Adequacy of cancer-related pain management and predictors of undertreatment at referral to a pain clinic

Abstract

Background

Several guidelines have advocated the need for adequate cancer-related pain (CRP) management. The pain management index (PMI) has been proposed as an auditable measure of the appropriateness for analgesic therapy.

Objectives

To determine the adequacy of CRP management based on the PMI status and its patient-related predictors at the point of referral to a pain clinic (PC).

Methods

Consecutive patients referred to a PC had standardized initial assessments and status documentation on the Brief Pain Inventory (BPI) ratings; pain mechanism, using a neuropathic pain diagnostic questionnaire (the Douleur Neuropathique 4 tool); episodic pain; oral morphine equivalent daily dose; the Hospital Anxiety Depression Scale and the Emotion Thermometer scores; and cancer diagnosis, metastases, treatment, and pain duration. Predictors of “negative PMI status” [PMI(−)] were examined in logistic regression models. Variables with p<0.25 in an initial bivariable analysis were entered into a multivariable model.

Results

Of 371 participants, 95 (25.6%) had PMI(−), suggesting undertreatment of CRP. Both female sex and higher scores on the BPI’s “interference with general activity” more strongly predicted PMI(−). Patients who received either radiotherapy or one or more adjuvant analgesics prior to the initial consultation at the PC, those who had neuropathic pain, those who had a greater need for emotional help, and those with higher BPI’s “relief ” scores were all less likely to be PMI(−).

Conclusion

The potential burden of patient and family distress associated with suboptimal CRP management in one in four patients should generate major public health concern and prompt appropriate educational and health policy measures to address the deficit.

Keywords:

• cancer pain
• pain management
• opioid analgesics
• pain measurement

Acknowledgments

This study was funded by Grunenthal S.A. Portugal. The funders have had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.

This research has been presented in part at the 8th World Research Congress of the European Association for Palliative Care, Lleida, Spain, June 5–7, 2014.

Author contributions

PR-P conceived the study and was responsible for recruitment and data collection. PGL performed the statistical analysis. PR-P also drafted the manuscript with contributions from the other authors. All authors made substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; took part in drafting the article or revising it critically for important intellectual content; gave final approval of the version to be published; and agree to be accountable for all aspects of the work.

Disclosure

At the time the study was carried out, Dr Reis-Pina was a member of the clinical staff at the PC of the Portuguese Cancer Institute (Lisbon, Portugal). In the past 5 years, Dr Reis-Pina has received honoraria from Laboratórios Vitória, S.A. Portugal; Grünenthal, S.A. Portugal; and Angelini Farmacêutica, Lda. The other authors report no conflicts of interest in this work.