Elderly and minority patients at risk for mismanaged cancer-related pain

Patient-controlled analgesia and simplified dosing regimens with long-acting medications could minimize problems.

Issue: June 1, 2006

BOSTON — Elderly and minority patients with cancer are likely to receive inadequate treatment and management for their cancer-related pain, according to research presented here at the Oncology Nursing Society 31st Annual Congress.

Disparities in the management of pain represent weakness in the quality of care for all patients, said Jeanette McNeill, RN, PhD, AOCN, professor of nursing at the University of Texas in Houston. Health care providers need to develop protocols that make pain assessment and reassessment routine. They need to pay particular attention to patients with severe pain ratings and ensure appropriate assessment methods that account for cultural, developmental or language-based factors. Ethnic minority and older patients are at the highest risk for undertreatment.

Previous research has found that more than 40% of patients with cancer do not get adequate pain relief in spite of the fact that there a number of medications and therapies to relieve most cancer-related pain.

Understanding pain

There are various barriers to the management of cancer-related pain, noted Janice Reynolds, RN, BSN, OCN, a staff nurse at the Mid Coast Hospital in Brunswick, Maine.

Patients and their families might believe myths regarding cancer pain. Some patients are afraid to admit that they are in pain. Health care providers must be careful to identify and correct these myths, Reynolds said.

Pain is common with cancer. About 30% of patients report pain at diagnosis. Among patients with advanced disease, between 70% and 90% report pain. Cancer treatment, comorbidities and the cancer itself can lead to debilitating pain.

“Almost all cancer pain can be relieved or lessened with current pharmacological and non-pharmacological therapies,” Reynolds said.

If pain is not relieved, it can adversely affect patients’ physical functioning, psychological well-being, social behaviors, the health care system and society, she continued.

Socioeconomic status can affect how patients manage the pain they suffer from cancer, Reynolds said. Poverty is associated with a lack of resources, information and knowledge. As a result, patients with a low socioeconomic status tend to experience greater pain and suffering from cancer than other patients.

Pharmacies also factor into patient pain management, according to Reynolds. However, pharmacies in inner cities and rural communities may carry insufficient or nonexistent supplies of analgesics, particularly opioids.

Similarly, Medicare, third-party insurers and hospitals also affect access to pain medications. Preferred drug lists and pre-approval can create barriers to receiving pain medication.

Covering pain relief

Nearly 48 million Americans are uninsured, Reynolds said. The highest underserved populations are minorities and children. Even more problematic, many patients with cancer are unable to receive their prescribed medication. Patients who are uninsured have to pay for medications themselves, according to Reynolds.

In many cases, only a portion of a scheduled drug is available. The remainder might only be dispensed within 72 hours. If the remainder of the dose is not available, the patient misses out on that portion of the treatment, Reynolds said. Many times insurance companies will treat the remainder as a second prescription and refuse to pay. Medicare also limits physician payment for pain management.

There is inconsistent coverage of nonpharmaceutical pain management. Although some plans offer physical therapy, acupuncture and/or massage, other plans cover none of these alternative therapies. Many insurance plans combine reimbursement for pain management with other therapies, which limits the billing of certain services.

When patients and their families are making end-of-life decisions, many are simultaneously dealing with inadequate insurance coverage, Reynolds said. According to a report from the University of Michigan in Ann Arbor, men and women aged 70 and older whose net worth was at least $70,000 were 30% less likely than poorer individuals to have experienced frequent pain during the year before they died. This difference existed after the researchers controlled for age, gender, ethnicity, education and diagnosis.

High-risk patients

McNeill discussed the difficulties minority patients have in obtaining quality treatment and management for cancer-related pain.

The Institute of Medicine (IOM) reported on unequal treatment in 2002 and found consistent disparities across disease areas, clinical services and clinical settings, she said.

Echoing this finding, the American Pain Society released their report, Position on Racial and Ethnic Identifiers in Pain Management in 2004. The American Pain Society acknowledged these differences and urged action from clinicians and researchers to examine the discrepancies in the context of cancer-related pain.

According to the National Medical Association, there are disparities in pain management by race. Racial profiling has been observed in pharmacies where many providers are reluctant to dispense opioids to minorities.

Cultural disparities

Evidence on disparities varies according to provider, clinical setting and patient group. Cultural disparities have been reported in emergency rooms, nursing homes and cancer centers. For instance, black and Hispanic patients were less likely to have pain documented in nursing homes, according to a previous trial.

Researchers have found that pain is underestimated in minorities, as well, and language barriers only magnify the problem, she added. Some studies have suggested that patient expectations differ according to race. Other factors relating to disparities in treatment are errors in analgesic choice and discrepancies in access and availability.

Patient and family issues might play a role in these disparities as well, McNeill said. Some minorities have fewer resources to pay for analgesics. Some patients might be cautious of aggressive treatment or might not be assertive in seeking their own care.

Some studies have reported disparities that occur in emergency room settings. For example, Hispanics are less likely than white non-Hispanics to receive analgesics for fractures. Hispanics received two-thirds the dose of morphine for fractures as whites. Overall, black patients received less analgesia and sedation. In post-operative, acute pain settings, whites received the largest doses of opioids, McNeill said.

There have been no racial/ethnic differences in the amount of self-administered opioids according to previous trials, though there are significant racial/ethnic differences in the amount of prescribed opioids (P<.01), McNeill said.

Patient education

There is a high potential for disparity in patient pain education, McNeill said. Some health care providers fail to educate patients about available pain management approaches. Health care providers must correct the myths and misinformation regarding pain and pain management. Many clinicians fail to provide culturally or language-appropriate instructions to patients regarding pain management.

Patient attitudes, beliefs about pain, treatment and provider relationship influence pain medication use, McNeill said. Previous research has found that pain intensity is inversely correlated with knowledge. There are also age-related differences in knowledge and the adequacy of pain management.

Minority elders are at the greatest risk for mismanaged pain, she said. Many of these patients are not alert and/or are cognitively impaired. Nursing-home settings might contribute to the problem, as well. Some patients in nursing homes do not receive any analgesia. Black and Hispanic nursing home residents were less likely to have pain documented than whites and were more likely to have received no analgesic in the nursing home setting, according to a trial.

In nursing home residents with cancer, 38% reported daily pain, 26% received no analgesic and 50% received non-opioids or weak opioids.

McNeill suggested that patient-controlled analgesia and simplified dosing regimens with long-acting medications could minimize problems. Furthermore, clinicians must identify and correct myths and misinformation regarding pain. Each treatment setting needs resources for patient and staff education, she said. – by Rebekah Cintolo

For more information:

Reynolds J, McNeill J. Cancer shouldn’t have to hurt: disparities in cancer pain management. Presented at: Oncology Nursing Society 31st Annual Congress; May 4-7, 2006; Boston.