Multidrug-resistant tuberculosis in rural China: lack of public awareness, unaffordable costs and poor clinical management.

China has the second highest global incidence and prevalence of multidrug-resistant tuberculosis (MDR-TB). We describe here the life experience of a rural Chinese farmer with complicated and aggressive TB. It is unclear if this patient contracted MDR-TB initially or developed MDR-TB during treatment because the initial laboratory results are dubious. The lack of public awareness of TB in rural China fuelled by a belief in toxicity of TB treatment, as mentioned by his brother, caused the patient to stop his TB treatment repeatedly long before completion. The cost of MDR-TB treatment in China is unaffordable for most Chinese, especially those in rural areas. He paid about ¥300 000 (almost US$50 000) for his TB treatment. He was discharged early twice for 'financial difficulties'. This case highlights excessive costs, lack of public awareness, poor patient education, inadequate follow-up, lack of coordination between clinical services and the importance of treatment adherence.

Disease-free ovarian cancer patients report severe pain and fatigue over time: prospective quality of life assessment in a consecutive series.

UNLABELLED: objective: Among ovarian cancer patients, cancer treatment is aggressive and yet survival is often so limited; hence, this study sought to measure quality of life with the ultimate goal of identifying ways of improving it over the duration of these patients' lives. MATERIALS AND METHODS: The medical records of all ovarian cancer patients who received some/all of their initial chemotherapy at the Mayo Clinic in Rochester, Minnesota from late 2010 through 2012 were reviewed. Patient-reported quality of life was derived from the following ten-point linear analogue scale questions which had been administered to all patients: 1) How would you describe your degree of pain, on average? 2) How would you describe your level of fatigue, on average? 3) How would you describe your overall quality of life? Quality of life data were censored upon cancer recurrence. RESULTS: Among 59 eligible patients, the median cumulative interval during which quality of life was serially assessed was 1.15 years (range: three months, 3.2 years). Area under the curve for pain, fatigue, and global quality of life showed no statistically significant differences between patients treated with dose-dense chemotherapy with carboplatin/paclitaxel (n = 10) versus three-week chemotherapy with carboplatin/paclitaxel (n = 36) versus other (n = 13). Although pain, fatigue, and global quality of life improved over time, 35 of 59 (59%) patients reported grade 4 or worse pain during follow up, and 47 of 59 (80%) reported grade 4 or worse fatigue (higher scores denote worse pain or fatigue). After completion of cancer treatment, 30 (51%) described grade 4 or worse pain or fatigue. The most common pain site was the abdomen/pelvis, followed by the back, followed by the hands, feet, fingers, and toes. CONCLUSION: In ovarian cancer patients who remain cancer-free, severe pain and fatigue occur years after cancer treatment. Further research should focus on how best to address these symptoms.

Cancer pain prevalence and its management.

Pain is a public health problem affecting more than half of cancer patients. Despite the success of the protocols currently used, pain cannot still be reduced satisfactorily in the large majority of patients. In order to improve pain management, all healthcare professionals involved with pain should have sufficient knowledge on pain assessment and treatment, and should inform patients to prevent patient-related barriers. In this compilation, the prevalence values and the treatment methods of cancer pain, and the barriers to pain management have been assessed.

Assessing the effectiveness and cost effectiveness of subcutaneous nerve stimulation in patients with predominant back pain due to failed back surgery syndrome (SubQStim study): study protocol for a multicenter randomized controlled trial.

BACKGROUND: Chronic radicular pain can be effectively treated with spinal cord stimulation, but this therapy is not always sufficient for chronic back pain. Subcutaneous nerve stimulation (SQS) refers to the placement of percutaneous leads in the subcutaneous tissue within the area of pain. Case series data show that failed back surgery syndrome (FBSS) patients experience clinically important levels of pain relief following SQS and may also reduce their levels of analgesic therapy and experience functional well-being. However, to date, there is no randomized controlled trial evidence to support the use of SQS in FBSS. METHODS/DESIGN: The SubQStim study is a multicenter randomized controlled trial comparing SQS plus optimized medical management ('SQS arm') versus optimized medical management alone ('OMM arm') in patients with predominant back pain due to FBSS. Up to 400 patients will be recruited from approximately 33 centers in Europe and Australia and will be randomized 1:1 to the SQS or OMM arms. After 9 months, patients who fail to reach the primary outcome will be allowed to switch treatments. Patients will be evaluated at baseline (prior to randomization) and at 1, 3, 6, 9, 12, 18, 24, and 36 months after randomization. The primary outcome is the proportion of patients at 9 months with a ≥50% reduction in back pain intensity compared to baseline. The secondary outcomes are: back and leg pain intensity score, functional disability, health-related quality of life, patient satisfaction, patient global impression of change, healthcare resource utilization/costs, cost-effectiveness analysis and adverse events. Outcomes arms will be compared between SQS and OMM arms at all evaluation points up to and including 9 months. After the 9-month assessment visit, the main analytic focus will be to compare within patient changes in outcomes relative to baseline. DISCUSSION: The SubQStim trial began patient recruitment in November 2012. Recruitment is expected to close in late 2014. TRIAL REGISTRATION: ClinicalTrials.gov NCT01711619.

A cost utilization analysis of intrathecal therapy for refractory cancer pain: identifying factors associated with cost benefit.

OBJECTIVE: Intrathecal therapy (ITT) for cancer pain is characterized by high initial cost followed by low maintenance costs. Non-ITT pain management is associated with steadily increasing cumulative cost that can equal the cost of ITT over time. The intent of this modeling project is to identify factors associated with relatively rapid achievement of cost-benefit with ITT. DESIGN: A retrospective chart review was performed on 36 patients with cancer pain who underwent ITT and survived beyond 4 weeks. METHODS: Data on the cost of conventional opioid therapy prior to ITT and at 4-6 weeks were collected and projected over time. ITT costs included all intrathecal pump implantation and maintenance costs. Pre-ITT opioid regimens were stratified into high-cost conventional (HCC-high-dose, nongeneric, or use of intravenous patient-controlled analgesia, N = 12) and low-cost conventional (low-dose or generic, N = 24) regimens. RESULTS: The median daily cost of opioid medications pre-ITT was $21.26 (25th-75th percentile $10.31-78.85, range 0-$971.97) vs $0 (25th-75th percentile $0-0.70), P = 0.007, post-ITT. In the HCC group, the median daily cost was $172.47 (25th-75th percentile $67.29-406.20). The median daily cost of ITT medications was $16.01 (25th-75th percentile $9.52-23.23).When these data were used to model costs over the long term, including pump implantation costs, cost-benefit for all patients compared with conventional therapy was predicted at 344 months but at 7.4 months in the HCC group. Seven patients (19%) achieved cost equivalence within 6 months and three of these within the first 3 months. CONCLUSIONS: In selected patients on high-cost opioid regimens, ITT may become cost-beneficial within 6 months. Factors associated with earlier attainment of ITT cost-benefit include the use of parenteral therapy, high-dose opioids, and the use of nongeneric opioid products.

Cancer pain management at home: voice from an underdeveloped region of China.

BACKGROUND: Pain is a major problem for patients with advanced cancer and one of the most frequent and disturbing of all cancer-related symptoms. Researchers continue to report that cancer pain remains undertreated. Inadequate pain control can significantly affect the patient's quality of life and may in turn affect the patient's will to live or comply with treatment recommendations. A better understanding of the experience of cancer pain management is important in identifying factors responsible for undertreated pain. OBJECTIVE: This study aimed to obtain the experience of cancer pain management. INTERVENTIONS: We used a phenomenological approach to explore the status of cancer pain management through participants' experience. Semistructured interviews were conducted with 14 family caregivers, patients, and acquaintances and 14 health professionals (nurses and physicians) from a regional tertiary hospital in northwest China. Data were collected by in-depth interviews. We used a qualitative description after full transcription of every interview. Analysis involved the identification of themes and the development of a taxonomy of participants' experience of cancer pain management. RESULTS: Taxonomy used in this study is to identify, code, group, and name meaning units of the transcribed interviews by reading through repeatedly to obtain an initial sense. Four themes were identified: (1) marginalization, (2) hopelessness and helplessness, (3) deficiency of access and resources, and (4) expectations related to pain. CONCLUSION: Findings from this study suggest that the situation of patients with undertreated cancer pain continues. IMPLICATIONS FOR PRACTICE: Special attention should be paid by policymakers, professionals, and family caregivers to the marginalized group of cancer patients who suffer with pain.

A systematic evaluation of content, structure, and efficacy of interventions to improve patients' self-management of cancer pain.

CONTEXT: Cancer pain continues to be extensively undertreated, despite established guidelines. Although the efficacy of interventions that support patients' self-management of cancer pain has been demonstrated in several studies, the most effective components of these interventions remain unknown. OBJECTIVES: The purpose of this review of experimental and quasi-experimental studies was to systematically describe the structure and content components, as well as the efficacy of various components, of interventions designed to improve patients' self-management of cancer pain. METHODS: A systematic review of the literature was done that supplemented the 2009 meta-analysis of Bennett et al. Intervention components were categorized using content analysis. The intervention components were compared based on their calculated largest effect sizes (ESs) within each study (i.e., Hedges G(u) for between-group differences in pain intensity scores). RESULTS: Based on 34 publications (i.e., 24 interventions), seven structure and 16 content components were identified. In 11 studies with statistically significant ESs, the largest ES within each study ranged from -1.87 to -0.44, which represented clinically meaningful effects. No single component was found to have a discernable influence on ES. CONCLUSION: This analysis provides researchers and clinicians with a detailed overview of the various structural and content components, as well as various combinations that were tested in intervention studies to improve cancer pain management. However, because of a variety of limitations, the most efficacious intervention components or combination of components remain to be determined in future studies.

Assessment of consecutive neurolytic celiac plexus block (NCPB) technique outcomes in the management of refractory visceral cancer pain.

OBJECTIVE: The objective of this study was to assess outcomes and safety of consecutive neurolytic celiac plexus block (NCPB) technique. DESIGN: Retrospective clinical data analysis. SETTING: The study was conducted in three pain departments and academic medical center. PATIENTS: The subject of this study was 12 patients with terminal visceral (mostly pancreatic) cancer who failed conservative measures. INTERVENTIONS: Twelve celiac plexus alcohol neurolytic procedures were performed for pain control after a positive diagnostic block. MATERIALS AND METHODS: Twelve patients with terminal visceral (mostly pancreatic) cancer who failed conservative measures were managed by consecutive NCPB guided by computed tomography at the pain department of Beijing Xuanwu Hospital between January 2005 and June 2010. The present study evaluated the efficacy of consecutive NCPB technique with regard to pain relief, as well as its adverse effects and complications. RESULTS: The efficacy of consecutive NCPB technique with regard to pain relief was observed by a marked decrease in the visual analog score and in opioid consumption, with preprocedural mean values dropping from (8.7±1.0) and (155±56)mg/day of morphine to (1.8±1.1) and (0)mg/day at the first postprocedural visit, respectively. These results persisted during the 6-month follow-up period or until death. Minor adverse effects (moderate diarrhea and mild hypotension) were frequent (N=3, and N=4, respectively), and severe complications occurred in one patient with a transient paraparesis (N=1). No procedure-related mortality was observed. CONCLUSIONS: The consecutive NCPB technique can provide analgesia and the alleviation of the secondary undesirable effects of analgesic drugs resulting from the decrease of morphine consumption in patients with upper abdominal malignancies. In the subject group, the reliability of its analgesic effect is high, with lower rate of severe complications.

Respiratory failure following delayed intrathecal morphine pump refill: a valuable, but costly lesson.

BACKGROUND: Spinal analgesia, mediated by opioid receptors, requires only a fraction of the opioid dose that is needed systemically. By infusing a small amount of opioid into the cerebrospinal fluid in close proximity to the receptor sites in the spinal cord, profound analgesia may be achieved while sparing some of the side effects due to systemic opioids. Intraspinal drug delivery (IDD) has been increasingly used in patients with intractable chronic pain, when these patients have developed untoward side effects with systemic opioid usage. The introduction of intrathecal opioids has been considered one of the most important breakthroughs in pain management in the past three decades. A variety of side effects associated with the long-term usage of IDD have been recognized. Among them, respiratory depression is the most feared. OBJECTIVE: To describe a severe adverse event, i.e., respiratory failure, following delayed intrathecal morphine pump refill. CASE REPORT: A 65-year-old woman with intractable chronic low back pain, due to degenerative disc disease, and was referred to our clinic for an intraspinal drug delivery evaluation, after failing to respond to multidisciplinary pain treatment. Following a psychological evaluation confirming her candidacy, she underwent an outpatient patient-controlled continuous epidural morphine infusion trial. The infusion trial lasted 12 days and was beneficial in controlling her pain. The patient reported more than 90% pain reduction with improved distance for ambulation. She subsequently consented and was scheduled for permanent intrathecal morphine pump implantation. The intrathecal catheter was inserted at right paramedian L3-L4, with catheter tip advanced to L1, confirmed under fluoroscopy. Intrathecal catheter placement was confirmed by positive CSF flow and by myelogram. A non-programmable Codman 3000 constant-flow rate infusion pump was placed in the right mid quandrant between right rib cage and right iliac crest. The intrathecal infusion consisted of preservative free morphine, delivering 1.0 mg /day. Over the following 6 months, the dosage was gradually titrated up to 4 mg/day with satisfactory pain control without significant side effects. However, the patient was not able to return to the clinic for pump refill until 12 days later than the previously scheduled pump-refill date. Her pump was accessed and was noted to be empty. Her intrathecal pump was refilled with preservative free morphine, delivering 4 mg/day (the same daily dose as her previous refill). However, on the night of pump refill, 10 hours after the pump refill, the patient was found to be unresponsive by her family members. 911 was called. Upon arriving, paramedics found her in respiratory failure, with shallow breathing at a rate of 5/min, pulse oxymetry showing oxygen saturation about 55-58%. She was emergently intubated on site and rushed to local hospital ER. The on call physician for our clinic was immediately contacted, and advised the administration of intravenous Naloxone. Her respiratory effort improved dramatically after receiving a total of 0.6 mg IV Naloxone IV over 25 minutes. Her intrathecal pump was immediately accessed by clinic on call physician and the remainder of the medication in the catheter space was aspirated. The pump infusate was immediately diluted with preservative free normal saline, to deliver preservative free morphine at 1mg/day. She was transferred to the intensive care unit and extubated the next morning. She recovered fully without any sequelae. CONCLUSION: Loss of opioid tolerance due to delayed pump refill may subject patients to the development of severe respiratory depression. Meticulous approach should be employed when refilling pumps in these patients when their pumps are completely empty. To our knowledge, this is the first reported case of this type.

Adult emergency department patients with sickle cell pain crisis: a learning collaborative model to improve analgesic management.

OBJECTIVES: The objectives were to report the baseline (prior to quality improvement interventions) patient and visit characteristics and analgesic management practices for each site participating in an emergency department (ED) sickle cell learning collaborative. METHODS: A prospective, multisite longitudinal cohort study in the context of a learning-collaborative model was performed in three midwestern EDs. Each site formed a multidisciplinary team charged with improving analgesic management for patients with sickle cell disease (SCD). Each team developed a nurse-initiated analgesic protocol for SCD patients (implemented after a baseline data collection period of 3.5 months at one site and 10 months at the other two sites). All sites prospectively enrolled adults with an acute pain crisis and SCD. All medical records for patients meeting study criteria were reviewed. Demographic, health services, and analgesic management data were abstracted, including ED visit frequency data, ED disposition, arrival and discharge pain score, and name and route of initial analgesic administered. Ten interviews per quarter per site were conducted with patients within 14 days of their ED discharge, and subjects were queried about the highest level of pain acceptable at discharge. The primary outcome variable was the time to initial analgesic administration. Variable data were described as means and standard deviations (SDs) or medians and interquartile ranges (IQR) for nonnormal data. RESULTS: A total of 155 patients met study criteria (median age = 32 years, IQR = 24-40 years) with a total of 701 ED visits. Eighty-six interviews were conducted. Most patients (71.6%) had between one and three visits to the ED during the study period. However, after removing Site 3 from the analysis because of the short data enrollment period (3.5 months), which influenced the mean number of visits for the entire cohort, 52% of patients had between one and three ED visits over 10 months, 21% had four to nine visits, and 27% had between 10 and 67 visits. Fifty-nine percent of patients were discharged home. The median time to initial analgesic for the cohort was 74 minutes (IQR = 48-135 minutes). Differences between choice of analgesic agent and route selected were evident between sites. For the cohort, 680 initial analgesic doses were given (morphine sulfate, 42%; hydromorphone, 46%; meperidine, 4%; morphine sulfate and ibuprofen or ketorolac, 7%) using the following routes: oral (2%), intravenous (67%), subcutaneous (3%), and intramuscular (28%). Patients reported a significantly lower targeted discharge pain score (mean +/- SD = 4.19 +/- 1.18) compared to the actual documented discharge pain score within 45 minutes of discharge (mean +/- SD = 5.77 +/- 2.45; mean difference = 1.58, 95% confidence interval = .723 to 2.44, n = 43). CONCLUSIONS: While half of the patients had one to three ED visits during the study period, many patients had more frequent visits. Delays to receiving an initial analgesic were common, and post-ED interviews reveal that sickle cell pain patients are discharged from the ED with higher pain scores than what they perceive as desirable.

Assessment and classification of cancer breakthrough pain: a systematic literature review.

Temporal variations in cancer pain intensity are highly prevalent, and are often difficult to manage. However, the phenomenon is not well understood: several definitions and approaches to classification and bedside assessment of cancer breakthrough pain (BTP) have been described. The present study is a systematic review of published literature on cancer BTP to answer the following questions: which terms and definitions have been used; are there validated assessment tools; which domains of BTP do the tools delineate, and which items do they contain; how have assessment tools been applied within clinical studies; and are there validated classification systems for BTP. A systematic search of the peer-reviewed literature was performed using five major databases. Of 375 titles and abstracts initially identified, 51 articles were examined in detail. Analysis of these publications indicates a range of overlapping but distinct definitions have been used to characterize BTP; 42 of the included papers presented one or more ways of classifying BTP; and while 10 tools to assess patients' experience of BTP were identified, only 2 have been partially validated. We conclude that there is no widely accepted definition, classification system or well-validated assessment tool for cancer-related breakthrough pain, but there is strong concurrence on most of its key attributes. With further work in this area, an internationally agreed upon definition and classification system for cancer-related breakthrough pain, and a standard approach on how to measure it, hold the promise to improve patient care and support research in this poor-prognosis cancer pain syndrome.

The validity of average 8-h pain intensity assessment in cancer patients.

Aim of this study was to validate the use of subjective average pain assessment over an 8-h time period to evaluate cancer pain intensity. A sample of 95 consecutive cancer inpatients were asked to score on 0-10 numerical scales the intensity of their pain at hourly intervals, and then, at the 8th hour, to rate their average pain intensity over the last 8h. Agreement between the average of the 8 hourly measures (8hA) and the single patient-rated average (PA8h) was examined with the intraclass correlation coefficient (ICC) and the absolute difference (AD) between the two measurements. Associations between AD, gender, age older than 70, somatic pain, visceral pain, neuropathic pain, pain on movement and the presence of pain exacerbations during the 8-h period, were also examined. Average pain intensity scores were very similar with the two measurement schedules: 3.4 for 8hA and 3.7 for PA8h, with a median AD of 0.44 points. Only six patients (6.3%) showed ADs higher than 2 points. Also the ICC (0.85) showed a substantial agreement between the two schedules. Among the examined variables, gender, age over 70years and presence of pain exacerbations showed a significant association with the agreement level. Overall, our results support the validity of a subjective average pain measurement over 8-h period in cancer patients.

Assessment of celiac plexus block and neurolysis outcomes and technique in the management of refractory visceral cancer pain.

OBJECTIVE: To assess demographic and clinical factors associated with celiac plexus neurolysis outcomes. DESIGN: Retrospective clinical data analysis. SETTING: A tertiary care, academic medical center. PATIENTS: Forty-four patients with terminal visceral (mostly pancreatic) cancer who failed conservative measures. Interventions. Fifty celiac plexus alcohol neurolytic procedures done for pain control after a positive diagnostic block. OUTCOME MEASURES: A successful treatment was predefined as >50% pain relief sustained for > or =1 month. The following variables were analyzed for their association with treatment outcome: age, gender, duration of pain, origin of tumor, opioid dose, type of radiological guidance used, single- vs double-needle approach, type of block (e.g., antero- vs retrocrural), immediate vs delayed neurolysis, volume of local anesthetic employed for both diagnostic and neurolytic blocks, and use of sedation. RESULTS: Those variables correlated with a positive outcome included lower opioid dose and the absence of sedation. Strong trends for a positive association with outcome were found for the use of computed tomography (vs fluoroscopy), and using <20 mL of local anesthetic for the diagnostic block. CONCLUSIONS: Celiac plexus neurolysis may provide intermediate pain relief to a significant percentage of cancer sufferers. Both careful selection of candidates based on clinical variables, and technical factors aimed at enhancing the specificity of blocks may lead to improved outcomes.

Analysis of patient-related barriers in cancer pain management in Turkish patients.

The purpose of this study was to evaluate the validity and reliability of the Barriers Questionnaire II (BQ-II) for Turkish patients and to define the patient-related barriers to cancer pain management in Turkey. For this, 170 patients with cancer who used or were still using analgesic medication for pain related to cancer participated in the study. It was found that patients have beliefs that may be barriers to optimal pain management, mostly in relation to addiction, and to a small extent, physical side effects. It was ascertained that male, unmarried patients, patients with cancer who also have another chronic disease, patients whose "average pain" intensity is more than 5 for the past 24 hours, and patients who use an inadequate analgesic have more beliefs that may be barriers to optimal pain management. It was concluded that the BQ-II is a valid and reliable scale in Turkey for defining patient-related barriers to cancer pain management.

Clinical assessment of prognostic factors for long-term pain and handicap after whiplash injury: a 1-year prospective study.

BACKGROUND AND PURPOSE: Physical mechanisms are the possible factors involved in the development and maintenance of long-term handicaps after acute whiplash injury. This study prospectively examined the role of active neck mobility, cervical and extra-cervical pains, as well as non-painful complaints after a whiplash injury as predictors for subsequent handicap. METHODS: Consecutive acute whiplash patients (n = 688) were interviewed and examined by a study nurse after the median of 5 days after injury, and divided into a high- or a low-risk group by an algorithm based on pain intensity, number of non-painful complaints and active neck mobility [active cervical range of motion (CROM)]. All 458 high-risk patients and 230 low-risk patients received mailed questionnaires after 3, 6 and 12 months. Two examiners examined all high-risk patients (n = 458) and 41 consecutive low-risk patients at median 11, 109, 380 days after injury. The main outcome measures were: handicaps, severe headaches, neck pain and neck disability. RESULTS: The relative risk for a 1-year disability increased by 3.5 with initial intense neck pain and headaches, by 4.6 times with reduced CROM and by four times with multiple non-painful complaints. CONCLUSION: Reduced active neck mobility, immediate intense neck pain and headaches and the presence of multiple non-painful complaints are the important prognostic factors for a 1-year handicap after acute whiplash.

High-dose propofol drip for palliative sedation: a case report.

Oftentimes, patients at the end of life may present with challenging symptoms refractory to conventional therapies. Agitation and terminal restlessness, 2 common symptoms encountered in the hospice population, are frequently managed using benzodiazepines or typical antipsychotics. In clinical scenarios that either preclude their use or in which they prove ineffective, alternative pharmacotherapy must be considered. Propofol, a sedative-hypnotic unrelated to any other class of drug, may provide palliation of agitation and terminal restlessness refractory to benzodiazepines or antipsychotics. Here, the authors present a hospice patient admitted to the general medical floor of a small community hospital for pain and symptom management. A history of polysubstance abuse contributes to rapidly escalating doses of opioids and midazolam. Failure to control her symptoms resulted in the initiation and successful titration of propofol.

Assessment of palliative care team activities--survey of medications prescribed immediately before and at the beginning of opioid usage.

We established the Terminal Care Study Group, consisting of physicians, pharmacists, and nurses, in September 2001, and developed the group into the Palliative Care Team. We have surveyed the state of concomitant medications immediately before and at the beginning of opioid usage (except injections) to assess the role of the Palliative Care Team. The survey period was 3 years from October 1, 2002 to September 30, 2005. While the frequency of the prescription of non-steroidal anti-inflammatory drugs (NSAIDs), laxatives, or antiemetics before the beginning of opioid administration did not differ significantly among the 3 periods, that at the beginning of opioid administration increased significantly in 2003 compared with 2002, and increased further in 2004. Many of the drugs used were those that were recommended in our cancer pain management program. Thus, the activities of the Palliative Care Team are considered to have led to proper measures for the control of the major adverse effects of opioids such as constipation and nausea/vomiting in addition to pain control in accordance with the WHO's pain ladder, and also contributed to improvements of the patients' QOL.

Physician attitudes toward opioid prescribing for patients with persistent noncancer pain.

OBJECTIVES: Physicians frequently express dissatisfaction about caring for patients with chronic pain and frequently report that inadequate training and concern about addiction are impediments to prescribing opioids. Elderly patients with chronic pain may be at increased risk of experiencing uncontrolled pain and this patient population is increasingly being cared for by geriatricians rather than internists. We sought to determine if there is a differential impact on internists and geriatricians of the factors that adversely affect attitudes toward opioid prescribing. METHODS: Anonymous survey of geriatric and internal medicine physicians at a large urban academic medical center about their beliefs and behaviors regarding opioid prescribing. RESULTS: One hundred thirty-two of 187 physicians completed the survey for an overall response rate of 71%. Controlling for level of training, internists were more likely to be concerned about illegal diversion (adjusted odds ratio=10.0, P=0.004), were more concerned about causing addiction (38% vs. 0%, P<0.001), and were more likely to be concerned about their inability to prescribe the correct opioid dose (adjusted odds ratio=11.1, P=0.020). DISCUSSION: Factors shown to have an adverse affect on opioid prescribing disproportionately impact on the attitudes of internists compared with geriatricians. Further research is needed to determine if there is also a differential impact on how internists care for their elderly patients with chronic pain.