Current Clinical Opinions, Attitudes and Awareness of Interns Regarding Post-operative and Cancer Pain Management in A Tertiary Care Centre

INTRODUCTION

Pain is one of the most distressing symptoms affecting almost every aspect of life, especially quality of life. Physicians face the challenge of managing postoperative and cancer pain quite frequently. Recently, in a prospective cohort study, Gerbershagen et al. observed that 20-40% of the surgical patients experienced severe pain in the first 24 hours of the postoperative period.[1] Acute postoperative pain management must be optimal in order to encourage early ambulation, thereby, avoiding postoperative pulmonary and cardiac complications and also the development of chronic persistent post-surgical pain.

In a developing nation like India, patients usually present in advanced stages of malignancy. So, in majority of them, palliative care and pain relief forms the mainstay of treatment. In a systematic review of prevalence of pain in cancer patients, it was observed that majority of cancer patients experienced pain in spite of being on anti-cancer treatment. The pooled prevalence of cancer pain was found to be 50% in all cancer types.[2] Prevalence of pain in cancer patients is quite high and 44% experience moderate to severe pain.[3] The characteristics of pain in medical and surgical groups were found to be similar and associated with high levels of anxiety and depression.[4] The worsening cancer-related chronic pain in survivors has been found to have a negative impact on quality of life.[56]

Various factors affecting pain management include the institutional set-up and the awareness and knowledge of patient, nursing staff and treating physicians. The knowledge and attitude of the physician plays a pivotal role in pain management. In our country, undergraduate medical teaching curriculum does not include formal training in pain management. Therefore, evaluation of interns’ opinion on various aspects of pain management is warranted so as to determine the need of change in the academic curriculum at undergraduate level. Numerous surveys have been conducted in various countries to assess their knowledge and attitude toward pain management;[7891011] however, none has been conducted in our country. Hence, the present study was designed to assess the knowledge and attitude of interns and essential barriers to cancer pain management by getting their opinion on various aspects of postoperative and cancer pain and the applied pharmacology.

MATERIALS AND METHODS

This prospective analytic study was carried out in University College of Medical Sciences, a medical institute under Delhi University, India. The interns posted in anesthesia department from November 2011- December 2012 were included in this study. A specific questionnaire [Tables 1–5] was designed to assess their opinions with respect to various aspects of pain management. The questionnaire was adapted from previous surveys conducted by Kim et al.,[7] Nimmaanrat et al.[12] and Ger et al.[13] Though none of the interns had undergone any formal training in pain management, they were involved in pain management in wards. The questionnaire was completed unaided and returned the same day.

Table 1 Interns’ personal experience of postoperative pain and cancer pain

Table 2 Awareness of Interns on use of various tools of pain assessment

Table 3 Opinions expressed by interns on pain characteristics and therapeutics

Table 4 Opinions expressed by interns regarding choice of opioids and side effects

Table 5 Attitudes of interns regarding cancer pain management

RESULTS

Out of 160 interns, 149 completed the questionnaire promptly and five did not agree to fill it. Six interns returned it on the next day, so they were excluded from the study. The data of only 149 interns were analyzed. Most of them were in the age group of 23-27 years and girls [n = 68 (35%)] were less as compared to boys [n = 81 (65%)].

Interns’ personal experience of postoperative pain and cancer pain

About 60% of interns had the prior experience of some of their family member being operated [Table 1]. And 15-30% accepted that postoperative pain management was suboptimal. Only 25% had the chance exposure to cancer pain management and none of them had received any formal classes or practical training in this field. About 60% of them agreed and 30% strongly agreed on the need for structured pain teaching in undergraduate medical curriculum [Figure 1].

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Figure 1

Need of structured pain teaching in undergraduate medical curriculum

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Essential barriers to cancer pain management

According to the majority of interns, lack of sufficient information about opioids, inadequate knowledge of staff and poor availability of opioids were essential barriers to cancer pain management. Lack of dedicated hospitals and lack of infrastructure were also considered significant factors in inadequate treatment of cancer pain [Figure 2].

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Figure 2

Essential barriers to cancer pain management as reported by interns

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DISCUSSION

The present survey reveals that majority of interns in our institute had inadequate knowledge and information about the postoperative and cancer pain management. Though they had positive attitude and were quite enthusiastic about relieving pain, their awareness and knowledge about pain management was not satisfactory.

The present survey highlights that majority of interns knew that pain can be assessed. Majority (67%) of interns agreed that VAS is a good way of measuring the pain intensity, whereas, only 30% and 25% were aware of NRS and facial scale, respectively. The knowledge of pain measurement tools is essential for optimal pain management. Previous studies that have been undertaken to assess the knowledge and attitudes of doctors on pain management, have only assessed their awareness on pain assessment; though, the assessment of knowledge on various pain measurement tools was lacking. A survey conducted by Kim et al.[7] assessing knowledge and attitudes about cancer pain management reported 33.9% had never heard of VAS, NRS, VRS and FPS; though 37.2% had heard of it, only 28.9% were using these scales in clinical practice.

In the present survey, 63% of the interns acknowledged PCA as an option for ensuring adequate postoperative pain management, but surprisingly, only 25% knew how to use it in clinical practice. The knowledge of PCA among physicians has not been assessed earlier in the previous studies.

The knowledge of pain characteristics and therapeutics is essential for optimal pain management. In a survey,[7] half the physicians knew that pain is the fifth vital sign, on the contrary, in our survey, only 30% knew it. The knowledge on neuropathic pain manifestations, multimodal pain management and non-pharmacological means was found to be satisfactory among interns in our survey. But a large majority of the physicians were unaware of neuropathic pain symptom inventory as a mean to assess neuropathic pain. WHO's concept of an ‘analgesic ladder’ involving a stepwise approach to the use of analgesic drugs is the most widely practiced method in cancer pain management. In our survey, approximately half of interns agreed that WHO step ladder approach is the best way of treating cancer pain and around 8% of interns agreed strongly. Physicians in Korea (62%) and Zaria (79%) have shown better awareness of this concept.[714]

The assessment of interns’ knowledge on opioid-related pharmacology was an important aspect of the present survey. As per Ger et al., the mean (SD) score of physicians’ overall knowledge of opioid prescribing and the correlates was 2.91 (0.68); whereas, in our survey it was 3.46 (0.23).[13] This study was conducted almost a decade before and the increasing awareness and advancement in the clinical pain practice may be considered as the contributing factors for this variation in results.

Kim et al. revealed that physicians with personal experience on opioids prescription and with educative experience were found to have significantly better knowledge on cancer pain management than others who had no such exposure. In personal experience, one of the factors used by them was self-rated comparative knowledge level about cancer pain management. Though, this factor may not be authentic, as it is self-rated, still it was observed in this survey that physicians with highly perceived knowledge status about cancer pain management had significantly better knowledge than others.

Regarding the need of potent opioids for cancer pain relief, Ger et al. revealed that almost half of the physicians preferred meperidine over morphine due to the less harmful effects in long-term use.[13] In a similar survey assessing interns’ knowledge on cancer pain management, approximately 40% preferred morphine, whereas, 30% considered meperidine instead of morphine.[12] On the contrary, majority (70%) of students during their clerkship considered morphine for cancer pain management as per Manalo.[15] However in this survey, opinion on meperidine was not obtained and approximately half of the interns considered morphine over meperidine as the opioid of choice for cancer pain management.

Majority of the interns in our survey agreed to increase the dose and frequency of opioids in case of persistent pain. Whereas, previous surveys[1213] revealed that 52.4% of the physicians and 41.4% of interns would increase opioids dosage and frequency for severe and persistent pain. The reason for only half of the physicians agreeing on this could be because of the fear of its side effects. This was further authenticated when they also considered lowering the dosages of opioids in view of its side effects. We have attempted to assess this and found that a large majority of interns agreed to transdermal fentanyl as a good option for cancer pain management.

Though oral morphine can very well be used for cancer pain management, still it is not preferred owing to its slow and erratic absorption. In the published literature, many studies have actually tried to take opinions specifically pertaining to oral route of morphine. Results in a study by Kim et al. revealed that around 70% of physicians were in favor of oral analgesics as first option for cancer pain relief. In other similar surveys, around 30-40% of the respondents agreed on avoiding oral morphine[1213] but in the present survey, about 38% of interns preferred oral morphine despite its slow and unpredictable absorption.

The attitude of the treating physician plays a pivotal role in cancer pain management. The knowledge depends on prior teaching, learning and experience; however, the attitude for treating pain is altogether, an independent factor. Adequate pain relief is equally important even in cases of terminal cancers with poor prognosis. In our survey, a very few number of interns agreed on providing adequate pain relief to cancer patients in face of poor prognosis and majority of the students had no viewpoint in this respect. Whereas, in other surveys, around 30-40% of physicians and interns considered maximal doses of analgesics for severe pain without considering its side effects even when the prognosis was less than 6 months.[1415] Von Roenn et al.[16] and Cleeland et al.[1718] observed that around 20-30% of physicians showed the tendency to wait to provide optimal analgesia until the life expectancy of patient is less than 6 months. Manalo revealed that 75% of medical students agreed on providing non- restricted use of opioids in final stages of cancer.[15]

Various factors may be responsible for higher requirement of drugs in cancer patients. In our survey, the factors that were felt by majority were associated depression/anxiety and tolerance/addiction. Nimmaanrat et al. also evaluated these parameters and revealed that majority associated the higher requirement of drugs in CPM with increased pain, whereas, very few associated it with anxiety or tolerance. This survey by Nimmaanrat et al. concluded that the participating interns had positive attitude toward optimal opioids usage in cancer pain but their knowledge was erroneous at many instances. This is in concordance to our results, where majority of interns were found to have positive attitude in CPM. Contrary to this, Ger et al. and Weinstein et al. had demonstrated the negative attitudes of physicians toward cancer pain management.[1319] They also highlighted that majority of physicians had substantial knowledge deficits in opioid usage.

Regarding essential barriers to cancer pain management, a large majority (65%) of the interns in our set-up attributed it to the lack of sufficient information about oral opioids. Other barriers identified were inadequate knowledge of staff, poor availability of opioids and lack of monitoring after administration. In a survey by Nimmaanrat et al., majority of interns considered inadequate knowledge of pain management, inadequate pain assessment and lack of time to focus on patients’ requirement being the foremost barriers to effective pain management.[12] The survey conducted in Israel revealed that inadequate assessment of the pain and pain relief, inadequate knowledge of pain therapy and physician reluctance to prescribe opioids were the common barriers in cancer pain management.[20] In Taiwan, the foremost barriers were physician-related problems like inadequate guidance, knowledge and pain assessment in cancer patients.[13] Manalo concluded that fear of addiction, lack of adequate knowledge and experience, and fear of complications are the limitations of opioid usage.[15] According to Peker et al., barriers originating from health professionals and systems are more important than the ones resulting from patients alone.[21] One of the barriers implicated in poor cancer pain management is misconceptions of the patient and their relatives. According to Tse et al., cancer pain management improves when patients are educated about different strategies of pain management.[22]

In addition to knowledge, experience in the field also plays an important role. Levin et al. found that patient volume is one of the factors affecting physicians’ knowledge of opioids.[23] So a physician treating more patients on a daily basis is likely to have better knowledge and liberal attitude toward opioids prescription. The limited availability of opioids and the traditional medical teaching which lacks structured pain curriculum are major contributors of knowledge deficiency in interns. Stiefel et al. derived contrary results as the treating physicians were provided with appropriate training before this.[24] This implies the need to include cancer pain management in teaching curriculum, practical training and case discussions projecting problems and management of these patients. There is also a need to reinforce the concepts of optimal pain management in surgeons as well as physicians.

There are some limitations of this study. First, the data were gathered from interns of single institution only. Thus, it was not possible to compare cross-national differences in opinions and attitudes of interns from across the nation. Additionally, if data could be collected from interns of multiple hospitals, that would have enhanced validity of the study. Second, the interns who participated in the survey had no prior exposure to awareness of pain and pain management.

In conclusion, majority of interns displayed inadequate knowledge, inadequate information but positive attitude toward optimal pain management and optimal use of opioids. This inverse relationship between undergraduate medical education and knowledge of interns must be further explored so as to establish the main causes for such an observation. Extensive joint multidisciplinary efforts and a well-designed pain education program are required to update the information and the knowledge of these interns about use of opioids in postoperative as well as cancer pain management. We also wish to influence the educational administrators to make appropriate changes in the undergraduate medical curriculum with special emphasis on pain management. Hence, enormous efforts are required to rectify this current prevailing situation so as to improve the awareness, knowledge and attitudes of interns with respect to satisfactory postoperative and cancer pain management.