Supportive Care in Cancer

, Volume 21, Issue 7, pp 2033–2039

A cross-sectional survey of pain in palliative care in Portugal

Authors

    • Instituto Português de Oncologia
    • Unidade de Cuidados PaliativosInstituto Português de Oncologia
  • Ana Almeida
    • Instituto Português de Oncologia
  • Catarina Antunes
    • Hospital do Mar
  • Maria Cardoso
    • Centro Hospitalar Lisboa Central
  • Margarida Carvalho
    • Hospital do Litoral Alentejano
  • Maria Claro
    • Unidade Local de Saúde de Matosinhos
  • Francisca Coimbra
    • Instituto Português de Oncologia
  • Inês Diniz
    • Hospital do Mar
  • Bruno Fonseca
    • Unidade Local de Saúde de Matosinhos
  • Emília Fradique
    • Hospital de St. Maria
  • Edna Gonçalves
    • Centro Hospitalar de S. João
  • Florbela Gonçalves
    • Instituto Português de Oncologia
  • Maria Gonçalves
    • Hospital do Litoral Alentejano
  • Américo Magalhães
    • Centro Hospitalar de Trás-os-Montes e Alto Douro
  • Paulo Pina
    • Instituto Português de Oncologia
  • Conceição Pires
    • Centro Hospitalar de S. João
  • Paula Silva
    • Instituto Português de Oncologia
  • Ricardo Silva
    • Centro Hospitalar Lisboa Central
  • Rui Silva
    • Instituto Português de Oncologia
  • Filipa Tavares
    • Hospital de St. Maria
  • Laura Teixeira
    • Centro Hospitalar de Trás-os-Montes e Alto Douro
Original Article

DOI: 10.1007/s00520-013-1746-2

Cite this article as:
Gonçalves, F., Almeida, A., Antunes, C. et al. Support Care Cancer (2013) 21: 2033. doi:10.1007/s00520-013-1746-2

Abstract

Objective

The purpose of this work is to study the prevalence, intensity, and treatment of pain in Portuguese palliative care teams.

Methods

Twenty-one palliative care teams were invited to participate in a cross-sectional survey. Ten of these accepted and were included in the study. Data of all patients observed on the 18th week of 2011 were collected. The data collected concerning pain were: demographic data, pain intensity, drugs prescribed, and invasive techniques. The intensity of pain was rated using a five-point verbal rating scale from none to maximum. The Pain Management Index (PMI) was used to calculate the adequacy of the analgesia.

Results

A total of 164 patients were included in this study. One hundred fifty-one (92 %) had cancer. The median age was 71 years (16 to 95). Eighty-four (51 %) were females. Pain was directly assessed in 136 (83 %) of the patients, whereas 27 patients could not report pain because of cognitive failure. Of those directly assessed, 77 (57 %) had pain when they were assessed: 42 (55 %) mild, 25 (32 %) moderate, 9 (12 %) severe, and 1 (1 %) maximum. Non-opioid analgesics were used: paracetamol in 61 (37 %) and NSAID in 20 (12 %). Tramadol was the only opioid for mild to moderate pain used in 25 (15 %) patients. The opioids most used for moderate to intense pain were: morphine 74 (45 %), transdermal (TD) fentanyl 32 (20 %), and buprenorphine TD 28 (17 %). The adjuvants most used were: corticosteroids 38 (23 %), gabapentin 37 (23 %), and amitriptyline 15 (9 %). Only five (4 %) patients had a negative PMI, meaning an inadequate analgesia.

Conclusion

The general prevalence of pain is similar to that reported by other. The prevalence of moderate to severe pain is also similar to that reported in other studies, although severe pain is somewhat lower than indicated in most reports. According to the PMI, pain control was acceptable to good.

Keywords

Palliative carePortugalPainPain controlPain Management Index

Introduction

Pain is one of the most prevalent symptoms observed in palliative care patients. The World Health Organization (WHO) published Cancer Pain Relief in 1986 where the guidelines for managing cancer pain, including the analgesic ladder, were presented. Since then, the effectiveness of the WHO analgesic ladder has been documented. For example, a systematic review showed that 69 to 100 % of patients with cancer pain had adequate analgesia with this method [1]. However, many studies report that cancer pain is undertreated. A review of the published literature concluded that nearly one of two patients with cancer pain is untreated [2]. A survey carried out in 11 European countries and Israel found out that 56 % of cancer patients suffered moderate to severe pain [3]. Other studies report similar results in individual European countries and in other parts of the world in cancer pain or in chronic pain in general [410]. These data suggest that despite the effectiveness of the WHO recommendations, pain is still not adequately treated, even in developed countries.

In Europe, one of the problems is the regulatory barriers to accessibility of opioids [11]. Those barriers differ among European countries but in many of them they are excessive and interfere with the adequate treatment of cancer pain. Other barriers have been identified which have their roots in social attitudes, knowledge deficits and training of the health professionals and the attitudes and meaning of pain among patients [12, 13]. A study identified barriers such as exaggerated fear of iatrogenic addiction, the attitude among health professionals that patients exaggerate the intensity of pain, and the poor correlation between pain behavior and pain intensity [14]. The data of an American national survey of medical oncologists’ attitudes and practice in cancer pain management suggest that medical oncologists do not address pain adequately, and only a minority frequently refer their patients to pain or palliative care specialists [15].

In Portugal, palliative care began in 1994. The first palliative care service was an in-patient palliative care service belonging to the Portuguese Institute of Oncology–Porto, whose initial history was described elsewhere [16]. That unit was built by the Portuguese League against Cancer. In 2006, the Portuguese Government created the National Network of Integrated Continuity Care which includes various types of services including palliative care and long-term care. Since then, the number of teams increased both inside and outside that network. However, the number of teams and beds are deemed far from satisfying the needs. Palliative medicine is not yet a recognized specialty.

As far as we know in Portugal, there are no data about palliative care teams’ outcomes, including the adequacy of cancer pain treatment, as there are no data on pain prevalence and pain management in palliative care as well. Pain is, however, one of the main focuses of symptom control in palliative care, and probably in this setting, the level of pain control does not reflect pain control in general. In this article, the data on the prevalence and treatment of pain in palliative care in Portugal are presented, as part of a survey of the palliative care practice in this country.

Methods

Twenty-one Portuguese palliative care teams were invited to participate in the survey, 19 identified through the website of the Portuguese Association for Palliative Care and 2 identified through the website of the Portuguese continuity care network. A questionnaire based on the study carried out by the European Association for Palliative Care in 2000 was constructed [17]. The questionnaire was sent to the 10 of the 21 palliative care teams that accepted to participate in the survey for evaluation. A new questionnaire was designed with the suggestions received, which was circulated for a final revision that was deemed by all the participants to be adequate for the aim of the study. Data of all patients observed on the 18th week of 2011 were collected. Each team filled out the questionnaire with the data of all patients seen in 1 day of that week. There was 1 day for each activity of the team (inpatient unit, intra-hospital team, outpatient clinic, and home care). The day of the week for each activity was the same for all teams, that is, the day for data collection was not chosen by each team but was previously indicated by the study coordinators. Data were collected by the researchers at each center from all patients who attended at that day that accepted to participate.

The data collected concerning pain, besides demographic data, were: pain intensity, drugs prescribed, and invasive techniques. The intensity of pain in the last 24 h was rated using a five-point verbal rating scale: none, mild, moderate, severe, and maximum.

The Pain Management Index (PMI) as described by Cleeland et al. was used to calculate the level of adequacy of the analgesia [8]. According to the PMI, the analgesics are classified as: 0—no analgesics, 1—non-opioids, 2—opioids for mild to moderate pain, and 3—opioids for moderate to severe pain. The pain is classified as: 0—no pain, 1—mild pain, 2—moderate pain, and 3—severe pain. Then, the PMI is computed by subtracting the pain level from the analgesic level. Therefore, the PMI ranges from −3 (a patient receiving no analgesics with severe pain) to +3 (a patient receiving opioids for moderate to severe pain with no pain, that is, pain completely controlled). Negative scores indicate inadequate analgesia, and scores 0 or positive indicate acceptable to good analgesia. In this study, for computing the PMI severe and maximum pains were classified together as severe.

An initial analysis was performed for statistical purposes, to identify coding errors, inconsistencies, and the presence of missing categories or small numbers, and corrections were made where needed. Missing data were omitted, an approach usually called listwise deletion or complete case analysis.

The variables were analyzed by proportions and means. To evaluate the existence or not of associations between categorical variables, the chi-square test was used. The level of significance was deemed to be 0.05. SPSS (Statistical Package for Social Sciences) version 19.0 statistical software was used to analyze the data. The study was approved by the ethics committees and authorized by the board of directors at each center.

Results

A total of 164 patients were included in this study with a median of 15.5 per team (4 to 32). One hundred fifty-one (92 %) had cancer (Tables 1 and 2). Patients included were observed: 60 (37 %) as inpatients in palliative care units, 59 (36 %) by an intra-hospital team, 26 (16 %) as outpatients, and 19 (12 %) at home (Table 3). The median age was 71 years (16 to 95). Eighty-four (51 %) were females. Pain was directly assessed in 136 (83 %) of the patients, whereas 28 patients could not report pain because of cognitive failure. Patient’s autonomy to dress, wash, etc. was: independent, 20 (12 %); independent with difficulty, 19 (12 %); needing a little of help, 22 (13 %); needing a lot of help, 32 (20 %); and unable, 71 (43 %). Of the 136 patients directly assessed, 77 (57 %) had pain on that day: 42 (55 %) mild, 25 (32 %) moderate, 9 (12 %) severe, and 1 (1 %) maximum. Dividing patients by the median age (71 years), there was no significant differences in pain reported in the two age groups (p = 0.266). There was no difference in pain reported by gender either (p = 0.581). The non-opioid analgesics used were: paracetamol in 61 (37 %) patients and non-steroidal anti-inflammatory drugs (NSAID) in 20 (12 %) (Table 4); in 11 patients, paracetamol and a NSAID were used together. Tramadol was the only opioid prescribed for mild to moderate pain, whose routes can be seen in Table 5. Morphine predominates among opioids for moderate to intense pain, in most cases by the oral route followed by the subcutaneous one (Table 6). Transdermal fentanyl and buprenorphine came next in frequency (Table 4). When a modified release opioid was used, a normal release opioid, usually oral or subcutaneous morphine, was used for breakthrough pain. The adjuvants more often used were: anticonvulsants, predominantly gabapentin; corticosteroids, mainly dexamethasone; and amitriptyline (Table 4). Ketamine, baclofen, and pamidronate were used rarely. The median equivalent daily dose of oral morphine was: 84 mg (range, 10 to 720). Opioids were used by the epidural route in three patients. No other invasive techniques were used for pain control. The questionnaires were in general carefully filled out, with few missing data. However, in nine the opioid dose was not filled out, and in one case, the birthday date to calculate age was also missing.
Table 1

Diagnoses

Diagnosis

N

(%)

Cancer

151

(92.1)

Neurological

6

(3.7)

Respiratory

2

(1.2)

AIDS

1

(0.6)

Renal

1

(0.6)

Hepatic

1

(0.6)

Postoperative complications

1

(0.6)

Undefined

1

(0.6)

Table 2

Cancer diagnoses and metastases

 

n

(%)

Cancer

Colorectal

22

(15)

Head/neck

17

(11)

Stomach

17

(11)

Breast

15

(10)

Lung

14

(9)

Brain

11

(7)

Prostate

10

(7)

Gynecologic

8

(5)

Pancreas

7

(5)

Esophagus

5

(3)

Urologic

4

(3)

Other

21

(14)

Total

151

(100)

Metastases

Locally advanced

79

(52)

Bone

44

(29)

Liver

37

(25)

Lung

29

(19)

Peritoneum

20

(13)

Brain

12

(8)

Skin

7

(5)

Pleura

5

(3)

Other

24

(16)

Table 3

Activities and number of patients per team

Institution type

Institution

Setting of care

PCU

Hospital

Home

Outpatient

Total

Oncology Center

Porto

15

   

15

Coimbra

14

  

2

16

Lisboa

 

3

6

2

11

General Hospital

São João

 

12

 

5

17

Santa Maria

 

8

 

4

12

Matosinhos

 

15

13

4

32

Litoral Alentejano

8

3

 

1

12

Mar

19

   

19

Lisboa Central

 

18

 

8

26

Other

Vila Pouca de Aguiar

4

   

4

Total

60

59

19

26

164

Table 4

Analgesics

 

N

(%)

Non-opioids

  

 Paracetamol

61

37

 NSAIDs

20

12

Opioids—mild to moderate pain

 Tramadol—total

25

15

Opioids—moderate to severe pain

 Morphine—total

74

45

 Buprenorphine—TD

28

17

 Buprenorphine—SL

3

2

 Fentanyl—TD

32

20

 Hydromorphone—O

2

1

 Alfentanil—SC

1

1

 Methadone—O

1

1

Adjuvants

 Dexamethasone

29

18

 Prednisolone

9

5

 Amitriptyline

15

9

 Gabapentin

37

23

 Sodium valproate

10

6

 Pregabalin

6

4

 Baclofen

2

1

 Ketamine—O

1

1

 Ketamine—SC

1

1

 Pamidronate

1

1

O oral, SC subcutaneous, SL sublingual, TD transdermal

Table 5

Routes for tramadol

 

N

(%)

Oral, normal release

10

(40)

Oral, modified release

11

(44)

Subcutaneous

2

(8)

Intravenous

2

(8)

 Total

25

(100)

Table 6

Routes for morphine

 

N

(%)

Subcutaneous

30

(41)

Oral, normal release

24

(32)

Oral, modified release

14

(19)

Intravenous

3

(4)

Epidural

3

(4)

 Total

74

(100)

The PMI shows a good level of adequacy of analgesia, with only 5 (4 %) patients with inadequate analgesia, 36 (27 %) scored 0, and all others had positive scores (Table 7). There were no statistically significant differences in the PMI by team (p = 0.285), gender (p = 0.335), or age (p = 0.214).
Table 7

Pain Management Index

Index

N

(%)

−1

5

(4)

0

36

(27)

1

30

(22)

2

39

(29)

3

26

(19)

Total

136

(100)

Discussion

This is the first survey carried out in Portugal concerning pain in palliative care patients which included a significant number of teams and patients. In the year 2000, a study was carried out as part of a European survey, but only three teams participated in an initial phase of development of palliative care in this country. Data from this study may be used as a baseline for comparison with future studies carried out in Portugal or perhaps even in other countries.

The prevalence of pain in this study is roughly in alignment with the reported prevalence of pain in patients with advanced, metastatic, or terminal cancer in other studies [18]. The prevalence of chronic pain in advanced non-oncological diseases is similar [19]. The prevalence of moderate to severe pain is also similar to that reported in other studies, although severe pain is somewhat lower than indicated in most reports [18].

Paracetamol is the non-opioid most used followed by NSAID. In fact, they are prescribed in rates comparable with those usually reported [20], despite the inconclusive results of research on the effectiveness of paracetamol in palliative care when combined with opioids for moderate to severe pain, with studies showing a positive effect [21] and others that do not [22, 23], although its analgesic effectiveness is well established in other situations [24]. In some patients, paracetamol and a NSAID were combined as is frequently recommended [25].

Tramadol was the only step II drug used. However, the level of evidence for the use of tramadol as a step II analgesic is low to very low [26]. However, this only means that there are insufficient data to support its routine use in cancer patients with mild to moderate cancer pain; it does not mean that tramadol is ineffective. In Portugal, codeine is used mainly as an antitussive. In fact, most formulations combine codeine with other antitussives, although there are commercial combinations of codeine and paracetamol. There is also a combination of dextropropoxyphene and paracetamol which is not recommended by the Portuguese health authorities [27]. Dihydrocodeine was discontinued some years ago.

Morphine was the opioid for moderate to severe pain most used, mainly by the oral route but also by the subcutaneous one. Morphine remains the step III opioid usually recommended in guidelines for cancer pain [28, 29]. These recommendations are produced based on familiarity, availability, and cost rather than proven superiority [28]. Other opioids such as oxycodone and hydromorphone may have similar efficacy and toxicity [30]. In this study, transdermal opioids came in second place concerning the use of opioids for moderate to severe pain. In a recently published systematic review, it was concluded that modified release morphine probably remains the preferred approach, with transdermal opioids reserved for selected patients [31]. Oxycodone is not available in Portugal, while methadone is only licensed for the treatment of drug addiction and is available for pain relief in only a few hospitals. In Portugal, there are no significant legal barriers to the prescription of opioids as nowadays there is no need for a special prescription and the State pays 95 % of most opioids price for cancer patients. However, there is a lack of training of doctors in the adequate use of opioids, causing reluctance in their prescription.

Anticonvulsant drugs were the most used adjuvants, and among them, gabapentin came in first place. Anticonvulsants as well as antidepressants may in fact be useful in neuropathic pain control although with a limited effect [32]. The strongest evidence concerns gabapentin according to a recent systematic review [32]. However, in a previous Cochrane review gabapentin did not prove to be superior to carbamazepine [33]. Curiously in this study there are no records of the use of carbamazepine. The second most frequent group of adjuvants is corticosteroids, mainly dexamethasone. Corticosteroids are used in palliative care with many purposes: pain control, dyspnea, anorexia, nausea, vomiting, weakness, and low mood [34, 35]. Corticosteroids have been used in different types of pain supporting their classification as multipurpose analgesics [36].

The adequacy of pain management in this study according to the PMI was acceptable to good as only 4 % of the patients scored negatively. This is much better than the data commonly reported in other studies where the rate of negative scores may reach 82 % [2, 5, 8, 9]. Those studies were not, however, carried out specifically in the palliative care setting. Therefore, it is natural that pain is better managed in the palliative care setting than in others. The PMI, however, is far from being a perfect tool to assess the adequacy of pain management because it does not take into account important aspects of pain management, such as the dosage, patients’ compliance with the therapy, the use of adjuvant drugs or nonpharmacological therapies [2].

The data seem to show an adherence to the WHO analgesic ladder as all the three steps are represented. Opioids for moderate to severe pain were used in most patients, mainly morphine but also the transdermal opioids buprenorphine and fentanyl. Adjuvant analgesics were also used extensively following the guidelines of the WHO for cancer pain relief. The drugs used in conjunction with the results of the PMI indicate that pain treatment by palliative care teams is probably adequate.

Comparing the data presented in this study with those concerning Portugal included in the European survey carried out in 2000 [20], when only three Portuguese centers participated (all that existed at that time), the main aspects observed are: the percentage of patients treated with paracetamol is higher now and those treated with NSAID is lower; the predominant step II opioid was already tramadol, although dextropropoxyphene and dihydrocodeine were used in a few cases; morphine was the step III opioid most used as it is nowadays; fentanyl was the only transdermal which existed at that time and was used in a percentage similar to that reported here; amitriptyline and corticosteroids were more often used in 2000, whereas gabapentin was much less used.

This study has some weaknesses as only 10 of the 21 teams identified have accepted to participate, which cast doubts in the generalizability of the data. However, we believe that it gives a picture of what is happening in Portuguese palliative care teams. Other issues which may be raised concern the methodology. However, the methods were similar to those used in a European survey carried out in the year 2000, in what respects the development of the questionnaire, whose face validity was done by the 21 researchers who participated, the cross-sectional method, and the sampling strategy. The similar methodology permitted the comparison of data as described above.

Palliative care is a relatively recent area of care in Portugal and, therefore, research is not yet a major concern of many teams. However, there was a significant improvement in the adherence to this study relative to a survey carried out previously about sedation when only 21 % of the teams invited participated [37], and hopefully in the future a higher adherence will occur to collaborative studies.

Conclusion

The prevalence of pain and pain treatment are similar to those reported in other studies. However, severe pain is somewhat lower probably reflecting the different settings where the studies were carried out, indicating that pain is much better controlled in palliative care, as would be expected. According to the drugs used and the results of the PMI, pain control was acceptable to good. The fact that cancer pain control in palliative care is more effective than the achieved in other settings is a strong argument for the integration of palliative care in the care of patients sooner than usually occurs “in conjunction with other therapies that are intended to prolong life, such as chemotherapy or radiation therapy” as the WHO recommends.

Conflict of interest

None.

Copyright information

© Springer-Verlag Berlin Heidelberg 2013