Pain Medicine 2015; 16: 2195–2203 Wiley Periodicals, Inc.
CANCER PAIN & PALLIATIVE CARE SECTION Original Research Article Physicians’ Practice, Attitudes Toward, and Knowledge of Cancer Pain Management in China
State Key Laboratory of Biotherapy and Department of Head and Neck Oncology, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan, PR China Reprint requests to: Yongsheng Wang, MD, PhD, West China Hospital, No. 37 Guo Xue Alley, Chengdu 610041, People’s Republic of China. Tel: 186-2885553329; Fax: +86-028-85423279; E-mail: [email protected].
Results. Five hundred (90.90%) physicians responded. About one-third (32.6%) of physicians assessed patients’ pain rarely, and 85.5% never or occasionally treated patients’ cancer pain together with psychologists. More than half of physicians indicated that opioid dose titration in patients with poor pain control and assessment of the cause and severity of pain were urgently needed knowledge for cancer pain management. Inadequate assessment of pain and pain management (63.0%), patients’ reluctance to take opioids (62.2%), and inadequate staff knowledge of pain management (61.4%) were the three most frequently cited barriers to physicians’ pain management.
Qiongwen Zhang and Chunhua Yu contributed equally to this work.
Conclusions. Physicians’ positive attitudes toward cancer pain management need to be encouraged, and active professional analgesic education programs are needed to improve pain management in China.
Conflicts of interest: The authors declare no conflict of interest.
Key Words. Cancer Pain; Practice; Attitudes; Knowledge; China Introduction
Abstract Subject. To evaluate physicians’ current practice, attitudes toward, and knowledge of cancer pain management in China. Methods. We conducted a face-to-face survey of physicians (oncologists, internists, hematologists) who are responsible for the care of cancer patient of 11 general hospitals in Sichuan, China between December 2011 and December 2013. Statistical analyses were performed using SPSS (SPSS, Chicago, IL) software. Setting and Design. A 23-item questionnaire was designed and distributed to 550 physicians in 11 medical facilities in China.
Pain is the most frequent and persistent symptom experienced by patients, and it is highly prevalent in patients with cancer [1–3]. Despite substantial evidence that available drugs and appropriate interventions can control 80–90% of cancer pain, this symptom is inadequately treated in an estimated 50–60% of patients [4–7]. Barriers to cancer pain management exist at all levels of the health care system, including the provider, organizational, and patient levels [8]. The responsibility for cancer pain management lies primarily with physicians [9]. The World Health Organization’s three-step analgesic ladder is in widespread use and is gaining increasing attention from physicians in China [10]. However, several problems with this pain management tool remain unaddressed and few researchers have examined physicians’ role in opioid prescription [11–16]. Hospitals 2195
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Qiongwen Zhang, MD, PhD, Chunhua Yu MD, Shijian Feng MD, Wenxiu Yao MD, Huashan Shi, MD, PhD, Yuwei Zhao PhD, and Yongsheng Wang MD, PhD
Zhang et al. in China are divided into three levels by national health and family planning commission of the people’s republic of China and cancer pain management differs among hospitals. Chinese patients are likely to seek care for any condition at the best local hospital for the best service they can get. Only one study has assessed physicians’ concern with and attitudes toward pain management in China [10]. A recently published study demonstrated that lack of knowledge is an impediment to morphine use [17], but no study has comprehensively and extensively investigated the impact of physicians’ basic characteristics and attitudes on the improvement of pain management in China.
percentages) were used to characterize the total sample. For multiple-choice questions, we calculated the percentage of responses to each item. Using chisquared analysis, we examined differences between categorical variables. The significance level was set to P < 0.05. Statistical analyses were performed using SPSS software (SPSS, Chicago, IL). Results We distributed 550 questionnaires and 500 of them responded, and the response rate was 90.9%. Sample Characteristics
Methods Study Design and Subjects Between December 2011 and December 2013, we conducted a face-to-face survey of physicians (oncologists, internists, hematologists) responsible for the care of patients with cancer in 11 tertiary general hospitals in Sichuan, China. All collected questionnaires were anonymous. Questionnaire The 23-item questionnaire, comprised of components from previously reported questionnaires [8,18–21], was designed by researchers from the Cancer Center of West China Hospital, Chengdu, and translated into Chinese. The first part of the questionnaire contained 22 items regarding physicians’ demographic and background characteristics (four items), current practice status (nine items), and attitudes toward (eight items) and barriers to (one item) cancer pain management. The second part consisted of eight items (seven negative and one positive) concerning physicians’ knowledge about analgesic prescription for cancer pain management drawn from a survey developed in Taiwan [20]. Responses to these items were structured by a scale ranging from 1 (strongly agree) to 5 (strongly disagree) for negatively worded questions and from 5 to 1 for positively worded questions. All response data were entried into PC and using statistic software to analyze. Statistical Analysis Physicians’ knowledge was classified according to the method of Ger et al. [20], in which a mean score 3 is considered to indicate “knowledge deficits to prescribe opioids.” Physicians were grouped according to categorical variables. Descriptive statistics (frequencies and 2196
The characteristics of respondents are summarized in Table 1. About half (41.4%) of participants had worked in the hospital for 5 years. Approximately 45% of physicians reported that they attended patients with cancer pain several times a week, and about 33% reported that they did so more than once a day. More than 80% of respondents had participated in one painmanagement training program. Almost half (48.1%) of physicians felt that they had fair knowledge of cancer pain management. Only 23.8% of physicians reported receiving adequate (excellent or good) training during medical school, but 51.6% reported that training had been adequate during residency. Current Cancer Pain Management Practice Chinese physicians’ current cancer pain management practice is described in Table 2. Most (62.2%) physicians assessed patients’ cancer pain every day, although only 14.5% reported that they often treated this pain in consultation with psychologists. Nearly all (95.4%) physicians used visual analog or numeric rating scales to assess cancer pain. Most (84.0%) physicians informed their patients about opioid side effects, and most managed the side effects of strong opioids when patients developed them (49.8%) or when the drugs were first prescribed (42.6%). Attitudes Toward Cancer Pain Management Responses to questions about physicians’ attitudes toward cancer pain management are shown in Table 3. Most respondents appreciated that >50% of patients with cancer experience severe chronic pain warranting analgesic therapy (73.5%), and that this therapy could control pain adequately in >50% of patients (77.2%). Approximately three-quarters of respondents rated their use of analgesics for patients with cancer as neither conservative nor liberal. A majority (78.2%) of surveyed physicians regarded the treatment of cancer pain and cancer itself as almost equal in priority. Physicians rated the titration of opioid dose in patients with poor pain control and the assessment of pain severity and cause as the knowledge most urgently needed to manage pain appropriately, followed by dose calculation when switching between opioids, management of nausea in
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To explore how to achieve the best outcome of cancer pain management in China, this study assessed Chinese physicians’ current clinical practice, attitudes toward and barriers to opioid use, and knowledge of cancer pain management. The results of this study provide basic data for recommendations and policies on physician education in this arena.
Chinese Physicians’ Practice Toward Cancer Pain
Table 1
Physician characteristics (n 5 500)
Characteristic
n
%
patients receiving opioids, and dose calculation when switching between oral and parenteral routes of opioid administration. Barriers Toward to Cancer Pain Management Table 4 shows respondents’ perspectives on barriers to physicians’ cancer pain management. The five most frequently cited barriers were inadequate assessment of
Knowledge Toward of Cancer Pain Management Physicians’ responses to questions about knowledge of cancer pain management are shown in Table 5. A majority (65.0%) of physicians responded incorrectly (60.0% agreed and 5.0% had no opinion) that they would increase the dosage of a potent opioid and
Table 2 Physicians’ current cancer pain management practices in China Item
n
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Sex Male 212 45.4 Female 255 54.6 Age (years) 10 178 35.6 Frequency of involvement in palliative care Almost never 4 0.8 Less than once a week 49 9.8 Several times a week 222 44.6 Daily 58 11.7 More than once a day 165 33.1 Participation in a pain-management training program Yes 395 81.1 No 92 18.9 Self-evaluation of knowledge of pain management Excellent 56 11.2 Good 176 35.3 Fair 240 48.1 Poor 24 4.8 Very poor 3 0.6 Adequacy of training in cancer pain management during medical school Excellent 31 6.7 Good 79 17.1 Fair 232 50.3 Poor 69 15.0 Very poor 50 10.9 Adequacy of training in cancer pain management during residency Excellent 50 11.0 Good 184 40.6 Fair 189 41.6 Poor 30 6.6 Very poor 1 0.2
pain and pain management (63.0%), patients’ reluctance to use opioids (62.2%), inadequate staff knowledge of pain management (61.4%), patients’ inability to pay for analgesics (39.0%), and patients’ or families’ reluctance to report pain (38.0%).
%
How frequently do you assess pain in patients with cancer? Every hour 8 1.6 Every few hours 18 3.6 Every day 307 62.2 Rarely 37 7.5 At admission or discharge 124 25.1 What percentage of your patients has cancer pain? 25% 129 25.8 25–50% 184 36.8 51–75% 149 29.8 75% 38 7.6 How often do you treat patients’ cancer pain in consultation with psychologists? Often 72 14.5 Occasionally 286 57.5 Never 139 28.0 Do you use the WHO three-step ladder to treat cancer pain? Yes 353 72.0 No 137 28.0 Do you use a VAS or NRS to assess cancer pain? Yes 475 95.4 No 23 4.6 Do you usually tell your patients about the side effects of opioids? Yes 419 84.0 No 22 4.4 Uncertain 58 11.6 When do you start to manage the side effects of strong opioids? When patients develop them 248 49.8 When opioids are first 212 42.6 prescribed Uncertain 38 7.6 WHO 5 World Health Organization; scale; NRS 5 numeric rating scale.
VAS 5 visual
analog
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Zhang et al.
Table 3 Item
Physicians’ attitudes toward pain management practice in China n
%
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In what percentage of patients do you think cancer pain therapy can achieve a satisfactory outcome? 0–25% 28 5.6 26–50% 99 19.9 51–75% 221 44.5 76–100% 144 29.0 Do not know 5 1.0 In your experience, in what percentage of patients does pain therapy actually achieve a satisfactory outcome? 0–25% 33 6.7 26–50% 75 15.1 51–75% 238 48.1 76–100% 144 29.1 Do not know 5 1.0 Compared with your professional peers, how conservative or liberal are you concerning the use of analgesics for patients with cancer? Much more or somewhat more conservative 50 10.0 Somewhat more or much more liberal 77 15.4 No more conservative or liberal 373 74.6 In your practice, how much of a priority is the management of pain compared with the treatment of cancer and its complications? Less of a priority 41 8.2 Almost equal 391 78.2 As much of a priority 68 13.6 What concerns you most about the use of opioids for cancer pain when you make a prescription? Patient safety 340 68.0 Difficulty in controlling severe side effects 330 66.0 Patient or family fear of narcotics 181 36.2 Insufficient literature to support dosage decision 136 27.2 Cost to the patient/family 88 17.6 Regulatory investigation for narcotic prescription 65 13.0 Diversion of drug(s) to illegal market 145 29.0 Which of the following to you consider to be urgently needed knowledge for the management of cancer pain? Assessment of the cause of pain 261 52.2 Assessment of the severity of pain 288 57.6 Use of nonopioid analgesics for mild pain 146 29.2 Management of somnolence or confusion in patients receiving opioids 193 38.6 Management of nausea in patients receiving opioids 209 41.8 Selection of an initial opioid dose 197 39.4 Titration of opioid doses in patients with poor pain control 296 59.2 Management of postoperative pain 52 10.4 Management of procedural pain 59 11.8 Management of bone pain 74 14.8 Management of pain caused by compression of nerves by tumor 150 30.0 Identification of addiction 101 20.2 Use of controlled-release opioid formulations 58 11.6 Use of “rescue doses” 99 19.8 Use of opioid infusions 96 19.2 Dose calculation when switching between opioids 237 47.4 Dose calculation when switching between oral and parenteral routes of 201 40.2 opioid administration Management of opioid withdrawal symptoms 121 24.2
Chinese Physicians’ Practice Toward Cancer Pain
Table 4
Barriers to physicians’ pain management practice in China
Item
n
%
What are potential barriers in your setting or department to optimal cancer pain management? Inadequate assessment of pain and pain management 315 Inadequate staff knowledge of pain management 307 Lack of staff time to attend to patients’ pain needs 182 Lack of access to different opioid types and formats 171 Medical staff reluctance to administer opioids 105 Patient or family reluctance to report pain 190 Patient reluctance to take opioids 311 Patient inability to pay for analgesics 195
63.0 61.4 36.4 34.2 21.0 38.0 62.2 39.0
ate or severe pain. Additionally, the majority (60.4%) of physicians had accurate knowledge regarding the absorption of oral morphine.
Conversely, the majority of respondents had accurate knowledge of meperidine use; 67.4% would not prescribe meperidine rather than morphine to patients requiring potent opioids, 55.0% did not agree that meperidine caused less harmful effects in long-term opioid use, and 59.4% would not prescribe 50 g intramuscular meperidine q4h PRN to patients with moder-
The purposes of this study were to evaluate physicians’ current practice, attitudes toward, and knowledge of cancer pain management and to examine the relationship between their basis which is the hospital and knowledge deficits. Such an evaluation is a first step in the development of educational projects and management strategies for optimal pain control in China. The
Table 5
The odds ratios presented in Table 6 demonstrate the risks of factors in a group of physicians with knowledge deficits compared with the reference group. Discussion
Physicians’ knowledge of pain management practice in China
Item 1. When a patient needs potent opioids, I would prescribe meperidine rather than morphine. 2. Meperidine causes less harmful effects (such as tolerance, addiction, or side effects) in long-term opioid use. 3. For cancer patients with moderate or severe pain, I would prescribe meperidine 50 mg q4h PRN, IM. 4. For patients with persistent and severe pain, I would increase potent opioid dosage and administer it q4h PRN. 5. Administering opioids on a PRN dosing schedule can decrease the harmful effects of opioids, such as tolerance, addiction, or side effects. 6. Most patients prefer parenteral administration to oral administration. 7. Parenteral administration is more efficacious than oral administration for pain management. 8. The absorption of oral morphine in the gastrointestinal tract is slow and incomplete. Although my patients can eat food normally, I do not like them to take morphine orally.
Strongly Agree (%)
Agree (%)
No Opinion (%)
Disagree (%)
Strongly Disagree (%)
18.2
13.4
1.0
12.6
54.8
21.2
19.0
4.8
18.8
36.2
19.6
14.0
7.0
15.0
44.4
30.4
29.6
5.0
15.4
19.6
23.4
16.6
7.2
16.6
36.2
22.2
24.8
3.2
25.0
24.8
22.2
28.8
4.4
24.0
20.6
19.4
15.4
4.8
20.6
39.8
q4h PRN, IM: Quartus in die Pro kre nata, Injectio intramuscularis.
2199
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administer it every 4 hours as needed (q4h PRN). In addition, about half of physicians had the misconception that opioid administration on a PRN dosing schedule could reduce the side effects of these drugs. A majority of physicians also erroneously favored parenteral over oral administration (50.2%; 47.0% agreed and 3.2% had no opinion), as they believed that the former was more efficacious for pain management (55.4%; 51.0% agreed and 4.4% had no opinion).
Zhang et al.
Table 6
Logistic regression analysis of factors associated with knowledge deficits in opioid prescription
Variable
Percentage of Physicians in Category (%)
Percentage with Inadequate Knowledge (%)
Odds Ratio (95% CI)
CI 5 confidence interval. * P < 0.05.
results of this study demonstrate that lack of experience in cancer care, positive self-evaluation of knowledge on pain management, and positive perception of training in medical school or residency were predictors of inadequate knowledge of cancer pain management. 2200
A large majority (81.1%) of Chinese physicians included in this study had participated in a pain-management training program, in contrast to percentages reported from other countries (30–65%) [21–24]. Most physicians in China have opportunities to receive education in
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Sex Male 45.4 33.0 Female 54.6 34.5 1.07 (0.73–1.57) Age (years) 35 42.1 30.4 10 35.6 30.3 5.1–10 23.0 40.9 1.61 (0.64–1.61) 0.1–5 41.4 40.6 1.59 (1.06–2.33)* Frequency of involvement in palliation Almost never/less than once a week 10.6 49.1 Several times a week 44.6 38.3 0.64 (0.35–1.18) Daily/more than once a day 44.8 33.2 0.73 (0.51–1.06) Participation in a pain-management training program Yes 81.1 36.2 No 18.9 35.9 0.99 (0.61–1.58) Self-evaluation of knowledge of pain management Poor/very poor 5.4 14.3 Fair 48.1 37.1 4.76 (2.85–7.69)* Excellent/good 46.5 73.6 5.88 (3.33–10.00)* Adequacy of training in cancer pain management during medical school Poor/very poor 25.9 27.7 Fair 50.3 33.6 2.04 (1.28–3.22)* Excellent/good 23.8 50.9 1.67 (1.06–2.63)* Adequacy of training in cancer pain management during residency Poor/very poor 6.8 38.7 Fair 41.6 25.9 2.04 (1.33–3.03)* Excellent/good 51.6 41.5 0.83 (0.39–1.75) When do you start to manage the side effects of strong opioids? Uncertain 7.6 23.6 When opioids are first prescribed 42.6 40.1 2.56 (1.75–3.70)* When patients develop them 49.8 63.3 3.57 (1.67–7.69)* In your experience, in what percentage of patients does pain therapy actually achieve a satisfactory outcome? 0–25% 6.7 39.4 26–50% 15.1 33.3 0.77 (0.33–1.80) 51–75% 48.1 34.5 0.97 (0.60–1.56) 76–100% 29.1 41.0 1.31 (0.88–1.95) Do not know 1.0 60.0 2.61 (0.43–15.70)
Chinese Physicians’ Practice Toward Cancer Pain cancer pain management in medical school and during residency. Most physicians (93%) also considered training in cancer pain management to be adequate (excellent/good or fair), whereas dissatisfaction with cancer pain education has been identified in Israel, France, the United States, Finland, and Sweden [22,25–28].
Despite growing attention and increasing knowledge, however, Chinese physicians continue to face challenges to adequate management of cancer pain. Studies conducted in various countries have identified barriers to optimal cancer pain management [5,8,18], and barriers at the health professional level are regarded as the main issue. The main barriers reported by Chinese physicians (inadequate assessment of pain and its management, inadequate staff knowledge, and patients’ reluctance to use opioids) are remarkably similar to those reported in studies conducted in Turkey, Israel, Sweden, Korea, the United States, and France [8,18,21,22,27–29]. These findings indicate the urgent need for educational programs for physicians on the management of pain in patients with cancer and increased emphasis on cancer pain management in physicians’ clinical practice. Patient education and the provision of information on opioid use should also be a priority. Various physician-related factors were evaluated to identify predictors of knowledge deficits in cancer pain management. We found no significant relationship between participation in a pain-management training program and adequate knowledge of opioid prescription. Furthermore, physicians who perceived that they had received good/fair cancer pain management training (in medical school or during residency) were at greater risk of knowledge deficits. These findings confirm that current education in cancer pain management in China is insufficient for physicians’ optimal management of this pain. Physicians’ experience also affected their knowledge of opioid prescription, similar to the finding of Ger et al. [20]. Physicians with more experience in the treatment of cancer pain were more likely to have accurate knowledge of cancer pain management. Thus, clinical practice is another learning source for physicians that could correct misconceptions acquired in preclinical training. As evidenced by the results of similar studies conducted 7year ago [15,16,20], attention to and physicians’ ability to
This study has several limitations. We recruited physicians from medical centers in Sichuan Province only and we surveyed only oncologists, internists, and hematologists, excluding other professionals who might prescribe opioids, such as surgeons and anesthesiologists. Nevertheless, the relationships identified in this study between inadequate knowledge of cancer pain management and physicians’ current practices or attitudes will be useful for further development of active analgesic training programs in China. Although the opioid management remains the core of cancer pain treatment, there are some therapies we do not mention in our survey which are also used in clinical practice in China, such as non-steroidal anti-inflammatory drug (NSIADs), controlled-release morphine, the transdermal fentanyl patch, patient-controlled techniques [30]; and medications such as tricyclic antidepressants (TCAs) and gabapentinoids that are often used to treat neuropathic cancer pain. Also, a high-quality trial showed that auricular acupuncture therapy, which we did not survey for, was significantly superior to placebo in cancer pain alleviation [31]. In summary, our results revealed that physician education in cancer pain management in China does not currently provide the necessary levels of knowledge and skills. Although most physicians had positive attitudes toward cancer pain management, many showed knowledge deficits, especially those who perceived that they had received adequate training. These findings suggest that effective strategies and professional education are needed to encourage physicians’ concern with, experience in, and knowledge of cancer pain management in China. Acknowledgments The authors are very grateful to Wenxiu Yao, Xie Ke, Zumei Luo, Xiaobo Du, Jingbo Wu, Sichuan Tumor Hospital, Sichuan Provincial People’s Hospital, the Second Chengdu People’s Hospital, the Third Chengdu People’s Hospital, North Sichuan Medical College, Mianyang Central Hospital, the Second Yibing Hospital, and Luzhou Medical Hospital/College for their kind assistance with data collection. The authors extend special thanks to the physicians who participated in this study.
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Most surveyed physicians regarded the treatment of cancer pain and cancer itself as having equal priority, whereas 13.6% considered cancer pain treatment and 8.2% considered cancer to be more important. These findings reflect Chinese physicians’ positive attitudes toward the management of cancer pain. In contrast to the findings of other studies, Chinese physicians reported that, in their experience, the outcomes of cancer pain treatment were equivalent to or better than what they knew could be achieved. This finding can be attributed largely to physicians’ increasing knowledge of cancer pain management.
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CANCER PAIN & PALLIATIVE CARE SECTION Original Research Article Physicians’ Practice, Attitudes Toward, and Knowledge of Cancer Pain Management in China
State Key Laboratory of Biotherapy and Department of Head and Neck Oncology, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan, PR China Reprint requests to: Yongsheng Wang, MD, PhD, West China Hospital, No. 37 Guo Xue Alley, Chengdu 610041, People’s Republic of China. Tel: 186-2885553329; Fax: +86-028-85423279; E-mail: [email protected].
Results. Five hundred (90.90%) physicians responded. About one-third (32.6%) of physicians assessed patients’ pain rarely, and 85.5% never or occasionally treated patients’ cancer pain together with psychologists. More than half of physicians indicated that opioid dose titration in patients with poor pain control and assessment of the cause and severity of pain were urgently needed knowledge for cancer pain management. Inadequate assessment of pain and pain management (63.0%), patients’ reluctance to take opioids (62.2%), and inadequate staff knowledge of pain management (61.4%) were the three most frequently cited barriers to physicians’ pain management.
Qiongwen Zhang and Chunhua Yu contributed equally to this work.
Conclusions. Physicians’ positive attitudes toward cancer pain management need to be encouraged, and active professional analgesic education programs are needed to improve pain management in China.
Conflicts of interest: The authors declare no conflict of interest.
Key Words. Cancer Pain; Practice; Attitudes; Knowledge; China Introduction
Abstract Subject. To evaluate physicians’ current practice, attitudes toward, and knowledge of cancer pain management in China. Methods. We conducted a face-to-face survey of physicians (oncologists, internists, hematologists) who are responsible for the care of cancer patient of 11 general hospitals in Sichuan, China between December 2011 and December 2013. Statistical analyses were performed using SPSS (SPSS, Chicago, IL) software. Setting and Design. A 23-item questionnaire was designed and distributed to 550 physicians in 11 medical facilities in China.
Pain is the most frequent and persistent symptom experienced by patients, and it is highly prevalent in patients with cancer [1–3]. Despite substantial evidence that available drugs and appropriate interventions can control 80–90% of cancer pain, this symptom is inadequately treated in an estimated 50–60% of patients [4–7]. Barriers to cancer pain management exist at all levels of the health care system, including the provider, organizational, and patient levels [8]. The responsibility for cancer pain management lies primarily with physicians [9]. The World Health Organization’s three-step analgesic ladder is in widespread use and is gaining increasing attention from physicians in China [10]. However, several problems with this pain management tool remain unaddressed and few researchers have examined physicians’ role in opioid prescription [11–16]. Hospitals 2195
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Qiongwen Zhang, MD, PhD, Chunhua Yu MD, Shijian Feng MD, Wenxiu Yao MD, Huashan Shi, MD, PhD, Yuwei Zhao PhD, and Yongsheng Wang MD, PhD
Zhang et al. in China are divided into three levels by national health and family planning commission of the people’s republic of China and cancer pain management differs among hospitals. Chinese patients are likely to seek care for any condition at the best local hospital for the best service they can get. Only one study has assessed physicians’ concern with and attitudes toward pain management in China [10]. A recently published study demonstrated that lack of knowledge is an impediment to morphine use [17], but no study has comprehensively and extensively investigated the impact of physicians’ basic characteristics and attitudes on the improvement of pain management in China.
percentages) were used to characterize the total sample. For multiple-choice questions, we calculated the percentage of responses to each item. Using chisquared analysis, we examined differences between categorical variables. The significance level was set to P < 0.05. Statistical analyses were performed using SPSS software (SPSS, Chicago, IL). Results We distributed 550 questionnaires and 500 of them responded, and the response rate was 90.9%. Sample Characteristics
Methods Study Design and Subjects Between December 2011 and December 2013, we conducted a face-to-face survey of physicians (oncologists, internists, hematologists) responsible for the care of patients with cancer in 11 tertiary general hospitals in Sichuan, China. All collected questionnaires were anonymous. Questionnaire The 23-item questionnaire, comprised of components from previously reported questionnaires [8,18–21], was designed by researchers from the Cancer Center of West China Hospital, Chengdu, and translated into Chinese. The first part of the questionnaire contained 22 items regarding physicians’ demographic and background characteristics (four items), current practice status (nine items), and attitudes toward (eight items) and barriers to (one item) cancer pain management. The second part consisted of eight items (seven negative and one positive) concerning physicians’ knowledge about analgesic prescription for cancer pain management drawn from a survey developed in Taiwan [20]. Responses to these items were structured by a scale ranging from 1 (strongly agree) to 5 (strongly disagree) for negatively worded questions and from 5 to 1 for positively worded questions. All response data were entried into PC and using statistic software to analyze. Statistical Analysis Physicians’ knowledge was classified according to the method of Ger et al. [20], in which a mean score 3 is considered to indicate “knowledge deficits to prescribe opioids.” Physicians were grouped according to categorical variables. Descriptive statistics (frequencies and 2196
The characteristics of respondents are summarized in Table 1. About half (41.4%) of participants had worked in the hospital for 5 years. Approximately 45% of physicians reported that they attended patients with cancer pain several times a week, and about 33% reported that they did so more than once a day. More than 80% of respondents had participated in one painmanagement training program. Almost half (48.1%) of physicians felt that they had fair knowledge of cancer pain management. Only 23.8% of physicians reported receiving adequate (excellent or good) training during medical school, but 51.6% reported that training had been adequate during residency. Current Cancer Pain Management Practice Chinese physicians’ current cancer pain management practice is described in Table 2. Most (62.2%) physicians assessed patients’ cancer pain every day, although only 14.5% reported that they often treated this pain in consultation with psychologists. Nearly all (95.4%) physicians used visual analog or numeric rating scales to assess cancer pain. Most (84.0%) physicians informed their patients about opioid side effects, and most managed the side effects of strong opioids when patients developed them (49.8%) or when the drugs were first prescribed (42.6%). Attitudes Toward Cancer Pain Management Responses to questions about physicians’ attitudes toward cancer pain management are shown in Table 3. Most respondents appreciated that >50% of patients with cancer experience severe chronic pain warranting analgesic therapy (73.5%), and that this therapy could control pain adequately in >50% of patients (77.2%). Approximately three-quarters of respondents rated their use of analgesics for patients with cancer as neither conservative nor liberal. A majority (78.2%) of surveyed physicians regarded the treatment of cancer pain and cancer itself as almost equal in priority. Physicians rated the titration of opioid dose in patients with poor pain control and the assessment of pain severity and cause as the knowledge most urgently needed to manage pain appropriately, followed by dose calculation when switching between opioids, management of nausea in
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To explore how to achieve the best outcome of cancer pain management in China, this study assessed Chinese physicians’ current clinical practice, attitudes toward and barriers to opioid use, and knowledge of cancer pain management. The results of this study provide basic data for recommendations and policies on physician education in this arena.
Chinese Physicians’ Practice Toward Cancer Pain
Table 1
Physician characteristics (n 5 500)
Characteristic
n
%
patients receiving opioids, and dose calculation when switching between oral and parenteral routes of opioid administration. Barriers Toward to Cancer Pain Management Table 4 shows respondents’ perspectives on barriers to physicians’ cancer pain management. The five most frequently cited barriers were inadequate assessment of
Knowledge Toward of Cancer Pain Management Physicians’ responses to questions about knowledge of cancer pain management are shown in Table 5. A majority (65.0%) of physicians responded incorrectly (60.0% agreed and 5.0% had no opinion) that they would increase the dosage of a potent opioid and
Table 2 Physicians’ current cancer pain management practices in China Item
n
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Sex Male 212 45.4 Female 255 54.6 Age (years) 10 178 35.6 Frequency of involvement in palliative care Almost never 4 0.8 Less than once a week 49 9.8 Several times a week 222 44.6 Daily 58 11.7 More than once a day 165 33.1 Participation in a pain-management training program Yes 395 81.1 No 92 18.9 Self-evaluation of knowledge of pain management Excellent 56 11.2 Good 176 35.3 Fair 240 48.1 Poor 24 4.8 Very poor 3 0.6 Adequacy of training in cancer pain management during medical school Excellent 31 6.7 Good 79 17.1 Fair 232 50.3 Poor 69 15.0 Very poor 50 10.9 Adequacy of training in cancer pain management during residency Excellent 50 11.0 Good 184 40.6 Fair 189 41.6 Poor 30 6.6 Very poor 1 0.2
pain and pain management (63.0%), patients’ reluctance to use opioids (62.2%), inadequate staff knowledge of pain management (61.4%), patients’ inability to pay for analgesics (39.0%), and patients’ or families’ reluctance to report pain (38.0%).
%
How frequently do you assess pain in patients with cancer? Every hour 8 1.6 Every few hours 18 3.6 Every day 307 62.2 Rarely 37 7.5 At admission or discharge 124 25.1 What percentage of your patients has cancer pain? 25% 129 25.8 25–50% 184 36.8 51–75% 149 29.8 75% 38 7.6 How often do you treat patients’ cancer pain in consultation with psychologists? Often 72 14.5 Occasionally 286 57.5 Never 139 28.0 Do you use the WHO three-step ladder to treat cancer pain? Yes 353 72.0 No 137 28.0 Do you use a VAS or NRS to assess cancer pain? Yes 475 95.4 No 23 4.6 Do you usually tell your patients about the side effects of opioids? Yes 419 84.0 No 22 4.4 Uncertain 58 11.6 When do you start to manage the side effects of strong opioids? When patients develop them 248 49.8 When opioids are first 212 42.6 prescribed Uncertain 38 7.6 WHO 5 World Health Organization; scale; NRS 5 numeric rating scale.
VAS 5 visual
analog
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Table 3 Item
Physicians’ attitudes toward pain management practice in China n
%
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In what percentage of patients do you think cancer pain therapy can achieve a satisfactory outcome? 0–25% 28 5.6 26–50% 99 19.9 51–75% 221 44.5 76–100% 144 29.0 Do not know 5 1.0 In your experience, in what percentage of patients does pain therapy actually achieve a satisfactory outcome? 0–25% 33 6.7 26–50% 75 15.1 51–75% 238 48.1 76–100% 144 29.1 Do not know 5 1.0 Compared with your professional peers, how conservative or liberal are you concerning the use of analgesics for patients with cancer? Much more or somewhat more conservative 50 10.0 Somewhat more or much more liberal 77 15.4 No more conservative or liberal 373 74.6 In your practice, how much of a priority is the management of pain compared with the treatment of cancer and its complications? Less of a priority 41 8.2 Almost equal 391 78.2 As much of a priority 68 13.6 What concerns you most about the use of opioids for cancer pain when you make a prescription? Patient safety 340 68.0 Difficulty in controlling severe side effects 330 66.0 Patient or family fear of narcotics 181 36.2 Insufficient literature to support dosage decision 136 27.2 Cost to the patient/family 88 17.6 Regulatory investigation for narcotic prescription 65 13.0 Diversion of drug(s) to illegal market 145 29.0 Which of the following to you consider to be urgently needed knowledge for the management of cancer pain? Assessment of the cause of pain 261 52.2 Assessment of the severity of pain 288 57.6 Use of nonopioid analgesics for mild pain 146 29.2 Management of somnolence or confusion in patients receiving opioids 193 38.6 Management of nausea in patients receiving opioids 209 41.8 Selection of an initial opioid dose 197 39.4 Titration of opioid doses in patients with poor pain control 296 59.2 Management of postoperative pain 52 10.4 Management of procedural pain 59 11.8 Management of bone pain 74 14.8 Management of pain caused by compression of nerves by tumor 150 30.0 Identification of addiction 101 20.2 Use of controlled-release opioid formulations 58 11.6 Use of “rescue doses” 99 19.8 Use of opioid infusions 96 19.2 Dose calculation when switching between opioids 237 47.4 Dose calculation when switching between oral and parenteral routes of 201 40.2 opioid administration Management of opioid withdrawal symptoms 121 24.2
Chinese Physicians’ Practice Toward Cancer Pain
Table 4
Barriers to physicians’ pain management practice in China
Item
n
%
What are potential barriers in your setting or department to optimal cancer pain management? Inadequate assessment of pain and pain management 315 Inadequate staff knowledge of pain management 307 Lack of staff time to attend to patients’ pain needs 182 Lack of access to different opioid types and formats 171 Medical staff reluctance to administer opioids 105 Patient or family reluctance to report pain 190 Patient reluctance to take opioids 311 Patient inability to pay for analgesics 195
63.0 61.4 36.4 34.2 21.0 38.0 62.2 39.0
ate or severe pain. Additionally, the majority (60.4%) of physicians had accurate knowledge regarding the absorption of oral morphine.
Conversely, the majority of respondents had accurate knowledge of meperidine use; 67.4% would not prescribe meperidine rather than morphine to patients requiring potent opioids, 55.0% did not agree that meperidine caused less harmful effects in long-term opioid use, and 59.4% would not prescribe 50 g intramuscular meperidine q4h PRN to patients with moder-
The purposes of this study were to evaluate physicians’ current practice, attitudes toward, and knowledge of cancer pain management and to examine the relationship between their basis which is the hospital and knowledge deficits. Such an evaluation is a first step in the development of educational projects and management strategies for optimal pain control in China. The
Table 5
The odds ratios presented in Table 6 demonstrate the risks of factors in a group of physicians with knowledge deficits compared with the reference group. Discussion
Physicians’ knowledge of pain management practice in China
Item 1. When a patient needs potent opioids, I would prescribe meperidine rather than morphine. 2. Meperidine causes less harmful effects (such as tolerance, addiction, or side effects) in long-term opioid use. 3. For cancer patients with moderate or severe pain, I would prescribe meperidine 50 mg q4h PRN, IM. 4. For patients with persistent and severe pain, I would increase potent opioid dosage and administer it q4h PRN. 5. Administering opioids on a PRN dosing schedule can decrease the harmful effects of opioids, such as tolerance, addiction, or side effects. 6. Most patients prefer parenteral administration to oral administration. 7. Parenteral administration is more efficacious than oral administration for pain management. 8. The absorption of oral morphine in the gastrointestinal tract is slow and incomplete. Although my patients can eat food normally, I do not like them to take morphine orally.
Strongly Agree (%)
Agree (%)
No Opinion (%)
Disagree (%)
Strongly Disagree (%)
18.2
13.4
1.0
12.6
54.8
21.2
19.0
4.8
18.8
36.2
19.6
14.0
7.0
15.0
44.4
30.4
29.6
5.0
15.4
19.6
23.4
16.6
7.2
16.6
36.2
22.2
24.8
3.2
25.0
24.8
22.2
28.8
4.4
24.0
20.6
19.4
15.4
4.8
20.6
39.8
q4h PRN, IM: Quartus in die Pro kre nata, Injectio intramuscularis.
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administer it every 4 hours as needed (q4h PRN). In addition, about half of physicians had the misconception that opioid administration on a PRN dosing schedule could reduce the side effects of these drugs. A majority of physicians also erroneously favored parenteral over oral administration (50.2%; 47.0% agreed and 3.2% had no opinion), as they believed that the former was more efficacious for pain management (55.4%; 51.0% agreed and 4.4% had no opinion).
Zhang et al.
Table 6
Logistic regression analysis of factors associated with knowledge deficits in opioid prescription
Variable
Percentage of Physicians in Category (%)
Percentage with Inadequate Knowledge (%)
Odds Ratio (95% CI)
CI 5 confidence interval. * P < 0.05.
results of this study demonstrate that lack of experience in cancer care, positive self-evaluation of knowledge on pain management, and positive perception of training in medical school or residency were predictors of inadequate knowledge of cancer pain management. 2200
A large majority (81.1%) of Chinese physicians included in this study had participated in a pain-management training program, in contrast to percentages reported from other countries (30–65%) [21–24]. Most physicians in China have opportunities to receive education in
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Sex Male 45.4 33.0 Female 54.6 34.5 1.07 (0.73–1.57) Age (years) 35 42.1 30.4 10 35.6 30.3 5.1–10 23.0 40.9 1.61 (0.64–1.61) 0.1–5 41.4 40.6 1.59 (1.06–2.33)* Frequency of involvement in palliation Almost never/less than once a week 10.6 49.1 Several times a week 44.6 38.3 0.64 (0.35–1.18) Daily/more than once a day 44.8 33.2 0.73 (0.51–1.06) Participation in a pain-management training program Yes 81.1 36.2 No 18.9 35.9 0.99 (0.61–1.58) Self-evaluation of knowledge of pain management Poor/very poor 5.4 14.3 Fair 48.1 37.1 4.76 (2.85–7.69)* Excellent/good 46.5 73.6 5.88 (3.33–10.00)* Adequacy of training in cancer pain management during medical school Poor/very poor 25.9 27.7 Fair 50.3 33.6 2.04 (1.28–3.22)* Excellent/good 23.8 50.9 1.67 (1.06–2.63)* Adequacy of training in cancer pain management during residency Poor/very poor 6.8 38.7 Fair 41.6 25.9 2.04 (1.33–3.03)* Excellent/good 51.6 41.5 0.83 (0.39–1.75) When do you start to manage the side effects of strong opioids? Uncertain 7.6 23.6 When opioids are first prescribed 42.6 40.1 2.56 (1.75–3.70)* When patients develop them 49.8 63.3 3.57 (1.67–7.69)* In your experience, in what percentage of patients does pain therapy actually achieve a satisfactory outcome? 0–25% 6.7 39.4 26–50% 15.1 33.3 0.77 (0.33–1.80) 51–75% 48.1 34.5 0.97 (0.60–1.56) 76–100% 29.1 41.0 1.31 (0.88–1.95) Do not know 1.0 60.0 2.61 (0.43–15.70)
Chinese Physicians’ Practice Toward Cancer Pain cancer pain management in medical school and during residency. Most physicians (93%) also considered training in cancer pain management to be adequate (excellent/good or fair), whereas dissatisfaction with cancer pain education has been identified in Israel, France, the United States, Finland, and Sweden [22,25–28].
Despite growing attention and increasing knowledge, however, Chinese physicians continue to face challenges to adequate management of cancer pain. Studies conducted in various countries have identified barriers to optimal cancer pain management [5,8,18], and barriers at the health professional level are regarded as the main issue. The main barriers reported by Chinese physicians (inadequate assessment of pain and its management, inadequate staff knowledge, and patients’ reluctance to use opioids) are remarkably similar to those reported in studies conducted in Turkey, Israel, Sweden, Korea, the United States, and France [8,18,21,22,27–29]. These findings indicate the urgent need for educational programs for physicians on the management of pain in patients with cancer and increased emphasis on cancer pain management in physicians’ clinical practice. Patient education and the provision of information on opioid use should also be a priority. Various physician-related factors were evaluated to identify predictors of knowledge deficits in cancer pain management. We found no significant relationship between participation in a pain-management training program and adequate knowledge of opioid prescription. Furthermore, physicians who perceived that they had received good/fair cancer pain management training (in medical school or during residency) were at greater risk of knowledge deficits. These findings confirm that current education in cancer pain management in China is insufficient for physicians’ optimal management of this pain. Physicians’ experience also affected their knowledge of opioid prescription, similar to the finding of Ger et al. [20]. Physicians with more experience in the treatment of cancer pain were more likely to have accurate knowledge of cancer pain management. Thus, clinical practice is another learning source for physicians that could correct misconceptions acquired in preclinical training. As evidenced by the results of similar studies conducted 7year ago [15,16,20], attention to and physicians’ ability to
This study has several limitations. We recruited physicians from medical centers in Sichuan Province only and we surveyed only oncologists, internists, and hematologists, excluding other professionals who might prescribe opioids, such as surgeons and anesthesiologists. Nevertheless, the relationships identified in this study between inadequate knowledge of cancer pain management and physicians’ current practices or attitudes will be useful for further development of active analgesic training programs in China. Although the opioid management remains the core of cancer pain treatment, there are some therapies we do not mention in our survey which are also used in clinical practice in China, such as non-steroidal anti-inflammatory drug (NSIADs), controlled-release morphine, the transdermal fentanyl patch, patient-controlled techniques [30]; and medications such as tricyclic antidepressants (TCAs) and gabapentinoids that are often used to treat neuropathic cancer pain. Also, a high-quality trial showed that auricular acupuncture therapy, which we did not survey for, was significantly superior to placebo in cancer pain alleviation [31]. In summary, our results revealed that physician education in cancer pain management in China does not currently provide the necessary levels of knowledge and skills. Although most physicians had positive attitudes toward cancer pain management, many showed knowledge deficits, especially those who perceived that they had received adequate training. These findings suggest that effective strategies and professional education are needed to encourage physicians’ concern with, experience in, and knowledge of cancer pain management in China. Acknowledgments The authors are very grateful to Wenxiu Yao, Xie Ke, Zumei Luo, Xiaobo Du, Jingbo Wu, Sichuan Tumor Hospital, Sichuan Provincial People’s Hospital, the Second Chengdu People’s Hospital, the Third Chengdu People’s Hospital, North Sichuan Medical College, Mianyang Central Hospital, the Second Yibing Hospital, and Luzhou Medical Hospital/College for their kind assistance with data collection. The authors extend special thanks to the physicians who participated in this study.
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Most surveyed physicians regarded the treatment of cancer pain and cancer itself as having equal priority, whereas 13.6% considered cancer pain treatment and 8.2% considered cancer to be more important. These findings reflect Chinese physicians’ positive attitudes toward the management of cancer pain. In contrast to the findings of other studies, Chinese physicians reported that, in their experience, the outcomes of cancer pain treatment were equivalent to or better than what they knew could be achieved. This finding can be attributed largely to physicians’ increasing knowledge of cancer pain management.
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