Cancer Patients' Pain Untreated in Nursing Homes, Says Study in JAMA
Nursing homes are not adequately treating the pain of many of their charges who have cancer, according to a study published in the Journal of the American Medical Association (JAMA). The study said 90% of those suffering severe pain could be helped with drugs that are currently available. JAMA editors called the problem a "first-line indicator of poor quality of medical care" (Roberto Bernabei, MD, et al., "Management of Pain in Elderly Patients With Cancer," Journal of the American Medical Association, June 17, 1998, Vol. 279, No.23, pp.1877-1882; Michael Vitez, "Pain Going Untreated, Study Says," Houston Chronicle, June 17, 1998).
Between 1992 and 1995 a team of researchers from the Systematic Assessment of Geriatric Drug Use via Epidemiology (SAGE) Study Group studied the treatment of over 13,000 cancer patients at least sixty-five years old in 1,492 nursing homes. Of the 4,003 people who said they suffered pain daily, the study found that 16% received an over-the-counter painkiller, 32% were supplied with weak opioids such as codeine, and 26% received morphine. Twenty-six percent of those in pain every day were given nothing to alleviate it. Researchers defined "daily pain" as any physical pain or discomfort anywhere in the body that occurred every day.
The study found that nursing home patients who were members of minority groups were significantly less likely to be given pain relievers than whites. African Americans were 63% more likely to have their pain go untreated.
Laura Fenwick, the associate director of community relations at the American Health Care Association (AHCA), which represents over 11,000 nursing homes, told NewsBriefs that it was unfair for nursing homes to be singled out for improper pain management. She pointed out that the first page of the JAMA article contained a list of settings, including emergency departments and oncology wards, where it has been found that cancer-related pain often goes untreated. Fenwick said AHCA had already recommended that their members use federal standards for health care and that their pursuit of better pain management is "ongoing."
A recent issue of Provider, a publication of the AHCA, featured an article detailing doctors' fears of prescribing narcotics to treat pain. According to the article, one of the reasons doctors avoid narcotics is that they believe their patients will become addicted, despite studies that contradict this concern. The article pointed to several health professionals who concluded that people who use narcotics for pain are much less likely to become addicted to the drug than those who use it for recreation. The article added, "Physicians and consultant pharmacists are concerned about possible sanctions for prescribing large amounts of Schedule II drugs (narcotics) to nursing facility residents" (Marla Fern Gold, "Pain Management: The Ethical Dilemma," Provider, May 1998, p. 44-50). [also see: Jacob Sullum, "No Relief in Sight," Reason, January 1997, Vol. 28, No. 8. pp. 22-28]
In an editorial, the Wall Street Journal (WSJ) said, "Many states impose restrictions on the amount of painkillers a doctor can prescribe ... and others require physicians to file elaborate forms with state agencies, making it time-consuming and professionally risky to prescribe large quantities of certain drugs. The motive, of course, is to prevent doctors' offices from becoming a channel for the illegal marketing of drugs." Noting the history of such government control of pain management, the WSJ noted, "The Supreme Court, in 1919, essentially criminalized doctors who prescribe opiates to addicts, and ever since the professional ethos has been to bend over backward not to look like pushers. ..."(Editorial, "Treat the Pain," Wall Street Journal, July 27, 1998, p. A14).
Contact for the SAGE Study Group - Giovanni Gambassi, MD, Center for Gerontology and Health Care Research, Brown University, Box G-B213, Providence, RI 02912, E-mail: <Giovanni_Gambassi@brown.edu>.
Laura Fenwick, American Health Care Association, 1201 L Street NW, Washington DC, 20005, Tel: (202) 842-4444, Fax: (202) 842-3860
For a copy of the study, contact the American Medical Association's James S. Todd Memorial Library at (312) 464-4855 or fax them at (312) 464-5226.