Undertreatment of cancer pain: barriers and remedies

Over 70% of patients with cancer have moderate to severe pain during their illness and many fear pain more than death itself. There is consensus among experts that most patients can be well-palliated using knowledge, medications, and techniques that are readily accessible. Despite this, only a small proportion of patients with cancer pain receive adequate analgesia. Some of the barriers that interfere with the delivery of appropriate analgesia are patient-related, while others involve health-care providers. Patients frequently do not communicate the intensity of their pain to care-givers and are often hesitant to take opiates. Health-care providers receive scant teaching on cancer pain, have little awareness of pain intensity in their patients, and may be overly concerned about opiate toxicities. They lack appropriate role models in academic institutions and may be concerned about the potential for investigation by law-enforcement agencies. These obstacles can be largely overcome by (a) emphasizing the importance of pain control in cancer patients, (b) considering the etiology of pain in each patient, (c) weighing the full range of available therapeutic options, (d) ensuring that "user-friendly" opiate-equivalence information is available, (e) using pain assessment tools routinely and recording pain intensity scores in the medical record, and by (f) not being easily dissuaded from providing adequate doses of opiates for pain relief. The rationale for and current efforts in each of these areas are discussed in this review.