 83-90

Acknowledgment Sponsored by the German Ministry of Health (BMG) with federal grant number FB 2-43332-50/11

CANCER PAIN RELIEF - KNOWLEDGE AND ATTITUDES OF GENERAL PRACTITIONERS

Romania Lupsa. Csongor Csiki*, Dept of Oncology, Medical Univ, Tg. Mures, Romania

Aim of Investigation We evaluated the knowledge and attitudes of GPs connected to the cancer pain treatment with opioids and adjuvants for analgesic effect.

Methods 43 general practitioners who attended a one-day course on palliative care were questioned We compared the answers before and after the course, and we expressed the results in percentage

Results According to the opinion of most doctors, 79 06 (before) and 86 66% (after the course), cancer pain is treatable Before the course, 39 5% of participants considered that opioids have to be used for cancer pain treatment alone or associated with NSAI and adjuvants After the course this percentage grew up to 80% Only 53 48% of GPs know the legislation on using opioids Also, there is a lack of knowledge in side effects of morphine. All the participants agreed with the importance of a course based on this topic

Conclusions General practitioners lack knowledge in cancer pain treatment, in using opioid analgesics and other drugs for cancer pain relief We have to change the attitudes concerning cancer pain management of doctors, nurses and other health care workers That is necessary because in Romania there are not any hospices yet, or specially trained medical staff in this field

IS THANATOPHOBIA AN IMPEDIMENT TO OPIOID USE BY HOSPICE NURSES?

Joseph M. Memll. A. Dale, C. Stratton Hill, Ronald I Lonmor, Jack I Thomby, Sharon M. Weinstein (SPON S Wemstem), Dept of Family and Community Medicine Baylor College of Medicine and The Univ of Texas M D. Anderson Cancer Center Houston, TX.

Aim of Investigation: Because reluctance to prescnbe opioids (OP) often prevents pain relief even in end-of-life patients, we investigated the relationship between thanatophobia (TP), the desire to avoid terminally ill patients, and opiophobia (OP)

Methods. Measures for both OP (SIA 84) and TP (SIA 0 87) constructs were developed High scorers on the OP measure believe that opiates should be reserved for terminally ill patients High scorers on TP feel uncomfortable, helpless, or frustrated when providing end-of-life care Hospice nurses (n=39) and senior medical students (SMS) (n=213) completed a 110-item survey that included the OP and TP scales with a battery of personal and professional role traits

Results: (1) Higher TP scores predicted higher OP scores in hospice nurses (p< 01) and SMS (p< 001) (2) Among hospice RNs, TP accounted for 24% ofOP's variance (3) Nonetheless, hospice nurses scored lower on both OP and TP (p< 001). (4) Structural equation modeling using LISREL 8 revealed that nurses' and medical students' mental models ofOP and TP differed (5) Hospice RNs' OP was predicted primarily by TP and SMS' OP, by reliance on hi-tech medicine. (6) For the hospice RNs, TP was predicted by higher scores on authontananism, TP for the SMS, by intolerance to clinical uncertainty

Conclusions Hospice nurses' thanatophobia is the major predictor of their opiophobia Structural equation modeling identified the personal traits that are the major sources of these caregivers' angst With this information, better counseling strategies can be devised that should lead to improved end-of-life care

A MODEL FOR DELIVERY OF CANCER PAIN RELIEF IN DEVELOPING COUNTRIES.

Dr M R Raiagopal* (SPON D E. Joranson) Prof ofAnesthesiol-ogy, Pain & Palliative Care Society (PPCS), World Health Org Demonstration Project, Medical College and Hospitals, Calicut 673-008 INDIA

Aim of Investigation- Develop cost-effective cancer pain relief for rural population in India.

Methods. 1) Impediments to cancer pain relief identified poor patient access to pain relief, low awareness about cancer, pain, palliative care, fears of morphine, stringent morphine regulations, 2) PPCS (South Indian State ofKerala, 29 million) developed palliative care and pain relief program with limited resources by operating out of existing hospitals to avoid costs of construction, obtaining funds from non-governmental organizations, 3) Low cost palliative care provided by home care service to large population, home visits made by physicians, nurses who tram and empower families, volunteers to provide basic nursing care Coverage achieved using referral unit, out-reach network of 11 satellite clinics, 4) Education aimed at the public, professionals and regulators to improve awareness and remove fear of morphine, 5) Morphine regulations are being simplified in cooperation with the Kerala State Government and WHO Collaborating Center, Univ of Wisconsin, USA

Results. In 1998, 1400 late stage cancer patients received good quality pain relief regardless of financial condition, using oral morphine supplied by PPCS, there was no shortage and no diversion to illicit use

Conclusions. A large portion of pain due to cancer in third world can be relieved by using existing resources, well trained staff, families and volunteers, and by working with government to improve patient access to oral morphine

GLOBAL AVAILABILITY OF MORPHINE

David Joranson. Aaron Gilson, Karen Ryan, John Nelson, Pain & Policy Studies Group, Univ of Wisconsin, World Health Organization Collaborating Center, 1900 Univ Ave, Madison, Wisconsin, 53705 USA

Aim of Investigation To 1) report global morphine consumption as one indicator of progress to improve pain relief; 2) determine if countries' development status predicts morphine consumption, 3) determine if increased morphine use increases its abuse

Methods 1) updated morphine consumption data from the International Narcotics Control Board will be presented graphically; 2) these data will be compared to each countries' Human Development Index score, and 3) trends in morphine abuse statistics in the U S will be compared to medical consumption

Results Significant increases in global morphine consumption have occurred since the publication of the WHO Three-Step Analgesic Ladder. Most increases in morphine use have occurred in developed countries, with recent increases in developing countries, however, a country's development status continues to be highly predictive of its morphine consumption In the U S , morphine abuse has been very low and stable for the last fifteen years, despite substantial increases in medical use

Conclusions Although morphine is not the only opioid for cancer pain, it is the most widely available and consumption data are easily accessible. Morphine availability is improving in the developed world, while cancer patients in developing countries, comprising the majority of the world's population of cancer patients, continue to have little access In the U S , it is clear that significant increases in medical use of morphine have not affected its low and stable level of abuse

OPIOID CONSUMPTION PROFILE OF THE SCANDINAVIAN COUNTRIES

Torben G Clausen, Multidisciphnary Pain Center, National Hospital, Tagensve) 18 B, DK.-2200 Copenhagen, Denmark

Aim of Investigation' To make a survey of the opioid consumption (OC) profile of the Scandinavian countries

Methods The OC was evaluated from the annual statistics on opi-oids, reported to The International Control Board, WHO The observation period was 1976 96 The study included the Scandinavian countnes and their consumption of morphine, methddone and pethidine An analysis for 1996, including all opioids was performed The consumption of the vanous drugs is presented as equipotent analgetic doses (EADD) per mill inhabitants

Results The Scandinavian countries increased their OC of morphine, methadone and pethidine with 904% on average Sweden 1559%, Denmark 962%, Norway 632% and Finland 243% In 1996, the total Danish OC exceeded 1 mill EADD, compared with Sweden (272 000), Norway (145 000) and Finland (51 000). The study revealed considerable discrepancies in OC compared with the WHO statistics

Conclusion Denmark is the most opioid consuming country in Scandinavia The total Swedish and Finish OC comprised only 25% and 5% of the Danish opioid use, respectively These differences in OC may reflect discrepancies in national legislations on opioid prescription, use of opioids in cancer and non-cancer patients, myths or insufficient knowledge concerning opioids among the prescnbers.

MYTHS AND DIFFICULTIES IN MORPHINE PRESCRIPTION ON ONCOLOGIC PAIN

Silva R. Correia D, Freitas D*, Femandes F*, Alves E*, Centro Hospitalar do Funchal, Madeira Island, Portugal Introduction In oncological disease, pain is one of its most worrying and incapacitating symptoms, being frequently necessary to prescribe morphine

Aims of investigation The authors analyzed the opioids' therapeutics in Madeira Island, its myths and difficulties involved with dealing with this kind of analgesic drug

Methods After building-up a questionnaire, the authors tested its reliability (test/retest/reliability) and validity (contents, construction and validity criteria) They applied it to two different professional groups (Doctors and Nurses) in a universe of 350 individuals.

Results The authors obtained and analyzed 300 questionnaires and documented fears, difficulties and inherent myths of morphine prescription, having also made a data statistic with these results

Conclusion. The authors concluded that fears and myths of morphine use are so important and very significant on both analyzed professional groups and contribute to the difficulties in prescribing these pharmacological products, with its inherent minor use A better education and knowledge in both professional groups is necessary in order to dimmish or vanish the stigma of morphine use

METHADONE MAINTENANCE PATIENTS WITH PAIN AND CHRONIC PAIN PATIENTS ON OPIOIDS: HOW DIFFERENT ARE THESE POPULATIONS?

Nathaniel P Katz. Jamce Kauffman, Edgar Ross, and Robert N Jamison, Depts of Anesthesia and Psychiatry, Bngham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA

Aim of Investigation The aim of this study was to compare chronic pain patients at pain centers who were taking opioids for pain and individuals with chronic pain at methadone maintenance centers who have a substance abuse history

Methods and Results 217 patients at two pain centers and 248 participants at three methadone maintenance centers were surveyed, 112 (50 2%) of the pain patients were taking opioids and 152 (61 3%) methadone maintenance patients reported chronic pain Methadone maintenance patients with pain reported significantly more health problems (p<0.01), more psychiatric disturbance (p<0.05), more prescription and nonprescnption medication use (p<0 01), and greater disability (p < 0 05) Methadone patients with pain had longer duration of pain and longer opioid history with greater perceived tolerance The majority of these patients hac fear of addiction yet believed that methadone was helpful for their pain

Conclusions Some chronic pain patients who have limited access to opioids may be redirected to methadone maintenance centers for management of their pain These results raise many questions about chronic-pain treatment policies and resources for chronic pain patients with a history of substance abuse

9th WORLD CONGRESS ON PAIN, 1999, Vienna, Austria, p.231 - 233

   

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