Data from three large health maintenance organizations reveal that 85% of a group of 421 women who were dying of ovarian cancer had documented pain, but only about half of these women were given a high-intensity medication regimen (intended for severe pain). The study, funded by the Centers for Disease Control and Prevention, found “very little evidence of systematic assessment of pain or its management.”
The study used the World Health Organization (WHO) three-step ladder as a guide. Treatment usually starts with non-opioid analgesics and moves to strong opioids. At all steps of the ladder, adjuvant medications, such as anti-depressants and corticosteroids, can be used. This approach, the researchers say, allows 90% of cancer patients and more than 75% of terminally ill cancer patients to control pain.
At five to six months before they died, 55% of women were either receiving no pain medication or they received medication generally indicated for mild pain. Only 9% were using the highest-intensity regimen. The percentage using the highest-intensity regimen increased to 22% at three to four months before death and to 54% at one to two months. Older women were less likely to receive the highest intensity of medication. This finding might reflect a possible lower tolerance in older women for the strong opioids, or it might be that younger women were more likely to ask for pain relief, the researchers suggest.
Reports of undertreatment are not new, of course. Even now, misconceptions associated with morphine use prevent adequate pain relief. The researchers cited a study in which 50% of health care providers said they would provide a weak opioid for a woman with bone metastasis and a predicted survival of more than 24 months. Other case studies have described providers who were unaware of the WHO ladder of treatment.
The researchers also state that a lack of communication between physicians and patients can be a barrier to adequate pain management. Providers might not be trained to comfortably—or at least willingly—discuss palliative and end-of-life issues with patients. And without direct communication, health care providers might not be aware of pain levels. Patients need to be given the opportunity and permission to raise the subject of pain.