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Analgesics; Opioid; Palliative Care; Hospices; Opioid Epidemic; Pain

Introduction

A poor quality of life, declining psychological functioning, an increase in depressive symptoms, and clinical demoralisation may be the results of inadequate pain management [1]. In patients with advanced or terminal cancer illness, the prevalence of pain increased from 64.0% to 66.4% between 2007 and 2016 [2, 3], with comparable increases seen during anti-cancer therapy (55% to 59%) and in the post-treatment patient environment (33.0% to 39.3%). According to a review of publications published between 2014 and 2020, 55% of people experience discomfort three months after receiving anti-cancer medication [4]. One of the factors keeping patients from pursuing aggressive therapy is poorly managed pain, which results in subpar functional outcomes and a desire for euthanasia [5]. This is consistent with the signs of a putative "demoralisation syndrome," which include a lack of purpose and meaning in life as well as a sense of helplessness and hopelessness. These symptoms may thus raise the possibility of poor long-term therapy adherence [6].

Oncological therapy is characterised as include analgesic therapy [7]. The European Society for Medical Oncology (ESMO) 2018) established the idea of patient-centered care, which incorporates both supportive and palliative therapy, and supportive care [8,9] has since been included within it. A delay in treatment referral and acceptance, even for interventions focused at pain management, can be caused by the term "palliative" having negative connotations for medical professionals, patients, and their caregivers. The effectiveness of the treatment process depends in large part on the beliefs and attitudes of the patients about pain management. Patients' interactions with doctors throughout their treatments are a significant contributor to these attitudes. Graczyk et al. showed the detrimental impact of physician consultations on patients' perceptions and attitudes about opioid usage [10]. Triggering or reinforcing patients’ fear of opioid analgesic treatment occurred in interactions with physicians whose fear of using such treatment influenced their clinical decision making [11]. The process of informing patients about treatment options includes, in addition to the information message, presenting the physicians’ attitudes, which either strengthens or weakens patients’ defense mechanisms, attitudes and expectations.

There are two main reasons why the opioid pandemic that has spread to several nations, such as the US and Canada, exists. It is connected, on the one hand, to the non-medical use of opioids. On the other side, it is connected to addiction to opiates that physicians have prescribed. In fact, from the 1990s to the height of the first wave of the US pandemic (2000-2016), the number of opioid prescriptions quadrupled, peaking in 2011. The decision of whether to use opioid analgesics early on and risk the possibility of addiction and difficult-to-mitigate side effects, or to undertreat their patients' pain, is a difficult one for oncologists and palliative medicine specialists who care for patients with long life expectancies [12]. Analyzing factors for adherence to a chronic pain treatment regimen in cancer patients revealed similar concerns [13].

Compared to Western and Northern European nations, the usage of opioid drugs is substantially lower in Eastern and Southern European nations. Between the years 2004–2006 and 2014–2016, there was an increase in opioid use in the EU, from 6,477 to 8,967 s-DDD (daily doses for statistical purposes)/1 million (+38.4%). These figures climbed by 13% in the US, from 14,598 to 16,491 s-DDD/1 million. Between 2004 and 2006, there were 1,357 s-DDD/1 million opioid users in Poland; this number increased to 1,840 s-DDD/1 million users between 2014 and 2016 [14]. Among order to reduce opioid usage in patients receiving or having finished anticancer therapy, the Centers for Disease Control and Prevention in the US released recommendations for the use of opioids in the management of chronic pain in 2016. Over the past several years, the quantity of opioids administered has steadily decreased as a result of the adoption of these guidelines and legislation [15].

Poland is among a select group of nations having an established palliative care system and complete access to opioid medications, at least for cancer patients. Despite this, Poland still has a low level of opioid drug use. The usage of morphine equivalents excluding methadone in Poland was 36.6 mg/capita, which was less than the European average of 107 mg/capita, according to the Atlas of Palliative Care in Europe (2019) [16]. As a result, many patients could not be obtaining the necessary pain management that is provided in Poland under the Act's provisions [17]. The third wave of the opioid epidemic is having an impact on Poland's public perception, and this is reflected in later medical community guidelines and recommendations [18-20].

In nations where the opioid epidemic has taken root, advice and laws intended to reduce opioid usage are not applicable to oncology patients. However, stigmatisation of opioids is widespread, and even when their use is strongly suggested, it might be constrained due to internalised anxiety and the fear of being judged by others. In fact, "opioid stigma" is widespread (61%) among cancer patients in nations like the US dealing with the assault of the opioid crisis [21]. The significance of language in patient referrals for opioid therapy is becoming more and more recognised. This is anticipated to result in the growth of "patientfirst" language that stays clear of cognitive preconceptions that connote drug misuse or dependency [22]. Recommendations from the Polish Association of Palliative Medicine (Polskie Towarzystwo Medycyny Paliatywnej) and the Polish Association of Pain Research (Polskie Towarzystw Badania Bólu), both of which are aimed at reducing pain, are the equivalent activities carried out in Poland, among others, by the European Pain Federation, the International Association for Hospice and Palliative Care, International Doctors for Healthier Drug Policies, It is advised to stop using terminology like "drug" and "narcotic" in non-medical contexts since they can make patients and their families anxious, exacerbate opioid phobia, and spread false information about the therapeutic use of opioid analgesics [23].

The opinions of patients and doctors may play a role in ineffective or insufficient therapy. This is dependent on, among other things, whether patients disclose the pain they are feeling, how well they describe the pain, whether they express their worries or scepticism about the dosage of the prescribed medication, and, finally, how closely they follow instructions for long-term treatment, which may include skipping or adjusting dosages based on changes in pain intensity as perceived by the patient [24]. The most frequently self-reported patient opinions about opioid analgesics are related to concerns about diverting attention away from cancer during treatment, being seen as a difficult patient, or the conviction that opioid analgesic use is inevitable as the disease progresses and pain develops or worsens [25]. Strong opioids are frequently used as a "last option" and are seen as a symptom of imminent mortality in the latter stages of sickness. The "morphine myth" that has been explored in the medical literature upholds worries about declining cognitive function, a shorter life expectancy, and ineffective treatment outcomes [26]. The degree to which patients express their thoughts is greatly influenced by how well they communicate with and how much they trust their doctor, both of which are essential for obtaining an accurate and knowledgeable therapeutic advice [27-29].

Patients, caregivers, and medical professionals frequently lack current knowledge, have incorrect ideas, and have unfavourable attitudes about opioid analgesics. According to a 2017 comprehensive review, both patients and clinicians frequently have unfavourable attitudes toward the use of opioids, including concerns about addiction, tolerance building, and adverse effects [30]. Patients' resistance to using opioid drugs, insufficient evaluation of pain and its management, and insufficient medical staff understanding are some of the major barriers to opioid therapy identified by doctors [31, 32]. Another study released in 2017 came to the conclusion that a minority of healthcare professionals' belief that patients can tolerate cancer-related pain, which is the primary cause of the undertreatment of cancer pain, is less important than knowledge of and confidence in the benefits of opioid analgesics [33]. According to a 2015 research done in 10 Asian nations, there is a mismatch in the way physicians and patients measure pain levels. While 88.3% of doctors said they used a scale to gauge pain levels, only 49.5% of patients said the same [34]. Other studies also suggested that doctors from various nations may have diverse viewpoints on opioid analgesics. Although high-dose opioids are generally avoided, many doctors in several US states, Australia, and Denmark are less worried about their patients developing addictions and tend to prescribe opioids more frequently [35]. The purpose of this study was to examine physician and oncology patient perspectives on the use of opioids during palliative care. The efficacy of opioid analgesics, their safety profiles, risk for addiction, treatment expectations, and prior experiences with opioid use were among the outcomes of interest.

Materials and Methods

Study design and setting

The Medical University of Warsaw's Bioethics Committee granted this project ethical permission. The guidelines of the Helsinki Declaration were followed in conducting the study. A survey was created with closed-ended questions that asked participants to rate a statement's agreement with it on a 5-point Likert scale. Instead of obtaining detailed information on each item, the goal was to collect a general view. In order to better understand how patients personally experienced opioid analgesic pain management, open-ended questions were included to the questionnaire.

Participants in the study were asked to complete the survey between March 15 and June 30, 2020. We chose patients who were admitted to the St. Christopher's Oncology Hospice Foundation's inpatient hospice, home hospice, and palliative care outpatient clinics in Warsaw, Poland (Fundacja Hospicjum Onkologiczne w. Krzysztofa).

We included specialty doctors who work in hospice, primary care, and in-patient settings in addition to patients. Using a snowball sample approach, doctors were attracted from various parts of the nation. The initial participants invited others to participate in the study, and these participants in turn invited others, etc. The researchers gave the participants an explanation of the survey's methods and goal. Participation in the study was entirely voluntary, and the data obtained were collected and are stored in accordance with all anonymity rules.

Results

We included 104 cancer patients (mean age: 70.3 11.2 years), the majority of whom were female (60.4%), in an outpatient palliative care clinic, home hospice, or inpatient hospice. In the palliative care group, 38% of respondents had finished their secondary school, 15% had finished their basic vocational education, and 38% had finished their higher education. The majority (71%) of respondents lived in a metropolis with more than 100,000 residents, followed by communities with 50,000-100,000 people living there (14.1%) and those with fewer than 50,000 people (9.1%), with 6% of patients living in rural areas. In addition to the patient group (n=104), we included 216 physicians (mean age= 39.1± 14.4 years), the majority of whom were female (62.4%). Most physicians (93.4%) resided in a city of more than 100,000 inhabitants, while 3.9% lived in a city of 50,000-100,000 residents, and 2.6% in a city or town of up to 50,000 inhabitants. We present participant’s characteristics in Table 1.

Table 1: Summary of the demographic characteristics of patients and physicians.

Most patients with cancer reported that they experienced pain over the course of their illness (87.5%), with a mean pain severity of 7.01 ± 2.44 in Visual Analog Scale (“no pain” score of 0, and “worst imaginable pain” score of 10). In total, 29.7% of patients were not offered analgesic treatment by their doctor during their illness.

When asked whether the physician informed about the effects of the drugs, possible side effects and how to deal with them, 60.2% of the patients answered that he/she did not. In addition, 13.2% of respondents were told that prematurely introduced analgesics may no longer be effective when they are more needed, whereas 10.2% admitted that their physician talked to them about the possibility of addiction or worsening of the course of the disease when using analgesics.

Pain treatment

A total of 34.3% have training in pain management or palliative care. Only 9.4% of doctors said they never treat cancer patients who have chronic pain that has a malignant aetiology. The remainder of the population deals with such patients on a regular basis (15.1% daily, 9.4% weekly, 24.1% monthly). 7.9% of doctors felt "very competent" to use opioids to manage pain, while 37.9% felt "somewhat capable." 16.8% of respondents chose "neither yes nor no" as their response.

Overall, 16% of doctors agreed that "most patients can do without analgesics," and 4.7% said they "completely agree" with this statement. Additionally, 35% of those surveyed stated that "patients frequently exaggerate about their pain," and 46.3% thought that patients overuse medications. Overall, 26.7% of doctors believed that pain should be treated without the use of medications, whereas 15.9% said that paracetamol or ibuprofen is adequate for treating pain, even chronic pain, and 33.2% were undecided. 11.2% of physicians considered the evaluation made by a doctor or nurse to be a fair substitute for the selfdescriptive assessment of pain completed by the patients themselves, while 19.6% had no view on the subject.

Examining point correlations was not feasible since there was no combination of replies from patients and doctors and because there were different numbers of respondents for the two groups. These two groups' response distributions were compared, and the correlation between the distributions for the entire group and each particular subgroup was examined. Equal distributions of the responses between the groups were required in order to properly examine the patient-physician correlation concerns in the context of the replies to the closed-ended questions. Only broad generalizations about group behaviour could be drawn from the association at this level. Table 2 provides a description of these connections.

Table 2: Summary of the linear relationships between patient and physician responses for closed-ended questions.

Discussion Poor cancer patient pain management may be a contributing factor in Poland's low opioid analgesic use. According to this study, 87.5% of the participants reported pain at some point throughout their illness, with a mean pain intensity of 7.01 2.44. These figures are higher than those found in a global analysis of 4,117 studies, which found that 66.4% of patients reported experiencing pain during the advanced, metastatic, and terminal stages of their illness, and 55.0% of patients reported experiencing pain while receiving anti-cancer treatment. 38.0% of patients reported having pain with an intensity of less than 5.

Conclusion

In conclusion, we discovered strong general agreement between cancer patients' and doctors' views on the usage of opioid analgesics. The viewpoints of doctors converged significantly, which may be supported by medical studies and suggestions from nations with a severe opioid issue. The biggest differences in opinions were in the area of medical knowledge, which may be an indication of inadequate patient education about opioid usage and poor patient-physician communication. The wide variations in opioid use are alarming since individuals believed that using opioids would help them manage their pain and improve their quality of life.

Acknowledgements

Not applicable.

Conflicts of Interest

The authors declare no conflict of interest.

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