To the IZditor: The problem of chronic pain in ~ilucer pwtie~~ta is urgent,.
Although
tbc World Mcalth
Organization IIiMimised ptih mcl palliative CilW specialists from many countries, there continues to be no effective system of care for most c4 these patients. Many l~tients spend their IilSt months, weeks, or $ay~ sufferil~g fl om pain and finding themselves alone. One can find no other disease manifestation that so frightens the patient and the family. Recently, efforts have begun to improve the quality of life of cancer patients in the USSR through development of progra~ns of palliative care and pain management. Since communication with like-minded professionals in other countries is important as we seek to make improvements, we would like to describe the current situation in aur country for our colleagues elsewhere. In 19$9, the USSR ministry of Public Health, togetller with the All-Union Cancer Research Center, founded the Coordinating Council on pain relief care of terminal cancer patients. Concurrently, pain treatment rooms commenced functioning in some oncological dispensaries. More than 10 such rooms were opened during f year, This progress highligl~ted the many difticulties we face in i~pr~~fing the care in our coountry. First, we must overcome the resistance of the health authorities, many of whom continue to believe that they have more important tasks than palliative care. Large sums of money are spent on diagnosis and treatmer~t of cancer, but when all the ~ssibilities for antitumor therapy are in vain and the time comes for pain relief alone, then the public health system has no @U.S. Cancer Pain Rclicf Cummittcr, IY!)I Publishedby Elscvier.New York. New York
money for this. This is so despite analyses that prove that the costs of p~~Iliativ~rare are minimal c~)lnpare~~with those expended to support diaguosis and antitumor therapy. Second, there continues to be u lack 01’effecrive analgesics in the USSK, Spccilically, we lack OraI formulations of narcotics. The need fol; such drugs in the treatment of terminal cancer lx&m3 is evident, p~~rticuk~rlyin the USSR, where it is often il~~p~~ssi~~le to ~r~~il~i~ca treatment based on frequent injections, given our great shortage of nurses. Inadequate availability of oral narcotics has led to consideration of other methods of pain control. Neurolytic nerve blocks have not been adopted widely in oncolagic clinics due to the risk of serious complic~tioI~s. We often use epiduraf or su~~rach~ noid administration of narcotics, and this approach has been particularly useful in emaciated patients; intraspinal opioids are also used in some ambulatory patients. Facing many difficulties in providing drug treatment to our patients, we often use methods of electroanalgesia, for which we have Soviet-~nade equip ment; in most cases, however, the short duration of effects limits the benefit of these treatments. Unfortunately, methods of subcutaneous continuous infusion that are applied all over the world are not used by us because we lack the special equipmenr required for this ap preach. A third problem wc face in tr~ting the pain of patients with advanced cancer is the attitude of oncologists. These physicians may not pay much attention to pain, and often concentrate their efforts solely on the disease itself. Many physicians also have the conviction that pain is an inevitably result of cancer and that nothing can bring relief from it, Although the p~blems we face touch on many ~~r~ar~i~ational, scienti~c and practical aspects, the needs of these patients
are still not a subject of discussion in medical journals, at meetings or congresses, or in training programs for students or continuing education for physicians. The inertia of physicians and pharmacists must be overcome, and they
must be taught that their fear of producing addiction from the treatment of pain with narcotics is groundless. The education of the professional community will require a great effort. Some specialized department of palliative care, or so-called “hospices,” are being orga nixed in the USSR. However, the shortcoming of the public health system also reflect on this aeon. There is a shorta of n~oney and medical staff for these prqjecto, This is another out-
To the Editor: Recently, there has been a growing realization that opiate analgesics may be safely and efficaciously used in patients suffering from chronic nonmaiignant pain syndromes. The c~te~a that have recently been proposed by Dr. ~~enoy ’ include monthly physician’s visits and the relative contraindication of treatment in patients who have a history of substance abuse. I would like to put these commendations into perspective by describing two patients who had a history of su~~uce abuse and were successfully maintained on narcotics for chronic pain problems, without escalation of dme or abuse. Case1 Through his teens and early 2Os, the patient drank heavily and abused marijuana, amphetamines (i~ludiug parenteral use), ~xyc~one, and codeine. All substance abuse ceased more than 20 yr ago. The patient, now 49 yr old, has had chronic pain since a work-related injury 17 yr ago that was followed by spinal surgery. Palamine another work=~la~ injury in 1980, he * cd worsening of his pain, and in April : he infant his third spinal pmedure wiih the placementof Hartington rods. In April of 1983, because of continuing pain, he underwent a two-level posterior interbody fusion. When ev&ated, 7 yr ago, the patient was a
come of the lack of understanding or social significance attached to palliative care. In sum, we have made some progress in the USSR in recent years, but continue to face many problems. We need scientific studies that describe the incidence and costs of cancer pain in our country, and continued efforts to educate physicians, policymakers, and patients about this problem. We hope to continue to work with our colleagues on this important problem. Vladimir Bryuzgin, MD Reprtment of Ambulatory Care All-Union Cancer Research Center Moscow, USSR
reluctant participant in the examination and interview process. In addition to his pain complaint, he was experiencing irritability, diminished appetite, sleep ~~tur~nce, and some lability of mood with ease of crying. His medication regimen included diazepam 30 mg/ day, hyd~~on~cetaminophen cum~nation product 4 to 6 tablets/day and indomethacin 21 day. He related that he was using alcohol on occasion, but denied abuse. Albeit reluctantly, to try a new treatment with a taper off diazepam and a change of analgesics He was treated with methadone and reported benefit at a dose of 10 mg t.i.d. During the intervening years, the patient has, on his own, diminished the dose of methadone when attempting to return to work, despite medical recommendations to the contrary. He has never escalated the dose, nor taken any medication other than as directed. He is exceedingly pleased with his treatment and denies any significant depression. This impression has been confirmed during multiple conjoint visits with his wife. He is folfowed on an every 2- to 3-mo basis or as needed, should any emergency arise, and these have been very infrequent,
Case2 The second patient had a longstanding history of abuse, including alcohol and heroin, in addition to abuse of amphetamine and hallucinogens. Past history includes repeated incarcerations totaling more than I5 yr. At the time of his evaluation, there had been no substance abuse for 1% yr. Despite his pain, substance
Although
tbc World Mcalth
Organization IIiMimised ptih mcl palliative CilW specialists from many countries, there continues to be no effective system of care for most c4 these patients. Many l~tients spend their IilSt months, weeks, or $ay~ sufferil~g fl om pain and finding themselves alone. One can find no other disease manifestation that so frightens the patient and the family. Recently, efforts have begun to improve the quality of life of cancer patients in the USSR through development of progra~ns of palliative care and pain management. Since communication with like-minded professionals in other countries is important as we seek to make improvements, we would like to describe the current situation in aur country for our colleagues elsewhere. In 19$9, the USSR ministry of Public Health, togetller with the All-Union Cancer Research Center, founded the Coordinating Council on pain relief care of terminal cancer patients. Concurrently, pain treatment rooms commenced functioning in some oncological dispensaries. More than 10 such rooms were opened during f year, This progress highligl~ted the many difticulties we face in i~pr~~fing the care in our coountry. First, we must overcome the resistance of the health authorities, many of whom continue to believe that they have more important tasks than palliative care. Large sums of money are spent on diagnosis and treatmer~t of cancer, but when all the ~ssibilities for antitumor therapy are in vain and the time comes for pain relief alone, then the public health system has no @U.S. Cancer Pain Rclicf Cummittcr, IY!)I Publishedby Elscvier.New York. New York
money for this. This is so despite analyses that prove that the costs of p~~Iliativ~rare are minimal c~)lnpare~~with those expended to support diaguosis and antitumor therapy. Second, there continues to be u lack 01’effecrive analgesics in the USSK, Spccilically, we lack OraI formulations of narcotics. The need fol; such drugs in the treatment of terminal cancer lx&m3 is evident, p~~rticuk~rlyin the USSR, where it is often il~~p~~ssi~~le to ~r~~il~i~ca treatment based on frequent injections, given our great shortage of nurses. Inadequate availability of oral narcotics has led to consideration of other methods of pain control. Neurolytic nerve blocks have not been adopted widely in oncolagic clinics due to the risk of serious complic~tioI~s. We often use epiduraf or su~~rach~ noid administration of narcotics, and this approach has been particularly useful in emaciated patients; intraspinal opioids are also used in some ambulatory patients. Facing many difficulties in providing drug treatment to our patients, we often use methods of electroanalgesia, for which we have Soviet-~nade equip ment; in most cases, however, the short duration of effects limits the benefit of these treatments. Unfortunately, methods of subcutaneous continuous infusion that are applied all over the world are not used by us because we lack the special equipmenr required for this ap preach. A third problem wc face in tr~ting the pain of patients with advanced cancer is the attitude of oncologists. These physicians may not pay much attention to pain, and often concentrate their efforts solely on the disease itself. Many physicians also have the conviction that pain is an inevitably result of cancer and that nothing can bring relief from it, Although the p~blems we face touch on many ~~r~ar~i~ational, scienti~c and practical aspects, the needs of these patients
are still not a subject of discussion in medical journals, at meetings or congresses, or in training programs for students or continuing education for physicians. The inertia of physicians and pharmacists must be overcome, and they
must be taught that their fear of producing addiction from the treatment of pain with narcotics is groundless. The education of the professional community will require a great effort. Some specialized department of palliative care, or so-called “hospices,” are being orga nixed in the USSR. However, the shortcoming of the public health system also reflect on this aeon. There is a shorta of n~oney and medical staff for these prqjecto, This is another out-
To the Editor: Recently, there has been a growing realization that opiate analgesics may be safely and efficaciously used in patients suffering from chronic nonmaiignant pain syndromes. The c~te~a that have recently been proposed by Dr. ~~enoy ’ include monthly physician’s visits and the relative contraindication of treatment in patients who have a history of substance abuse. I would like to put these commendations into perspective by describing two patients who had a history of su~~uce abuse and were successfully maintained on narcotics for chronic pain problems, without escalation of dme or abuse. Case1 Through his teens and early 2Os, the patient drank heavily and abused marijuana, amphetamines (i~ludiug parenteral use), ~xyc~one, and codeine. All substance abuse ceased more than 20 yr ago. The patient, now 49 yr old, has had chronic pain since a work-related injury 17 yr ago that was followed by spinal surgery. Palamine another work=~la~ injury in 1980, he * cd worsening of his pain, and in April : he infant his third spinal pmedure wiih the placementof Hartington rods. In April of 1983, because of continuing pain, he underwent a two-level posterior interbody fusion. When ev&ated, 7 yr ago, the patient was a
come of the lack of understanding or social significance attached to palliative care. In sum, we have made some progress in the USSR in recent years, but continue to face many problems. We need scientific studies that describe the incidence and costs of cancer pain in our country, and continued efforts to educate physicians, policymakers, and patients about this problem. We hope to continue to work with our colleagues on this important problem. Vladimir Bryuzgin, MD Reprtment of Ambulatory Care All-Union Cancer Research Center Moscow, USSR
reluctant participant in the examination and interview process. In addition to his pain complaint, he was experiencing irritability, diminished appetite, sleep ~~tur~nce, and some lability of mood with ease of crying. His medication regimen included diazepam 30 mg/ day, hyd~~on~cetaminophen cum~nation product 4 to 6 tablets/day and indomethacin 21 day. He related that he was using alcohol on occasion, but denied abuse. Albeit reluctantly, to try a new treatment with a taper off diazepam and a change of analgesics He was treated with methadone and reported benefit at a dose of 10 mg t.i.d. During the intervening years, the patient has, on his own, diminished the dose of methadone when attempting to return to work, despite medical recommendations to the contrary. He has never escalated the dose, nor taken any medication other than as directed. He is exceedingly pleased with his treatment and denies any significant depression. This impression has been confirmed during multiple conjoint visits with his wife. He is folfowed on an every 2- to 3-mo basis or as needed, should any emergency arise, and these have been very infrequent,
Case2 The second patient had a longstanding history of abuse, including alcohol and heroin, in addition to abuse of amphetamine and hallucinogens. Past history includes repeated incarcerations totaling more than I5 yr. At the time of his evaluation, there had been no substance abuse for 1% yr. Despite his pain, substance
