Challenges of treating patients with chronic pain with dysphagia (CPD): physician and patient perspectives

Abstract

Objective:

Dysphagia—difficulty eating and swallowing—can significantly impair a patient’s ability to maintain adequate nutritional and medication intake. There are a large number of patients with chronic pain, including pediatric, geriatric, and palliative care patients, who suffer from dysphagia and, therefore, have difficulty achieving optimal pain management with solid, oral formulations. The objective of this study was to survey physicians and patients in the US to understand their knowledge, attitudes, and clinical management/analgesic usage patterns in the treatment of patients with chronic pain with dysphagia (CPD).

Research design and methods:

Two separate surveys were administered to physicians and patients. The physician survey design was qualitative; physicians participated in a semi-structured phone interview. The patient survey design was quantitative; patients participated in a structured online survey. Purposive sampling was used to recruit participants into both studies. Physician participants were identified based on their specialty, prescribing practices, and geographic location. Patient participants were recruited through a consumer panel of pre-identified individuals who, for 3 months or longer, had chronic pain and were taking opioids.

Results:

Thirty-four physicians and 1021 patients were surveyed. Physicians indicated that 5–20% of their patients had difficulty swallowing. Treatment for CPD consisted of the fentanyl patch, immediate-release opioids, methadone liquid, or extended-release morphine products. Physicians were not satisfied with currently available treatment options. Twenty-nine per cent of patients surveyed had trouble swallowing or disliked swallowing pills. Eighty per cent of patients were not asked about their ability to swallow solid, oral dosage forms by their physician. To circumvent swallowing difficulties, some patients (16%) cut/crush/grind their medication to facilitate swallowing. Most of these patients (65%) did not know that altering tablets could potentially change the drug release (pharmacokinetic) characteristics of the tablet and lead to serious adverse events.

Limitations:

Qualitative survey research can be influenced by responder bias as well as selection bias. The number of survey participants for both the physician and patient surveys was small, thus responses may not reflect those in the general population.

Conclusion:

A proportion of patients with chronic pain have dysphagia and cannot swallow solid, oral dosage forms, which creates a serious treatment challenge for pain specialists and other healthcare providers. Currently available treatment options have limitations; new treatment options would be welcomed by both physicians and patients. Physician and patient education should be enhanced in order to promote awareness of the deleterious consequences associated with altering currently available analgesic formulations. Facilitating patient–physician communication on this topic may help to improve treatment outcomes.

Keywords::

• Dysphagia
• Chronic pain
• Swallowing
• Analgesia
• Patient education

Transparency

Declaration of funding

The funding for the surveys was provided by Collegium Pharmaceutical, Inc.

Declaration of financial/other relationships

Dr Pergolizzi and Dr Nalamachu are consultants for Collegium Pharmaceutical. Dr Taylor is an employee of NEMA Research. Dr Raffa is a speaker, consultant, and/or basic science investigator for several pharmaceutical companies involved in analgesics research, but receives no royalty (cash or otherwise) from the sale of any product. Douglas Carlson, Ravi Varanasi, and Dr Kopecky are employees of Collegium Pharmaceutical. Collegium Pharmaceutical, Inc. provided funding to NEMA Research Inc. for editorial support, manuscript preparation, and submission. CMRO Peer Reviewers on this manuscript have received an honorarium from CMRO for their review work, but have no other relevant financial or other relationships to disclose.

Acknowledgments

The authors thank Navigant Consulting, Inc. and MedPanel, LLC for conducting the physician and patient surveys, respectively.