Introduction

! Pain : one of the most feared symptom

among cancer patients
! Nearly 50-50-80% of patients do not have
adequate pain control
Overcoming Barriers ! Up to 25 % die without adequate pain
1

To Pain Management relief 2

George Taye Wei Chun 1. Bonica JJ (Advances in Pain Research ad Therapy 589-
589-616 ,1985

2. Saunders C The Therapy of Pain 215, 1981

MBBS (Malaya) MRCP (UK)

Introduction Aims
" Recognize the burden of pain
! 75% of advanced cancer patients experience " That its suboptimal management is a
pain significant problem

! 2/3experience 2 or more types of pain at the " Identify possible barriers to better
pain management in Malaysia
same time
" Suggests ways to overcome those
! 90% of cancer pain can be controlled barriers
" Analyse the costs involved and the
possible impact of these steps
WHO cancer and palliative care unit, Geneva

Definition of pain “Pain is a more terrible lord of mankind than

even death itself ”
International Association for
the Study of Pain (IASP) Albert Schweitzer
# «Pain is an unpleasant
sensory and emotional
experience associated with
actual and potential tissue
damage or described in terms
of such damage ».

# Pain is always subjective.

DRAWN BY SIR CHARLES BELL

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 More Literally! Pain…..The Reality in Melaka
" Pain is the most common reason cancer patients
seek palliative attention (68 % N=52) 1
" 72 % of patients did not have good pain control on
! It is what the patient says that their initial visit to the PCU (VAS >5) 1
" 29% still had VAS>5 after their 4th consultation
HURTS! (N=31)1
! Undertreatment continues 2
! Pain is still viewed as expected and insignificant
! Pain is not routinely assessed, documented, and
reassessed
1. Palliative Care Unit Hospital Melaka Survey 2005
2. Berry PH, Dahl JL. J Pharm Care Pain Symptom Control. 2000;8:5-
20.

Remember…… Pioneering Study -Melaka

! Unrelieved pain DESTROYS quality of life for ! Pain Issues from the Palliative Perspective :
the cancer patient and the family A Survey Among Doctors at Hospital
Melaka MJM Oct 2006 GAWC Taye
! Relief of pain allows the person to live the rest ! Data from 2005

of his/ her life constructively and productively

The Barriers Healthcare Provider 1

Lack of knowledge/experience : the no. 1 reason

! Healthcare provider
"
given by doctors
! The Patient " Underexposure to palliative care in the
undergraduate level
! The Healthcare system " Failure to assess pain
" Rx with inappropriate drugs
at inadequate doses
" Fear of patient addiction/tolerance
! Basically the same here as in elsewhere " Attitudes : conservative

1 . Pain Issues from the Palliative Perspective : A survey among doctors

doctors in Hospital Melaka MJM
Barriers to Pain and Benefits. Journal of Pain and Oct 2006 GAWC Taye
Symptom Management, Volume 25, Issue 2, Pages 101-103
R. Gee

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The top 6 potential barriers to good cancer pain management Top 5 doctor’
doctor’s apprehensions in prescribing more potent analgesia
Potential Barriers Percentage (n=68)
Apprehensions in Analgesia Percentage (n=63)
Inadequate experience/knowledge of 69
doctors
Prescription
Patients reluctance to take opiods 62
Adverse effects 78

Poor pain assessment 60 Tolerance 59

Lack of proper local pain management 54
protocols Probable dug reactions 48

Poor patient/caregiver compliance to 51

medications Lack of knowledge 33

Limited emphasis from the psychological 47

Addiction to opiods 27
aspect

The Patient (and Family) The Patient (and Family)

" Pain is often under reported
" Belief that pain is a normal part of disease (wrong)
" Fear of addiction, adverse effects, etc (wrong)
" Asian attitudes : bear suffering including pain
(different from west) Differs between ethnic
groups as well Chinese, Malays, Indians, Orang
Asli etc
" Myth that “good patients don’
don’t complain”
complain”
(wrong)
" Inadequate education (Correct! Correct!
Correct!)
" Fear that pain is a sign of severity or poor
outcome
" Control of treatment (including pain) is
left to relatives-
relatives- who usually have the
same or even worse misconceptions !

Interestingly….. The Healthcare System

! A study : An Update of Pain management in
China by Wei Liu, M.D.
Department of Anesthesia, Peking Union Medical
College Hospital, Beijing, China
! Gave historical reason – the Opium War , fear of
addiction was deep imbedded in Chinese culture
! Equipment (or the lack of it)
! Failure to routinely use a specific assessment
tool (out of the many)
! Reduced access to specialists (only 1) ,
! Pain management facilities-
facilities- the chronic pain
clinic does not take in cancer patients
! Analgesics in managed care : Melaka PCU had
its drugs cut eg no COX 2 etc, unable to do
opiod rotation

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 The Healthcare system Depressingly…..
Lack of emphasis on pain management-
management-
!
palliative care is of secondary even tertiary
So Many Things Are
importance (quote
(quote by a real doctor!)
! Absence of any KPIs in the field (Melaka)
! Lack of review of efficacy of practices-
practices- we Lacking……
continue to do what we think is right without
evaluating treatment outcome.
! Evidenced based or Art based?

Overcoming the Barriers Overcoming the Barriers

The Patients (and Family) Healthcare System
! More specialists/ personnel
! More equipment ie more money!
! Knowledge ! Devise a way to measure the output-
output- administrators like
numbers!) all part of evidence based medicine
! Attitudes-
Attitudes- conservatism, Asian Values ! Disseminate info/ guidelines
! Perceptions ! ? Other fields eg TCM?1
! These are difficult to change especially the attitudes and perceptions.
perceptions.
! Long term issues but knowledge can be imparted fast with minimal costs-
costs-
1. An Update of Pain management in China
involves the providers educating them (at this stage education should
should be Wei Liu, M.D.
targeted and would be unrealistic to expect the patient to seek these
knowledge)

Important! Overcoming the Barriers

Healthcare System Healthcare Providers

! More emphasis-
emphasis- the need for the field to ! Knowledge
advertise itself to the others (ie
(ie don’
don’t be shy!), to ! Competence : the need to gain and retain the
tell what can be done for patients – palliative respect and cooperation of our colleagues
care cannot and must not be seen as the poor ! Evidence based practices
relation of the other discplines.
discplines. ! P-I-E Passion, Imagination, Enterprise
! Why I leave this last-
last- it is the most important –
yes it is really up to us! (put superman picture)

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! “There’
There’s no pain that’
that’s so easy to bear than that
of someone else.”
else.”
Leriche

Van Gogh:
“Old Man in Sorrow”
Sorrow”

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 Finally…..
! Barriers identified, solutions suggested
! Need to transform to uplift the standard of pain
management in Malaysia

Thank You!
Questions?