Dr. Payne Urges Strategies to Overcome Barriers to Use of Cancer Pain Guidelines

VANCOUVER, BC-The US Agency for Health Care Policy and Research(AHCPR) cancer pain practice guidelines, like the World HealthOrganization (WHO) 3-step ladder, emphasize a hierarchical painmanagement strategy, Richard Payne, MD, said at a symposium heldin conjunction with the 8th World Congress on Pain of the InternationalAssociation for the Study of Pain (IASP).

Dr. Payne, chief of the Section of Pain and Symptom Management,The University of Texas M.D. Anderson Cancer Center, describedthe AHCPR guidelines as a pyramid, with the base representinguse of oral, transdermal, and rectal drugs; circling the pyramid,in his imagery, are ribbons representing important adjuvant therapies.

Determine the Cause of Pain

"Although systemic analgesics are the base and cornerstoneof therapy, and are effective in at least 75% to 85% of cancerpatients reporting moderate to severe pain, they should alwaysbe used in the context of an appropriate assessment that triesto determine the cause of the pain," he said.

The cause should be treated, if possible, with antineoplastictherapies, palliative radiotherapy, adjuvant drugs, and physicaland psychosocial modalities.

The top of the pyramid includes more invasive approaches to paintreatment such as the use of intravenous and subcutaneous opioidsand epidural or intrathecal subarachnoid analgesia, Dr. Paynesaid.

At the very top, for use in perhaps 1% to 5% of the total universeof patients with severe cancer pain, are nerve blocks, palliativesurgery, and ablative neurosurgical approaches.

Although these guidelines have been widely promulgated, "thedata to suggest that they have been widely incorporated into practiceare much less convincing," Dr. Payne said, "so one hasto ask, what are the barriers to implementation?"

He noted that physicians have long been ambivalent about the useof guidelines of any sort, believing that they represent "cookbook"medicine and could lead to increased cost of care by mandatingprocedures that individual clinicians might not think necessaryfor specific patients.

Furthermore, the AHCPR cancer pain guidelines are relatively morecomplex than other practice guidelines issued by the agency. "Theyclearly call for more interaction with the patient," Dr.Payne said, "and in the United States, time spent talkingto patients is probably time that is poorly reimbursed or notreimbursed at all."

Physicians may also be concerned about the greater use of controlledsubstances called for in the guidelines, he said, and, finally,physicians may perceive the cancer pain guidelines as "valueadded" in the sense that they may improve the patient's qualityof life but will not have an impact on mortality.

Finally, he said, clinicians' poor pain assessment skills remaina major barrier to pain treatment.

Motivating the Clinicians

To overcome these barriers to implementation of the pain guidelines,Dr. Payne called for educational programs that would better motivatehealth care professionals to alter their clinical habits. "Simplyreciting facts to people is not the mode of education that mosteffectively leads to positive changes in practice," he said.

Emphasizing the cost of unrelieved pain might get some people'sattention. "We have an abstract at this meeting suggestingthat the cost of emergency admissions for pain at M.D. Andersonapproaches approximately $5 million a year," he said (seearticle on page 3).

An important strategy for integrating guidelines into oncologicpractice is the use of a standardized pain management protocol,"to essentially institutionalize a method of pain assessmentand treatment," he said.

Dr. Payne noted that such a protocol might be facilitated by theuse of laptop computers incorporating specialized software, similarto a new system being tested at M.D. Anderson (see article onpage 1).