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Cancer
Pain Widespread,
Often Untreated
One in four
elderly cancer patients
gets no medication for pain
April 3, 1999 Last year a five-state study showed
that daily pain among nursing home residents with cancer is widespread and
often untreated, especially among older and minority patients.
Appearing in the June 17 1998 Journal
of the American Medical Association, the study found that many frail
and older cancer patients receive inadequate medical treatment and that
dramatic room exists for improving how pain is managed in these individuals.
Among those affected by inadequate pain care in
nursing homes are patients who have advanced prostate cancer. Typically,
the disease spreads to the bones. It may cause flares of the extreme "breakthrough"
pain, which the new drug Actiq is designed to treat.
Almost forty thousand men a year die of prostate cancer. Knowing that it
kills some men in their forties and fifties, activists are fighting the
stereotype of prostate cancer as a disease of old men. Nonethless (as with
breast, lung, and colon cancer) the majority of patients are over 65. Many
are in nursing homes or VA hospitals.
These men are among patients who might benefit
from Actiq -- but only patients who are already on medication for around-the-clock
pain can use Actiq. The drug is specifically designed for patients who are
"already receiving, and tolerant to, opioid therapy for their underlying,
persistent cancer pain."
What of those who aren't getting even minimal care?
Last year, Giovanni Gambassi, M.D., visiting professor in the Center for
Gerontology and Health Care Research at Brown University, found that 1 out
of 4 cancer patients in nursing homes who said they had cancer pain never
received any medication at all.
More
Elderly Patients, Less Pain Care
"We're not pointing fingers,
but we know that nursing homes and many clinical settings do not do a good
job in this area, and here's more proof," Dr. Gambassi said.
"At some point, nursing home
staff and in-house doctors may give up on patients who they know are going
to die," he said. "The results of our study are particularly alarming
since there are ways to treat patients to greatly relieve their conditions.
There is no acceptable excuse for not treating pain appropriately in terminally
ill patients."
Gambassi and colleagues
examined data collected on 13,625 cancer patients aged 65 and older discharged
from hospitals to 1,492 nursing homes from 1992 to 1995. "In total,
4,003 patients reported daily pain. Of those, 16 percent received a simple
analgesic such as aspirin or acetaminophen. Thirty-two percent were given
codeine or other weak opioids, and 26 percent received morphine."
"However, 26 percent of patients with
daily pain received no analgesics, not even an aspirin or acetaminophen
tablet," the authors found. "Patients older than 85 years in
daily pain were about 50 percent less likely to receive any analgesic
than those aged 65 to 74 years. Only 13 percent of patients aged 85 years
and older received codeine or other weak opiates or morphine, compared
to 38 percent of those aged 65 to 74 years."
"Failure to prevent or to treat pain
effectively is unacceptable and should be considered a first-line indicator
of poor quality of medical care," Dr. Gambassi said. He and his team
called for solutions that address barriers to pain management including
the unwillingness of many nursing homes to handle opiates, inadequate
staff to provide and monitor adequate use of painkillers, and reluctance
or inability of some patients -- especially the elderly and patients who
don't speak fluent English -- to demand proper pain medication.
African Americans were fifty
percent less likely than whites to receive any analgesics. Although not
statistically significant, a similar trend in the data was noted for Hispanics,
Asians and American Indians. For minority patients,
the authors suggest that language barriers account for some of the differences.
Cultural and language backgrounds affect
ratings of how pain interferes with physical function, mood and sleep.
There is evidence that Hispanics are more reluctant to report pain and,
like African Americans, less willing to complete advanced directives.
Only recently have medical schools
offered training on the care of terminally ill elderly, Gambassi said. There
still is a need to educate individual clinicians and patients to influence
their behaviors, he said. "We must tear down the cultural, social and intellectual
barriers to do a better job of attending to those who are terminally ill."
How
This Study Was Done
The study came up with a one-time "snapshot" of cancer pain
management. The information came from the Systematic Assessment of
Geriatric Drug Use via Epidemiology (SAGE) database, established and
maintained by Brown University. The data was collected as part of
the Health Care Financing Administration's Multistate Nursing Home
Case-mix and Quality Demonstration Project.
Nursing home staff in all Medicare and
Medicaid facilities in Kansas, Maine, Mississippi, New York and South
Dakota evaluated patients using a 350-item data set. In addition,
nursing staff recorded up to 18 different medications received by
each resident in the prior seven days.
The SAGE group grew out of collaborative
effort between faculty at Brown and at Catholic University in Rome.
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