1 Quality of Cancer Care Branch, Research Institute and Hospital, National Cancer Center, Goyang, Gyeonggi; 2 Department of Family Medicine, Seoul National University, Seoul; 3 Cancer Information Branch, Research Institute, National Cancer Center, Goyang, Gyeonggi; 4 Department of Internal Medicine, Seoul National University Hospital, Seoul; 5 Department of Internal Medicine, Kyunghee University Hospital, Seoul; 6 Department of Internal Medicine, The Catholic University of Korea, Seoul, Korea
* Correspondence to: Dr B. Y. Huh, Department of Family Medicine, Seoul National University Hospital, 28 Yungun-dong, Jongro-gu, Seoul, Korea. Tel: +82-27603351; Email: bongyul{at}plaza.snu.ac.kr
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Abstract |
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Methods:: A questionnaire based on a hypothetical case designed to assess the prescription of morphine by physicians was administered to 800 specialists in the Korea Cancer Association, of whom 147 (18.4%) responded, and to 2200 specialists in the Korean Academy of Family Medicine, of whom 388 (17.6%) responded. We used a multidimensional approach to identify the predictors of prescription of morphine by physicians.
Results:: In the hypothetical case scenario, only 16.5% of the respondents stated that they would prescribe morphine for severe cancer pain. Multiple logistic regression analysis showed that physicians with a positive attitude regarding opioid addiction [odds ratio (OR) 2.62; 95% confidence interval (CI) 1.544.46], experience of pain assessment (OR 2.09; 95% CI 1.133.87), recent residency training (OR 2.27; 95% CI 1.304.0) and positive self-evaluation as an oncology specialist (OR 2.60; 95% CI 1.414.78) were more likely to prescribe morphine. None of the 13 variables in the knowledge dimension significantly predicted prescription of morphine for severe cancer pain.
Conclusions:: The results of the survey suggest that we need to develop strategies to develop a positive attitude toward opioids, to increase experience in pain assessment and to improve cancer pain management training among Korean physicians.
Key words: cancer pain, morphine, physician, prescription
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Introduction |
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Even though approximately 10 000 new cases of cancer are diagnosed each year in Korea [14], and cancer is the leading cause of death, no national policy for the improvement of cancer pain relief, such as national clinical guidelines or training programs for managing cancer pain, has been established. In addition, supplies of various opioids are limited, as is insurance coverage for them.
Although countries differ in training requirements, legal restrictions and drug availability, recent studies of physicians' attitudes have found that the most important barriers to appropriate CPM are problems related to the physician, including inadequate knowledge of CPM, inadequate pain assessment experience, excessive concern about addiction, tolerance and the side-effects of pain medications, underestimation of the number of patients in pain and the low priority of pain management in cancer care [5, 13
, 15
21
]. In addition, many studies identified predictors associated with less frequent morphine prescription [15
], earlier intervention with maximum analgesic therapy [15
, 16
, 20
], a reluctance to prescribe morphine and the physician's knowledge of cancer pain [13
, 18
].
To improve CPM in Korea, we believe that it is important to identify the predictors of prescription of morphine for severe cancer pain by physicians. We endeavoured to identify these predictors by conducting a national survey in based on a hypothetical case scenario.
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Methods |
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We received answers from 147 (18.4%) of the 800 specialists in the Korea Cancer Association at university or general hospitals and 388 (17.6%) of the 2200 specialists in the Korean Academy of Family Medicine. The overall response rate was 17.8% and 514 valid questionnaires were analyzed. Specialties included family medicine (71.4%), internal medicine (13.8%), surgery (5.3%), radiation oncology (3.3%) and others (6.3%).
Questionnaire
To evaluate physician attitudes to the prescription of morphine for severe cancer pain, we included the following hypothetical scenario in the questionnaire.
A 40-year-old man is hospitalized with severe untreated back pain of more than 1 month duration attributable to bone metastases without vertebral collapse. He weighs 70 kg; he has no cardiovascular or respiratory problems and his prognosis is <12 months. He has no history of medication allergies and is opioid naive. What would be your recommendation for an initial analgesic drug for the patient?
Physicians who indicated that they would use a strong opioid such as morphine were regarded as having answered the question correctly and in keeping with appropriate CPM practices.
The instrument, which comprised components of previously reported questionnaires [16, 18
], was designed to assess participating physicians on situational factors, attitudes, knowledge and personal experience (Table 1). Attitude questions used a scale, ranging from 1 (not at all concerned) to 5 (extremely concerned). Knowledge questions used a Likert scale, with 1 being strongly agree and 5 being strongly disagree. We considered a desired response to be one that indicated few knowledge deficits and appropriate attitudes.
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We used a three-step multidimensional approach to identify the predictors of prescription of morphine for severe cancer pain. In the first step, for the categorical variables within each dimension, we used 2 tests to screen the predictors significantly associated with the prescription of morphine In the second step, to identify potentially important predictors, we performed multiple logistic analyses with one-dimensional approaches. We then selected variables with significant associations for one-dimensional multiple stepwise logistic regression analysis. In the last step, to identify potentially important predictors, we performed multiple logistic analyses with a multidimensional approach from the second step. We used SPSS program version 11.0 and defined statistical significance as P <0.05.
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Results |
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Univariate analysis and one-dimensional predictors of prescription of morphine for severe cancer pain
In univariate analysis for situational dimension, age, practice setting, medical specialty, years in medical specialty and self-evaluation as an oncology specialist were significantly related to prescription of morphine for severe cancer pain (Table 3). One-dimensional multiple regression analysis with these five variables suggested that years in medical specialty, self-evaluation as an oncology specialist and practice setting were independent predictors (Table 4).
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Univariate analysis for attitude dimension showed that factors significantly related to prescription of morphine included regarding the patient as being the best judge of pain severity, lack of concern about the patient or a family member becoming addicted to opioids and earlier intervention with maximum analgesic therapy (Table 5). Multiple regression analysis also showed that these variables, except for lack of concern about a family member becoming addicted to opioids, were statistically significant predictors (Table 4).
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Multidimensional multivariate analyses of prescription of morphine for severe cancer pain
To conduct the final multidimensional logistic regression analysis, we combined the eight significant variables identified by one-dimensional multivariate analysis (Table 6). The three-step multidimensional multiple logistic analyses showed that four categories of physicians would prescribe a strong opioid for severe cancer pain: in the situation dimension, physicians with <10 years in their medical specialty and those who thought of themselves as oncology specialists; in the experience dimension, those who had used a pain scale; in the attitude dimension, those rarely concerned about patient addiction to opioids. No variable in the knowledge dimension significantly predicted prescription of morphine for severe cancer pain.
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Discussion |
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In response to a hypothetical severe cancer pain scenario, only 16.5% of respondents stated that they would prescribe a strong opioid such as morphine. Almost half the sample would use only codeine or non-steroidal analgesics, and almost a quarter would wait until the patient had end-stage disease. These findings were unfavorable compared with those of the Eastern Cooperative Oncology Group [17], the Radiation Therapy Oncology Group [20
] and an Israeli study [13
], in which 4152% of physicians stated that they would provide an opioid for the treatment of severe cancer pain. Furthermore, in contrast with previous surveys [13
, 16
, 17
, 20
], which showed that few physicians were concerned with the possibility of opioid addiction, we found that this was a concern with many family physicians and oncologists in Korea.
Physicians who had received training more recently were more likely to prescribe morphine for severe cancer pain. Other studies have also found that younger physicians had better CPM concepts [16, 17
, 22
]. In addition, self-evaluation as an oncology specialist was associated with prescription of morphine for severe cancer pain, but specialty and the number of cancer patients treated had no influence. Therefore our results indicated that recent training and more experience in specialized oncology were more important than physician age, specialty and patient volume [15
, 22
].
Multidimensional multiple regressions showed that inappropriate concerns regarding patient addiction were associated with inadequate prescription of morphine for severe cancer pain. In contrast, while regarding the patient as the best judge of pain severity and being willing to intervene early with a maximum dose of analgesics were associated with appropriate prescription of morphine for severe cancer pain in one-dimensional multiple regression, these factors lost their independence in multidimensional multiple regression. It should be noted that univariate analysis showed that knowledge regarding tolerance, adverse effects, risk of addiction, adjuvant and effectiveness of opioids were not significantly associated with a physician's ability to respond correctly to questions on the management of severe cancer pain. Although univariate analysis found that treatment of pain by the clock was a predictor in the knowledge dimension, it lost independence in multivariate analyses. Thus, overall, our results support previous findings that inappropriate attitudes regarding opioid addiction are a more important barrier to adequate CPM than physician knowledge about CPM [17], and that improved basic knowledge is not sufficient to improve cancer pain practice [8
, 11
, 15
].
We also found that experience with pain assessment was a strong predictor of prescription of morphine for severe cancer pain, confirming that poor pain assessment is the single most important barrier to optimal CPM [13, 18
, 20
]. Moreover, our findings and those of other studies indicate that new effective strategies and professional education regarding optimal CPM must address the attitudes of physicians toward opioid addiction [16
, 17
, 19
, 23
, 24
]. Because physician judgment plays a major role in the administration of morphine for severe cancer pain, incorporation of the principles of CPM into therapeutic protocols and residency training, improvement of health professionals' evaluation of pain as a vital sign during routine medical practice, and monitoring pain assessment and relief as indicators of quality of care may improve CPM [19
, 20
, 23
25
].
There were limitations to our study. The first was the low response rate (17.8%), perhaps indicating that physicians who responded were more interested in the issue of pain control and thus introducing a self-selection bias. Therefore our results may underestimate the percentage of physicians who appropriately prescribed morphine for cancer pain control. Secondly, although it may be regarded as questionable to use a hypothetical case scenario to assess prescription of morphine by physicians for severe cancer pain, this technique has been used elsewhere to evaluate physician pain management practice [1618
].
In conclusion, our results revealed that, in Korea, positive attitudes toward opioid addiction, experience in pain assessment, more recent training and self-evaluation as an oncology specialist were predictors of prescription of morphine for severe cancer pain and were more important than knowledge of CPM. This suggests that we need to develop strategies to develop a positive attitude toward opioids, to increase experience in pain assessment and to improve CPM training among Korean physicians.
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Acknowledgements |
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Received for publication October 3, 2004. Revision received January 9, 2005. Accepted for publication January 10, 2005.
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