National Hispanic Science Network 5th Annual Meeting

1
National Hispanic Science Network 5th Annual
Meeting

• Pain and Clinical Use of Opiates in Hispanic
  Populations
• Guadalupe R. Palos, RN, LMSW, DrPH
• Department of Symptom Research
• Email address gpalos_at_mdanderson.org

2
Self-Reflection Exercise

• Dependency on narcotics for pain relief is
  different from narcotic addiction or use for
  recreational purposes, thus narcotic addiction is
  rarely relevant in patients with cancer.
• Strong narcotics should not be use to control
  pain before a patient is terminal because
  tolerance may develop, resulting in ineffective
  analgesia at a later point.
• A patients request for increasing amounts of
  analgesic to control pain typically indicates
  increasing pain due to worsening of disease.

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Research and Clinical Questions

• Is cancer pain (or other types of pain) managed
  well in Latinos/Hispanics?
• What are the barriers to effective cancer pain
  management in Latino populations?
• What can be done to improve cancer pain
  management practice?
• What can be done to minimize fear of addiction as
  a risk factors for disparities in effective pain
  management?

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20 Years Ago Cancer Pain Assertions

• Intractable cancer pain is infrequent and is
  easily treated
• Narcotic medications should be used at the
  lowest effective dose and at the longest
  effective interval to protect against addiction
• Pain perception and the need for analgesics
  varies widely by race, ethnicity, and cultural
  background

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Documenting the Problem

• Research findings continue to document that
• Race and ethnicity are risk factors for the
  undertreatment of pain
• Certain types of pain (acute and cancer pain) are
  often poorly treated among certain ethnic groups
• Bonham, VL, 2001
• Todd, Samaroo Hoffman, 1993, 1994 Karpman, Del
  Mar Bay, 1996 Todd, Deaton, DAdamo Goe,
  2000
• Cleeland, Gonin, Baez, et. al, 1997 Anderson
  et. al., 2002.

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Disparities in Acute Pain

• Hispanics were twice as likely than white,
  non-Hispanics to receive inappropriate doses of
  analgesics for pain related to long-bone
  fractures (Todd, Samaroo Hoffman, 1993, 1994).
• Subsequent studies conducted seven years later
  found that the risk of receiving no analgesics
  was 66 greater for black patients compared to
  white patients (Todd, Deaton, DAdamo Goe,
  2000).

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Disparities in Cancer Pain

• Minority patients were found to have greater
  discrepancy between their provider and their own
  estimates of pain severity
• Patients cared for at minority treatment centers
  were three times more likely to be undermedicated
  with analgesics
• Cleeland CS et. al. Annals of Internal Medicine,
  27 9, 1997.

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Can We Trust Pain Measurement

• Medical management depends on systems of
  measurement
• Pain is a subjective state can we measure it?
• Can we believe patients?
• Can we base treatment on what patients tell us?
• Cleeland CS et. al. Annals of Internal Medicine,
  27 9, 1997.

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Components of Pain

• Sensory
• Intensity
• Quality
• Reactive
• Affective
• Motivational
• Interference with activities
• Cleeland CS et. al. Annals of Internal Medicine,
  27 9, 1997.

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Brief Pain Inventory (Severity)

2. Please rate your pain by circling the one
number that best describes your pain at its
WORST in the last 24 hours.
0 1 2 3 4 5
6 7 8 9
10 No Pain as bad as
Pain you can imagine
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Brief Pain Inventory (Interference)

Circle the number that describes how, during the
past 24 hours, pain has interfered with
your
A. General activity
0 1 2 3 4 5
6 7 8 9 10 Does
not Completely Interfere
Interferes
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Activities Impaired by Increasing Pain

relate
walk sleep active mood work enjoy
walk
sleep active mood
sleep active mood work enjoy
sleep active mood work enjoy
enjoy
work
work enjoy
enjoy
3 4 5 6
7 8
gt gt gt gt worst pain rating gt gt gt gt
n 186 Multi-institutional study
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NCCN Guidelines

• History
• Intensity use a 0 to 10 scale
• - 7 to 10 Pain Emergency
• - 4 to 6
• - below 4
• Location (drawing of location of painful areas on
  the body helpful)

National Comprehensive Cancer Network
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NCCN GuidelinesInitial Opioid Titration
Pain of 7 or more Morphine 15-30 mg PO q 4h ATC
5 to 15 mg. PO q 2h
prn Pain of 4 to 6 Morphine 15-30 mg PO q 4h
ATC 5 to 15 mg. PO q 2h
prn Or Oxycodone or 1- 2 tabs PO q
4h ATC Hydrocodone ½ tab 1 q 2h prn
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Measuring Adequate Pain Treatment The Pain
Management Index (PMI)

• Mild pain (1 - 4)
• Moderate Pain (5 - 6)
• Severe Pain (7 - 10)

NSAIDS 1 Codeine 2 Morphine 3
Pain 8 Med Codeine 2 2 - 8 - 6 Poor
Pain Treatment
Serlin, Mendoza, Nakamura, Cleeland, 1995
National Comprehensive Cancer Network, 2000
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(No Transcript)
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Predictors of Negative PMI(Undertreated with
Analgesics)
Odds Ratio 3.06 2.33 1.95
1.76 1.53 1.53

• Minority vs Non-Minority
• Discrepancy (pt. - physician)
• Cause of pain (ca vs non-ca)
• Performance Status (good vs bad)
• Age (70 gt vs 18 - 52)
• Gender (female vs male)

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Undertreatment of Cancer Patients
with Negative PMI 31
28
with Severe Pain 72
57
MD Under-estimate 74
64

• African - American or Black Caribbean
• Hispanic or Latino

Anderson et. al., 2000
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Results From PREMO Studies

• Findings from structured interviews
• Hispanics expressed concerns about opioid
  analgesics being too strong, addictive, and not
  effective when needed (n 64)
• Majority of patients said they would wait until
  their pain reached a 9 or 10 before calling their
  provider

Anderson et. al., 2000
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Patient Trade - offsPain vs. Side Effects
Cancer Pain Health States Health State 1 - mild
pain and presence of the three worst side
effects. Trade-off is more side effects and less
pain Health State 2 - moderate pain and presence
of the one worst side effect. Trade-off is more
pain but less side effects
Palos et. al., 2001
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Mean Preference Score forCancer Pain Health
States
More pain and less side effects 58.9 49.2
More side effects and less pain 57.8
58.1

• Preferred
• Language
• Spanish
• English

Palos et. al., 2001
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Provider Barriers to Cancer Pain Management

• Poor clinical pain assessment
• Conflicting patient - physician communication
• Poor staff knowledge of pain control
• Von Roenn et. al., 1993 Cleeland et. al, 1997

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Patient Barriers to Cancer Pain Management

• Concern over being a good patient
• Not wanting to distract the physician
• Afraid of new treatments or addiction
• Saving the effectiveness of medications
• Not wishing to complicate the treatment
• Wanting to be well enough for new treatment
  options

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Cancer Pain and Addiction
In patients with chronic pain who are taking
opioids on a long-term basis, we
expect -Tolerance requirements for increased
dose to produce the same effect - Physical
dependence receptor tachyphylaxis that results
in the development of a withdrawal syndrome when
the drug is withdrawn
Penson, RT, Nunn C, Younger J, etl al., (2003).
Trust Violated Analgesics for Addicts. The
Oncologist. 8199-209.
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Pain Management in Patients with a History of
Substance Abuse

• One study found evidence of addiction in 4 out of
  12,000 patients with no prior history of
  addiction (Porter J, 1980)
• Another study found that 40 of cancer patients
  believed ¼ of their peers were addicted to drugs
• (Passik SD et. al, 2000)
• With a people who have a history of substance
  abuse and develop cancer pain, my attitude is
  they win. Well do everything we can to get them
  out of pain (Penson RT et. al, 2003)

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JCAHO Pain Standards for 2001

• Rights and Ethics Functional Chapter
• Standard RI.1.2.8
• Patients have the right to appropriate
  assessment and management of pain.. . . After
  taking into account personal, cultural,
  spiritual, and/or ethnic beliefs, communicating
  to patients and families that pain management is
  an important part of care.

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Standards and Civil Rights

• Several JCAHO standards guarantee language access
  to patients.
• Joint Commission on Accreditation of Healthcare
  Organizations, 2001
• If health care providers do not provide
  information in the patients language of choice
  -- are we violating their civil rights?
• Title VI - Civil Rights Act of 1964

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Warning Use of Placebos

• Inactive substances (e.g. saline injections) used
  to determine if the effects are due to the
  ADMINSTRATION of the placebo rather than the
  pharmacological purpose
• Used to assess if ones pain is real if an
  individuals response is positive, it may be
  viewed as evidence of malingering, faking or
  exaggerating pain
• Oncology Nurses Society Position Statement, 1996

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Warning Use of Placebos

• Often used in vulnerable populations, such as
  those with histories of substance abuse or
  psychiatric problems
• The use of placebo involves deception and raises
  serious ethical concerns
• Placebos should not be used in the assessment and
  management of cancer pain
• Oncology Nurses Society Position Statement, 1996

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Conclusions

• In addicts, methadone may be used as an
  alternative to other opioids
• Educate the patient and family about early signs
  of dependency
• Develop contractual agreements with patient for
  medications and prescriptions
• Empower the patient and their family through
  trust and open communication

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Conclusions

• Conduct additional research that addresses the
  fear of addiction in different subgroups of
  Latino patients and their families
• Adequate pain and symptom management are a
  critical prerequisite for a better quality of
  life in patients who suffer from pain
• Remind ourselves that every person has a right to
  appropriate assessment and effective pain
  management

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Acknowledgements

• Department of Symptom Research
• Charles Cleeland, PhD, Chair
• Karen Anderson, PhD
• Tito Mendoza, PhD
• Maria Sanchez, LVN
• Ibrahima Gning MPH
• Hispanics and Latinos patients with cancer
  willing to participate in pain research and
  clinical trials
• National Cancer Institute funding