Why Are We Still Talking about Opiophobia?
A review article published recently by Alaa Bashayreh, RN, MSN, in the Journal of Pediatric Hematology/Oncology titled “Opioidphobia and Cancer Pain Management” (http://HCP.LV/ jGwnJC) stated that “opioidphobia is one of the major issues in cancer pain management,” a phenomenon that, left unaddressed, “could limit the efficacy of the treatment process.” Bashayreh noted that inadequate/ineffective cancer pain management can result from health care provider, patient/family, and health system-related barriers, and identified poor provider knowledge of opioids and fear of opioid overuse as among the key providerrelated barriers to care. A fear of opioid addiction and dependence among patients and family members is also a barrier.
Ineffective pain management in patients with cancer resulting from “opioidphobia” (which for the purposes of this article we’ll refer to as “opiophobia”) and other barriers “could lead to unnecessary suffering, decreased ability to cope with the disease, interference with activities of daily living, and extended or repeat hospital admissions. Uncontrolled pain may also delay or disrupt anticancer treatment, compromising its effectiveness.”
The author identified opiophobia as a fear shared by “regulatory agencies, healthcare professionals, clients experiencing acute and chronic pain, and their families,” despite the fact that “studies confirm that [opioid] abuse and addiction are rare among chronic pain clients including cancer patients.”
To further address the issue of opiophobia and its impact on the effectiveness and quality of cancer care, Bashayreh conducted a brief literature review and interviewed members of the oncology care team at a universityaffiliated hospital about their perceptions of opiophobia and its effects on quality of care.
Based on the results of the literature review and interviews, the author identified several themes common to providers regarding the use of opioids during cancer treatment. Fear of addiction and fear of opioid-induced side effects were the two main concerns among providers. Bashayreh reported that providers’ opiophobia stemmed from several common factors: inadequate training and knowledge about cancer pain management, lack of knowledge of and/or failure to follow treatment guidelines, greater focus on cancer treatment rather than pain management, and being swayed by the fears and concerns of patients and their families. The main sources of patients’ opiophobia were lack of education about the myths and facts of cancer pain management and management of the associated symptoms, and lack of knowledge about opioid medications and their side effects.
The author recommended the development of standardized protocols and tools for cancer pain management, and that greater emphasis should be placed on educating providers, patients, and families and assessing these groups for opiophobia. She also recommended the development of “continuous quality improvement programs for applying and monitoring of cancer pain management protocols and tools.”
If everyone agrees it’s a problem, then what’s the solution?
An editorial, titled “Opioids, Pain, and Fear,” published by Marco Maltoni in the January 2008 issue of Annals of Oncology (http://HCP. LV/iUIB35) also acknowledged several “system barriers” to effective opioid analgesia for cancer pain. The author noted that “various legal and regulatory obstacles to the use of opioids for cancer pain” risk turning the cancer patient into “an innocent victim of a war waged against opioid abuse and addiction if the norms regarding the two kinds of use (therapeutic or nontherapeutic) are not clearly distinct.” Additional physician-based barriers include lack of physician education and failure to follow existing guidelines, fear of patient addiction and analgesic tolerance, and “insufficient experience of pain management (poor knowledge of opioid pharmacology, conversion, equianalgesia, rotation, doses, and ratio for breakthrough pain drugs).” Physicians’ “concern about and failure to treat opioid sideeffects” is also an important barrier to care.
Maltoni identifies several patient-centered barriers to effective treatment with opioids as well, including “reluctance in taking pain medications due to the well-known ‘myths about opioids’, represented by fear of addiction and/or of being thought of as an addict, fear of analgesic tolerance, and fear of side-effects.”
He cited the study “Opioid Analgesics for Cancer Pain: Symptom Control for the Living or Comfort for the Dying? A Qualitative Study to Investigate the Factors Influencing the Decision to Accept Morphine for Pain Caused by Cancer,” also published in the January 2008 issue of Annals of Oncology (http://hcp.lv/lztj4W), which looked at “the factors that influence a patient’s decision to accept or refuse a strong opioid to treat cancer pain.” According to Maltoni, this study provides several interesting insights into physician barriers to opioid treatment in the cancer setting, chief of which is that “the way in which physicians broach the issue of starting opioid therapy… strongly influences the patient’s decision, as does the existing relationship between physician and patient.”
However, this communication with patients regarding the safety and efficacy of opioid therapy can be distorted or colored by the fact that “even professional figures fall victim to ‘the myths about morphine’ despite overwhelming evidence of the safety of opioids.” Indeed, in order to competently provide patients with accurate information about the benefits and risks of opioid treatment for their cancer pain, physicians must “be confident that treatment with opioids does not have a negative impact on survival, that the principle of double effect is not needed to justify this therapy from an ethical point of view, and that pain has an important antagonist effect on the modest respiratory depression of the drug.”
That is to say that misinformed or inadequately trained physicians only reinforce their patients’ misconceptions about the true risks and benefits of opioids; groundless fear leads to more fear, especially if patients falsely conceive of treatment with opioids as a “last ditch” effort at palliation. As Maltoni put it, “if patients receive unspoken confirmation from physicians of their idea of opioids as ‘a last resort’ and of the fact that treatment is linked to prognosis rather than to severity of pain, their determination to refuse treatment will be reinforced from a theoretical point of view.” Meanwhile, patients’ fears about the side effects of opioid treatment will blossom into justified (in the patients’ mind) refusal of treatment if “limited confidence and skills are shown by doctors in managing opioid side-effects.” Maltoni wrote that patients’ refusal “will take on empirical characteristics because of the ensuing damage they fear the drugs will cause.”
The only thing we have to fear…
In “Overcoming Opiophobia and Doing Opioids Right,” (http://HCP.LV/mT2e1P) Forest Tenant, MD, described the prevailing fears about opioids as irrational, with the resulting reluctance to use them often leading to major complications in patients with untreated chronic pain. In addition to producing “profound” benefits (including normalized blood pressure, pulse rate, and pituitaryadrenal secretions, along with other biologic and physical enhancements that improve quality of life), opioids are “the only treatment that can consistently and predictably control pain.” Tenant stressed the importance of initiating opioid therapy at low doses and titrating “until a dose is reached that reduces pain 70% to 90%, but does not impair or sedate the patient.” Ascribing the majority of overdoses and deaths to patients who fail to take their medications properly and/or who use other drugs or substances that cause an adverse interaction, he concluded that “opioids as formulated, marketed, and properly prescribed… are quite safe and have minimal clinical riskwhen they are taken as prescribed.”
If that is the case, then what is the cause of the irrational fear of opioids? Tenant blamed the constant barrage of negative and misleading information about opioids in the media, along with the pervasive belief among the public and many in the medical community that pain is a natural part of disease and illness, that patients in pain should just “deal with it” (when they’re not being accused of exaggerating their pain), and that patients who need pain medications are “weak-willed.”
However, these claims, beliefs, and stances have been identified and largely debunked. A quick search online can easily retrieve many links to articles and commentary decrying the fact that physicians and patients are undereducated regarding the true benefits and risks of opioid medications, identifying patients’ and providers’ belief in the myths about opioid side effects (especially regarding addiction and dependence) as key contributors to the chronic undertreatment of pain, and pointing to clinical studies demonstrating that these fears are overblown while calling for more robust education of physicians and patients about these medications.
This knowledge gap has been the impetus behind the creation of an assortment of CME programs that outline the steps clinicians can take to identify the right candidates for opioid therapy and devise an effective treatment plan that maximizes palliative effect and minimizes risk of addiction and other side effects (see left). There are even CME programs specifically designed to counter the prevailing myths and misconceptions regarding opioid therapy.
And yet, even with all the attention devoted to this topic, one can also find article after article lamenting the fact that patients and physicians still harbor (unwarranted) fears regarding these medications, discussing why cancer and non-cancer chronic pain is still criminally undertreated, and calling for increased educational efforts to inform patients and physicians of the pros and cons of opioid medications for pain management. And round and round it goes…
So, we put it to our readers: what is the source of this disconnect between a near universally identified problem and the oftexpressed solution to that problem? Why, with so much having been written about the problem, the nature of the misconceptions, and the probable solution, are we still talking about “opiophobia?”