Psychosocial Barriers to Pain Management Can Be Overcome

July 1, 1995

NEW YORK--Society throws up numerous barriers to effective management of cancer pain: Physicians who don't ask questions about pain because they weren't trained to do so or don't see it as their responsibility; patients who don't mention pain because they want their doctor to focus on their cancer; a regulatory system that places legal restrictions on opioid prescribing; and a health-care system that leaves many people uninsured or underinsured.

NEW YORK--Society throws up numerous barriers to effective managementof cancer pain: Physicians who don't ask questions about painbecause they weren't trained to do so or don't see it as theirresponsibility; patients who don't mention pain because they wanttheir doctor to focus on their cancer; a regulatory system thatplaces legal restrictions on opioid prescribing; and a health-caresystem that leaves many people uninsured or underinsured.

Any of these could be the reason that the best of discharge plansoften don't work out, said Myra Glajchen, DSW, at a symposiumsponsored by Cancer Care, Inc., where she is director of research.

Physicians who do not routinely ask questions about pain are amongthe chief psychosocial obstacles to better pain management, shesaid. "A lot of patients wait to be asked about their pain.Sometimes even the family members get frustrated. After the medicalappointment they say, Well, did you tell him about the pain? Thepatient will say, No, he didn't ask about it."

Dr. Glajchen urged physicians and other health-care professionalswho treat patients with cancer pain to develop the assessmentskills to ask the right questions, and to ask them every timethey meet with the patient.

A physician who suspects that pain may be psychogenic and refersa patient for counseling or psychiatric intervention should doa thorough pain assessment as well, Dr. Glajchen advised. "Otherwise,patients may think you don't believe they're in pain and may hesitateto share their pain problems with you again," she said.

Physicians should also take into account that the pain could beunrelated to the patient's cancer and easily reversible. She suggestedasking patients with cancer about any arthritic pain or problemswith headaches. "A colleague of mine had a patient who keptcomplaining about facial pain. The patient was seen by severalpsychiatrists before the oncologist ordered an x-ray. The patienthad a full-blown sinus infection."

Patients Who Downplay Pain

Many patients may not want a doctor to focus on their pain. Theyask the doctor to concentrate on treating their disease. The dangerof that, Dr. Glajchen said, is that as the pain escalates andmore pain medication is needed, these patients may experienceunnecessary suffering and hopelessness.

Patients should never be told to save their pain medication untilthe pain gets really bad. "When that happens," she said,"patients are not going to take their medicine when theyhave pain. They are going to store it and have escalating painin the meantime."

A complex medication regimen can also undermine compliance. "Wecome up with some very complicated programs. A patient could betaking a combination of 13 pills a day. It's just too difficult.Compliance is liable to break down. I've often felt that sendinga visiting nurse into these situations could make a huge difference,"she said.

Nor is enough effort made to acquaint patients with the medicationsthey are taking, she added. A Cancer Care study found that mostpatients could not name their medications. "Not knowing themedications or their dosing guidelines may make it easier forpatients to stop taking them," she said.

Family members should also be informed about medications and painmanagement plans. "If you don't discuss this with the family,"Dr. Glajchen warned, "when the patient goes home and haspain, the caregiver may say, I know what the doctor says, butlet's hold on to the pills and see if it goes away."

Transportation and home care problems are among the real worldfactors that can undermine patient compliance. "Who is goingto go for the prescription if there are small children at home?How is the patient going to keep her appointments if she doesnot have the money for transportation, or feel well enough todrive?" she asked.

Make the Patient a Partner

Empowering patients to feel they are partners in their pain careis at the heart of pain planning, she said. "Give patientsoptions--oral medication or a patch, for example. Ask patientswhat they think is going to work best for them? Give them educationalbooklets about pain and discuss the material at their next visit."

Patients can be encouraged to maintain a pain diary, so they canaccurately tell the physician when the pain was at its worst,the effectiveness of the treatment, and how long the effect lasted.

An institutional difficulty in regard to pain control is the absenceof a place on the medical chart to write a pain assessment. "Ifit's not on the medical chart, it doesn't exist. So one of thefirst steps for people who develop a pain service is to make surethat there is some mechanism for reporting pain," Dr. Glajchensaid.

The responsibility for pain follow-up should also be clearly defined,she said. "We all have a role to play, and it's better thatwe have some overlap in these responsibilities, rather than everybodysaying, That's not my area of expertise."

Other aspects of the health-care system that may play a role inpoor pain management include over-restrictive regulations of opioids.In New York State, for example, triplicate prescriptions are requiredfor opioid medications, she said.

Patients and their families need to be asked about any problemswith paying for medications before they leave the hospital. Oneway of getting around these difficulties is to help patients fillout a prescription for the hospital pharmacy, Dr. Glajchen suggested.

She noted that insurance coverage for pain medication "isvery spotty. You may get it from some carriers and not from others."She added that Cancer Care has given an average of $41,000 eachyear to cover the cost of pain medication for cancer patientswith financial difficulties.