VoL 5No. 1 Fdk~sm~ 1990
Joumal~[Pwmand S ~ o m ~
27
Original Article
Cancer Pain Management According to WHO AnalgesicGuidelines Stephan A. Schug, MD, Dedev Zech, MD, and Ulrike D6rr
D,~oan'ment ~ a n c s ~ ,
University of Cologne, Cologuc, FRG
Abstract On admi.tdon to a pain management unit, 92.5% of 174 cancer pain patients suffered from more amn modmae pain despiU prior treatmoU. T ~ bu~cncy was mainly due to umderdomge of drugs, inadequatm intake schedule, a~d hesitation to use strong opioids. Following introduction of an oral drug therapy ~ued on World Health Orgnnimtion (WHO) guiddincs, more than 80% of all patients described their pain as ranging between q,mne" and "moderate" on a six-step uerbal rating scale at all times. To obtain these results, it was necessary to adapt the therapy to inereadag pain in t ~ course terminal disease. Step I!1 (strong opiok~s) gained more and more imF:rtouce with time, amd step l (nonoploids) wo.sflnally useful on~ in a minoriey of pationts. Side,cots p/ayd a m/nor role as a reason to change therapy. Oral drug therapy following these guiddincs led to ~ pain control in most patients over the whole study period (7,400 days); only ! 1% of the patients required other methods o] pain managemem. J Pain Symptom Manage 1990;5:27-J2, g ~ Wor~
Cancer pain, WHO guidelines, strong opioids, side e~'ects
Introdua~on Since 1983, cancer pain patients have been treated by the Department of Anesthesiology at the University of Cologne. This is d~ne in connection with a research program of the Germart Cancer Foundation and with the cooperation of the Department of Surgery. Available treatments include a palliative care unit, a home care service, an education center, and a pain management unit. The whole project is a trial model and, at the mon~ent, unique in the Federal Republic of Germany. Patients are referred to this unit by colleagues aqlddms~ rt'~m~ to: Stephan A. Schug, MD, Pain Clinic. Auckland Hospital. Park Road. Auckland. New Zealand. Accet~dforpu~r.a~on: January 27. 1989. 0 U.S. Cancer ~ Rdief CommiRee, 1990 pablld~.d by Elwvler.NewYork,NewYork
within the University Hospital and other hospitals of the Cologne area, and by physicians in private practice. They are treated as inpatients at the palliative care unit and other hospitals, as well as on an outpatient basis whenever possible. Beside drug therapy, a wide spectrum of specialized techniques m'c applied for pain control. This retrospective study was performed to evaluate the efficacy, side effects, and importance of the different steps of oral therapy following the introduction of the WHO guidelines for the management of cancer pain?
Patients and Methods Patients with advanced cancer who were referred to the pain managcmont unit in 1986 088B-S924~g.~.50
were entered in this study only if oral analgesic therapy for pain control was indicated. They were i .led up as long as they were treated by oral drug therapy. The follow.up was fermiunfed ~ith the death of the patient, change of therapy to other methods (eg, neurulysic blocks, epidurr,,~ or parenteral opioids, etc.) or loss of contact (e8, transfer to other hospital). Ont' analgesics wets administered by experienced .,nesthesiolosists according to the WHO guidelines. Adjuvant drugs could be added at any time necessary. The treating physicians were free to cheese other methods of pain control if mei,d and necessary. Pain scores before and during therapy were m o n i t o r ; '3)' self-assessment by the patient. For this purpme, a sin-point verhai rating (VgS) was used. T I ~ scale offered the German words for "no," "mild ? "moderate," "severe," "very severe." am'] "pain as bad as could be inmgined." Detaiiz of the patient's condition, as wall as their drugs, side ~ and mamnc for change of therapy, were recorded by the treat. ing physician usin8 a standardized question. uaire. Assessments were performed at time intervals that were variable and dependent on the situation of the patient. The data were stored and processed by a computerized data base systenL
In 1986, 174 cancer w i n patients (97 male and 77 female; mean age 58 yr, range 15 to 88 yr) entered this study. The locations of cancer were as listed in Table I, In 87.4% of cases, the pain was caused by cancer, a . d in 6,0% it was associated with cancer therapy. The distribution of site of care was as follows: home, 5,165 days; palliative care unit, 583 days: and other haspinds. 1,6S2 days. The cumulative time of oral zreatment was 7,400 days. The mean time per patient was 43 days (range ! to 288). Reasons to terminate oral therapy were: use of other analgesic methods, 10.9%; death, $7.4%: and Ima of contact, 51,7%.
PnOveam~ Piss# On ndmlmion to the prolp~m, all padent, were under analgesic treatment by general practitioners and other physicians not spacifi.
ca6y trained in pain management. At this time. 92.5% of the patients described their pain as
greater than moderate on the VRS; the distribution of pain scores is presented in Figure 1. Prior ~ admission, 21.9% of the patients were treated with nonopiolds, 58.6% with weak opioids, and 10.5% with stro,g optut(is. ~ , t phine was used in 3.4% as morphine solution and in 5.2% as morphine sulfate sustained-release tablets. In 67.1% of the patients receiving an opioid, this drug was combined with a nonopiold. The distribution of t/Des of intake schedule is shown in Figure 2; 27.1% were taking their drugs regularly at adequate time intervals. One of the usual nonopioids in the Federal Republic of Germany is dipyrune (metamiml), which is highly effective in dnuges of $ to 0 g par day? This drug was used in ~5 of the patients, of which $1.4% received 0.5 to 2 g par day. $7.2% received 2.25 to 4 g, and $1.4% received more than 4.5 g. Similar distribution of dosages could be shown for tran~dol, a weak opioid used as a substitute for codeine in recommended dmages of 400 to 600 mg per day.' In the preatment phase, 72% of the 25 patients receiving tcamadol were taking 20(1 mg or less as a dally drae, 16% received 250 to SO() rag, and 12~ took 400 rag.
On admission, patients were administered an oral drug regimen by the treating physician, guided by pain intentit,r and both type and efli-
Table l Distritmtkm o[ Frlnmry Tumor Sites in 174 Cancer Pain Padents S~te
Number
Percent
C.,amrointesdusl system Head and neck Respimtory system Ge,il~uHnsry tract B~,mt Bone, skin, mft tissue Lymphatic system Brain and nerve system Unknown
48 87 26 22 17
27.6 21.4 14.9 12.6 9.8
I0 I0
58 5.8
3 1
1.7 0.6
Vol. 5 No. 1 Februar~1990
Cancer Pain ManagementAccording to WHO
none
mild
moderate
29
0.6~
~
r
1.1~k
5.8 ~&
severe
2a.6~
very lesenl
Fig. I. Effect of analgesic pretreatment: self-assessmentof pain on a VRShefor~ad- am bad au missionto the pain managementunit.
41.9"/*
could b e
cacy of the previous therapy. This first assessment led to the use of nonopioids (WHO step I) in 18.4% of cases, in combination with weak opioids (WHO step II) in 41.7%, and with strong opioids (WHO step llI) in 39.9%. Twenty-eight percent of the patients were given morphine solution, and 5.4% received morphine sulfate sustained-release tablets. At the first foliow-up examination (1 day to I wk after start of this initial therapy depending on clinical situation) patlenb were asked to recall their pain during the first days of therapy. l"wo-thirds described no pain or only mild pain for this period (Figure 3).
r
i
,
i
i
the step of therapy (Figure 6). Most changes were due to increased pain, new pain sites, inadequate pain relief, and lack of compliance. O f the entire 7,400 days of oral therapy, 13.6% involved treatment with step I analgesics, 31.7% with step 11 analgesics, and 54.7% with step 111 analgesics. Morphine was used as morphine solution in 38.4% of days and as morphine sulfate sustained-release tablets in 14.2%. Adjuvant drugs were u*~d in 94.5% of all days of therapy, in accordance with WHO guidelines. These drugs included corticosteroids, psychotropics, and anticonvulsants, as well as laxatives and antiemetics.
Addi6omd Treatment Further therapy was adjusted to the course of the disease. Changes in the analgesic ladder were performed according to efficacy of treatment and side effects. To cope with the individual situation of the patient, points of assessment were not preset at constant intervals but were defined by necessary changes of ~*.eps,drugs or dosages. The change of steps in the course of oral drug therapy is illustrated by Figure 4. At the end of the study, therapy was with step i in 6% of patlents, step 11 in 20%, and step I11 in 74%. At all tiraes, more than 80% of all patients in the study described their pain as "none," "mild," or "mode~te" on the six-step VRS (Figure 5). Side effects led to a change of step, drug, or dosage in about 5% of the cases, independent of
The efficacy of treatment by general practitioners and other physicians not trained in pain management prior to the study period was appallingly low. It could he shown that this ineffi-
tOO long intervals / " / ~ i k r ° ~ a L r r ° ~ s "
" lY
$6'/,
not eegalarly 8%
,
as required (p.r~.) 29'/.
Fig. ~ Distribution of type of in~Ju~ schedule in p~l~'atment ph;u~.
none
-
- J
....................
mllcl ~
44,|'
Zl.gq~
moderate
~ very x w r e ~ bad ue ~ u l d be
I ~
eA~ 4.115 6,111, I
I
I
I
cacy was due to a few, but relevant, faults that could be simply prevented by following the establisbed guidelines of cancer pain management: Although it is widely accepted that the treatment of chronic pain has to follow a regelar intake schedule with adequate dine intervals, most of the patients were prescribed their drugs on an as-needed basis, in mo-inng interor not regularly. The inadequate intake schedules resulted in umtable pain relief with unacceptable pain scores. The n.'zderdmage of drugs, as shown by the two examples dipyrone and tcamadol, was another important cause, as was the lack of knowledge of the potential enhancement of efftcacy of opioids by combination with nonopioids. Nearly one-third of the patients on opinids were not treated concurrently with a nonopinid.
lllml
Fig. $. Effectof fu'sttherapeutic approach: +elf-assessmentof pain on a VRSat firstfollow-up examinationafter induction of oral therapy.
Finally, there was hesitation to use strong opioids, especi~ll 7 morphine. This is shown by the fact that the number of patients with step I11 of therapy d~tlhled at the m,)me.t of admission. This hesitation is often caused by fear of addiction and tachyphylaxis, as well as by the lack of knowledge about the use of morphine within the medical community. The administrative difftculties in prescribing these drugs under the German Drug Control Act added a further obstacle (eg, special preacription forms to be ordered from federal authorities, difilcuh rules for filling in these forms, ~mplicated dose and time limits). The change of these laws in the last years to more usable ones for cancer pain control seemed to be unnoticed by most physicians (eg, relevant increase of dose and time limits).
O| PeI~MO UnOr tmetment
I041
40'11
II0'I~ i ~lnto
i
of Thin
- - WIIO111111 '*+'" WHO a l l p U
" ~ " WHO atsp III
Fig. 4. Changesof ~tep6~ftherapy i ,
the cour.eof tlme,
VoL S No. l Februa~1990
Can~r Pain Management Atcording to WHO
31
'& of Patients with No to Moderate Pale
69,8%
Fig.5. Efllcacyof therapyin the courseof time,
91.1flk
oJli/
Pretreatment Admission
let Change 2he GItanOe Laat Therapy
Points of Time
The introduction of an oral drug regimen following the WHO guidelines resulted in a rapid onset of pain relief within the first days of therapy. This acceptable level of pain relief could then be maintained for the du~tion of therapy in about 90% of the patients, whereas 11% had to be treated by other methods, such as neur~ !Ttic blocks, epidurai ~.d parenteral opinids, etc. These resldts are comparable to another field testing of WHO guidelines, where 87% of patients became peinfree by these methods, s It is quite obvious that the elficacy of this kind of thetdpy results from changing the steps at the right times. In the course of therapy, the strong opioids gained more and more importance, while the use of ,36rlopinidsalone proved
WHO
to be less effective. The final distribution of steps of therapy is siJnilar to the one described in another study with less patients,e The low percentage of patients who can finally be kept with step I is in ~:cordance with the fiteratore.r, s In most cases, the change of therapy was not due to side effec*,~. Compared to other studies,s the percentage of side effects leading to such a change of therapy at step I1 in this study is comparable, while the percentage of side effects leading to a change of therapy in step I is tenfold lower. As the study by Ventafi;dda and coneagues s describes mainly gastric side effects after using aspirin, this discrepancy may be caused by the low rate of this type of side effect
Step
atepl
fi~. 6. Chantiesof therapy"~amed sldceffects.
"8.ll~
[---
h
i
L
i
t
i ?*t
~ ~ n p s ~ s
~
8Mo E f ~
32
Sdmg et oA.
after dipyrone, which was preferred in the present study. Thus, the change of steps over time in this and other studiess-s must be seen mainly as an adaptive process to the increase of pain in the course o f terminal disease. The fact that more than 50% of the overall treatment time is spent at step I11 illustrates the importance o f strong opioids, and especially morphine, in the treatment o f cancer pain. The high efficacy and few side effects of the oral drug therapy enabled the patients to spend most of this treatment time at home. The findings of this study support the use of the W H O ~n~i,Jehnes m control cancer pain. The lack of knowledge o f these guidelines in the West C;~~nmn medical community results in intolerable suffering of terminal c a n e r patieats. The distribution o f information on the princlplos of oral drug therapy, eg, by manuals,e would enable general practitioners and other physicians to treat appro~mately 90% of cancer pain patients sulticiently. Without the m e of invasive methods, this high percentage o f patients would undergo an improvement o f quality o f life, spending most of their time at home.
Jourusl of Po~ ow,t ~,aptom M
~
1. World Health Organization. Cancer pain relief. Geneva: World Health Organization, 1986. 2. Merskey H, ed. Claudficafion ot chronic pain. Pain 1986;9($uppl):S1-226, 3. Rohdewald P, Nedderma:m E. Dosisabhaenglgkeit der analgeti~fien Wirkang von Metamizul. Auses. theMst 1988;$7:SI50-155. 4. Fridetichs E, Felgenfieuer F, Jongschaap P. Phar* makologische Untersuchungen zur Analgesic, Abhaengigkeits-und Tuleranzentwickinng yon Trama. dol, einem stark wirke.-.den Analgetikum. Arzneim Forsch 1978;28:SI22-134. 5. Takeda F. Results of field-testing in Japan of the WHO Draft Interim Guideline on Relief of Cancer Pain. Pain ~ 1986;!:83-89. ~ 6. Walker VA, Hoskin pJ, Hanks GW, et al. Evaluation of WHO analgesic guldefines for cancer pain in a hospital-besed palliative care unit. J Pain Symptom Manage 1988;3:145-149. 7. Ventafridda V, Salta L, Ripamouti C, et al. WHO Guidelines for the use of analgesics in cancer pain. lntJ TiN React 1985;7:95-96, & VentafrZdda V, Tamburini M, Caraceni A, et al. A Validation Study of the WHO Method for Cancer Pain Relief. Cancer 1987;59:850-856. 9. Zech D, &chug S, Horsch M. Therapiekompen. dinm Tumorschmerz. Erlangen: Perlmed-Verlag, 1988.
Joumal~[Pwmand S ~ o m ~
27
Original Article
Cancer Pain Management According to WHO AnalgesicGuidelines Stephan A. Schug, MD, Dedev Zech, MD, and Ulrike D6rr
D,~oan'ment ~ a n c s ~ ,
University of Cologne, Cologuc, FRG
Abstract On admi.tdon to a pain management unit, 92.5% of 174 cancer pain patients suffered from more amn modmae pain despiU prior treatmoU. T ~ bu~cncy was mainly due to umderdomge of drugs, inadequatm intake schedule, a~d hesitation to use strong opioids. Following introduction of an oral drug therapy ~ued on World Health Orgnnimtion (WHO) guiddincs, more than 80% of all patients described their pain as ranging between q,mne" and "moderate" on a six-step uerbal rating scale at all times. To obtain these results, it was necessary to adapt the therapy to inereadag pain in t ~ course terminal disease. Step I!1 (strong opiok~s) gained more and more imF:rtouce with time, amd step l (nonoploids) wo.sflnally useful on~ in a minoriey of pationts. Side,cots p/ayd a m/nor role as a reason to change therapy. Oral drug therapy following these guiddincs led to ~ pain control in most patients over the whole study period (7,400 days); only ! 1% of the patients required other methods o] pain managemem. J Pain Symptom Manage 1990;5:27-J2, g ~ Wor~
Cancer pain, WHO guidelines, strong opioids, side e~'ects
Introdua~on Since 1983, cancer pain patients have been treated by the Department of Anesthesiology at the University of Cologne. This is d~ne in connection with a research program of the Germart Cancer Foundation and with the cooperation of the Department of Surgery. Available treatments include a palliative care unit, a home care service, an education center, and a pain management unit. The whole project is a trial model and, at the mon~ent, unique in the Federal Republic of Germany. Patients are referred to this unit by colleagues aqlddms~ rt'~m~ to: Stephan A. Schug, MD, Pain Clinic. Auckland Hospital. Park Road. Auckland. New Zealand. Accet~dforpu~r.a~on: January 27. 1989. 0 U.S. Cancer ~ Rdief CommiRee, 1990 pablld~.d by Elwvler.NewYork,NewYork
within the University Hospital and other hospitals of the Cologne area, and by physicians in private practice. They are treated as inpatients at the palliative care unit and other hospitals, as well as on an outpatient basis whenever possible. Beside drug therapy, a wide spectrum of specialized techniques m'c applied for pain control. This retrospective study was performed to evaluate the efficacy, side effects, and importance of the different steps of oral therapy following the introduction of the WHO guidelines for the management of cancer pain?
Patients and Methods Patients with advanced cancer who were referred to the pain managcmont unit in 1986 088B-S924~g.~.50
were entered in this study only if oral analgesic therapy for pain control was indicated. They were i .led up as long as they were treated by oral drug therapy. The follow.up was fermiunfed ~ith the death of the patient, change of therapy to other methods (eg, neurulysic blocks, epidurr,,~ or parenteral opioids, etc.) or loss of contact (e8, transfer to other hospital). Ont' analgesics wets administered by experienced .,nesthesiolosists according to the WHO guidelines. Adjuvant drugs could be added at any time necessary. The treating physicians were free to cheese other methods of pain control if mei,d and necessary. Pain scores before and during therapy were m o n i t o r ; '3)' self-assessment by the patient. For this purpme, a sin-point verhai rating (VgS) was used. T I ~ scale offered the German words for "no," "mild ? "moderate," "severe," "very severe." am'] "pain as bad as could be inmgined." Detaiiz of the patient's condition, as wall as their drugs, side ~ and mamnc for change of therapy, were recorded by the treat. ing physician usin8 a standardized question. uaire. Assessments were performed at time intervals that were variable and dependent on the situation of the patient. The data were stored and processed by a computerized data base systenL
In 1986, 174 cancer w i n patients (97 male and 77 female; mean age 58 yr, range 15 to 88 yr) entered this study. The locations of cancer were as listed in Table I, In 87.4% of cases, the pain was caused by cancer, a . d in 6,0% it was associated with cancer therapy. The distribution of site of care was as follows: home, 5,165 days; palliative care unit, 583 days: and other haspinds. 1,6S2 days. The cumulative time of oral zreatment was 7,400 days. The mean time per patient was 43 days (range ! to 288). Reasons to terminate oral therapy were: use of other analgesic methods, 10.9%; death, $7.4%: and Ima of contact, 51,7%.
PnOveam~ Piss# On ndmlmion to the prolp~m, all padent, were under analgesic treatment by general practitioners and other physicians not spacifi.
ca6y trained in pain management. At this time. 92.5% of the patients described their pain as
greater than moderate on the VRS; the distribution of pain scores is presented in Figure 1. Prior ~ admission, 21.9% of the patients were treated with nonopiolds, 58.6% with weak opioids, and 10.5% with stro,g optut(is. ~ , t phine was used in 3.4% as morphine solution and in 5.2% as morphine sulfate sustained-release tablets. In 67.1% of the patients receiving an opioid, this drug was combined with a nonopiold. The distribution of t/Des of intake schedule is shown in Figure 2; 27.1% were taking their drugs regularly at adequate time intervals. One of the usual nonopioids in the Federal Republic of Germany is dipyrune (metamiml), which is highly effective in dnuges of $ to 0 g par day? This drug was used in ~5 of the patients, of which $1.4% received 0.5 to 2 g par day. $7.2% received 2.25 to 4 g, and $1.4% received more than 4.5 g. Similar distribution of dosages could be shown for tran~dol, a weak opioid used as a substitute for codeine in recommended dmages of 400 to 600 mg per day.' In the preatment phase, 72% of the 25 patients receiving tcamadol were taking 20(1 mg or less as a dally drae, 16% received 250 to SO() rag, and 12~ took 400 rag.
On admission, patients were administered an oral drug regimen by the treating physician, guided by pain intentit,r and both type and efli-
Table l Distritmtkm o[ Frlnmry Tumor Sites in 174 Cancer Pain Padents S~te
Number
Percent
C.,amrointesdusl system Head and neck Respimtory system Ge,il~uHnsry tract B~,mt Bone, skin, mft tissue Lymphatic system Brain and nerve system Unknown
48 87 26 22 17
27.6 21.4 14.9 12.6 9.8
I0 I0
58 5.8
3 1
1.7 0.6
Vol. 5 No. 1 Februar~1990
Cancer Pain ManagementAccording to WHO
none
mild
moderate
29
0.6~
~
r
1.1~k
5.8 ~&
severe
2a.6~
very lesenl
Fig. I. Effect of analgesic pretreatment: self-assessmentof pain on a VRShefor~ad- am bad au missionto the pain managementunit.
41.9"/*
could b e
cacy of the previous therapy. This first assessment led to the use of nonopioids (WHO step I) in 18.4% of cases, in combination with weak opioids (WHO step II) in 41.7%, and with strong opioids (WHO step llI) in 39.9%. Twenty-eight percent of the patients were given morphine solution, and 5.4% received morphine sulfate sustained-release tablets. At the first foliow-up examination (1 day to I wk after start of this initial therapy depending on clinical situation) patlenb were asked to recall their pain during the first days of therapy. l"wo-thirds described no pain or only mild pain for this period (Figure 3).
r
i
,
i
i
the step of therapy (Figure 6). Most changes were due to increased pain, new pain sites, inadequate pain relief, and lack of compliance. O f the entire 7,400 days of oral therapy, 13.6% involved treatment with step I analgesics, 31.7% with step 11 analgesics, and 54.7% with step 111 analgesics. Morphine was used as morphine solution in 38.4% of days and as morphine sulfate sustained-release tablets in 14.2%. Adjuvant drugs were u*~d in 94.5% of all days of therapy, in accordance with WHO guidelines. These drugs included corticosteroids, psychotropics, and anticonvulsants, as well as laxatives and antiemetics.
Addi6omd Treatment Further therapy was adjusted to the course of the disease. Changes in the analgesic ladder were performed according to efficacy of treatment and side effects. To cope with the individual situation of the patient, points of assessment were not preset at constant intervals but were defined by necessary changes of ~*.eps,drugs or dosages. The change of steps in the course of oral drug therapy is illustrated by Figure 4. At the end of the study, therapy was with step i in 6% of patlents, step 11 in 20%, and step I11 in 74%. At all tiraes, more than 80% of all patients in the study described their pain as "none," "mild," or "mode~te" on the six-step VRS (Figure 5). Side effects led to a change of step, drug, or dosage in about 5% of the cases, independent of
The efficacy of treatment by general practitioners and other physicians not trained in pain management prior to the study period was appallingly low. It could he shown that this ineffi-
tOO long intervals / " / ~ i k r ° ~ a L r r ° ~ s "
" lY
$6'/,
not eegalarly 8%
,
as required (p.r~.) 29'/.
Fig. ~ Distribution of type of in~Ju~ schedule in p~l~'atment ph;u~.
none
-
- J
....................
mllcl ~
44,|'
Zl.gq~
moderate
~ very x w r e ~ bad ue ~ u l d be
I ~
eA~ 4.115 6,111, I
I
I
I
cacy was due to a few, but relevant, faults that could be simply prevented by following the establisbed guidelines of cancer pain management: Although it is widely accepted that the treatment of chronic pain has to follow a regelar intake schedule with adequate dine intervals, most of the patients were prescribed their drugs on an as-needed basis, in mo-inng interor not regularly. The inadequate intake schedules resulted in umtable pain relief with unacceptable pain scores. The n.'zderdmage of drugs, as shown by the two examples dipyrone and tcamadol, was another important cause, as was the lack of knowledge of the potential enhancement of efftcacy of opioids by combination with nonopioids. Nearly one-third of the patients on opinids were not treated concurrently with a nonopinid.
lllml
Fig. $. Effectof fu'sttherapeutic approach: +elf-assessmentof pain on a VRSat firstfollow-up examinationafter induction of oral therapy.
Finally, there was hesitation to use strong opioids, especi~ll 7 morphine. This is shown by the fact that the number of patients with step I11 of therapy d~tlhled at the m,)me.t of admission. This hesitation is often caused by fear of addiction and tachyphylaxis, as well as by the lack of knowledge about the use of morphine within the medical community. The administrative difftculties in prescribing these drugs under the German Drug Control Act added a further obstacle (eg, special preacription forms to be ordered from federal authorities, difilcuh rules for filling in these forms, ~mplicated dose and time limits). The change of these laws in the last years to more usable ones for cancer pain control seemed to be unnoticed by most physicians (eg, relevant increase of dose and time limits).
O| PeI~MO UnOr tmetment
I041
40'11
II0'I~ i ~lnto
i
of Thin
- - WIIO111111 '*+'" WHO a l l p U
" ~ " WHO atsp III
Fig. 4. Changesof ~tep6~ftherapy i ,
the cour.eof tlme,
VoL S No. l Februa~1990
Can~r Pain Management Atcording to WHO
31
'& of Patients with No to Moderate Pale
69,8%
Fig.5. Efllcacyof therapyin the courseof time,
91.1flk
oJli/
Pretreatment Admission
let Change 2he GItanOe Laat Therapy
Points of Time
The introduction of an oral drug regimen following the WHO guidelines resulted in a rapid onset of pain relief within the first days of therapy. This acceptable level of pain relief could then be maintained for the du~tion of therapy in about 90% of the patients, whereas 11% had to be treated by other methods, such as neur~ !Ttic blocks, epidurai ~.d parenteral opinids, etc. These resldts are comparable to another field testing of WHO guidelines, where 87% of patients became peinfree by these methods, s It is quite obvious that the elficacy of this kind of thetdpy results from changing the steps at the right times. In the course of therapy, the strong opioids gained more and more importance, while the use of ,36rlopinidsalone proved
WHO
to be less effective. The final distribution of steps of therapy is siJnilar to the one described in another study with less patients,e The low percentage of patients who can finally be kept with step I is in ~:cordance with the fiteratore.r, s In most cases, the change of therapy was not due to side effec*,~. Compared to other studies,s the percentage of side effects leading to such a change of therapy at step I1 in this study is comparable, while the percentage of side effects leading to a change of therapy in step I is tenfold lower. As the study by Ventafi;dda and coneagues s describes mainly gastric side effects after using aspirin, this discrepancy may be caused by the low rate of this type of side effect
Step
atepl
fi~. 6. Chantiesof therapy"~amed sldceffects.
"8.ll~
[---
h
i
L
i
t
i ?*t
~ ~ n p s ~ s
~
8Mo E f ~
32
Sdmg et oA.
after dipyrone, which was preferred in the present study. Thus, the change of steps over time in this and other studiess-s must be seen mainly as an adaptive process to the increase of pain in the course o f terminal disease. The fact that more than 50% of the overall treatment time is spent at step I11 illustrates the importance o f strong opioids, and especially morphine, in the treatment o f cancer pain. The high efficacy and few side effects of the oral drug therapy enabled the patients to spend most of this treatment time at home. The findings of this study support the use of the W H O ~n~i,Jehnes m control cancer pain. The lack of knowledge o f these guidelines in the West C;~~nmn medical community results in intolerable suffering of terminal c a n e r patieats. The distribution o f information on the princlplos of oral drug therapy, eg, by manuals,e would enable general practitioners and other physicians to treat appro~mately 90% of cancer pain patients sulticiently. Without the m e of invasive methods, this high percentage o f patients would undergo an improvement o f quality o f life, spending most of their time at home.
Jourusl of Po~ ow,t ~,aptom M
~
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