Tuesday, March 30, 2010

Fear of morphine persists in around the globe


Last summer I had the distinct pleasure of hosting three medical students from Tongji University Medical School, Shanghai for a month elective in palliative care. The three students voraciously absorbed information about tending to patients with life-limiting illness - including communicating difficult news, negotiating goals of care, basic and complex symptom management. We reflected on the differences in practice and in palliative care medical education between UMass and Tongji U in Shanghai.


They were frankly surprised by how commonly morphine was prescribed for severe cancer pain. In China, they shared with me, meperidine is the drug of choice. I was equally stunned by their response as they were to our prescribing practices, to say the least. I wondered how much this was their level of experience versus a more general practice in China. Not long after, Supportive Care in Cancer published an article reviewing just this issue.

Physicians (including internists, surgeons, breast cancer specialists, gynecologists, orthopedists) from four tertiary care hospitals in Changchun (Northern China) and Changsha (Southern China) were surveyed, and the 201 of the 210 selected responded (97.5% response rate). The questionnaire evaluated 3 general categories:
  1. Knowledge of WHO guidelines and preference with drug choice for cancer pain management;
  2. Knowledge of cancer pain management and actual morphine utilization patterns;
  3. Physician perception of factors impeding use of morphine in clinical practice.
A brief overview of the results: Close to 50% of physicians had comprehensive understanding of the WHO guidelines. The drug of choice for severe cancer pain was meperidine (pethidine). Only 33.8% understood basic principles of opioid dosing (such as the lack of a maximal dose of morphine - despite China's State Food & Drug Administration officially supporting this fact since 2000), and this knowledge gap did not correlate with experience level of the physician, but rather with whether physicians had received specific training on opioids. The principle barriers to prescribing morphine included lack of training in cancer pain management, fear of addiction or diversion, and personal preference. Certainly, China's government has been on the forefront of supporting WHO initiatives in this arena and has one of the highest world-wide levels of access of opioids for severe pain.

Since that time, I have reflected on this data with trainees from different countries, including Peru and Korea - similar perceptions arise by the physicians reflecting on practice standards in their home countries. Experiences by colleagues teaching around the world suggest similar knowledge gaps, and fortunately, like this study suggests: providing education on cancer pain management quickly changes knowledge and practice by clinicians who have access to morphine and other opioids.

I applaud the efforts by Open Society Institute, Institute for Palliative Medicine, Institute Catalan de Oncologia (a palliative medicine WHO demonstration site), and the International Association for Hospice and Palliative Care in increasing expertise in pain management and palliative care across the globe. These groups have lead educational and consulting sessions in host countries, funded and invited physician leaders from across the globe to study with Palliative Care experts and take their knowledge home. Young physicians and medical students interested in International Medicine may want to consider HPM as a specialty because of the opportunity for international collaboration. Holly Yang MD - a good friend, excellent teacher, and Midwesterner-turned-California-surfer - is a great example of the upcoming Palliative Care physicians (HPM-LEAD participant) delving into international medicine by teaching international fellows at San Diego Hospice and traveling across the Globe to "spread the knowledge" of this field, promising to continue and to expand upon the work of current leaders in this field like Frank Ferris MD and Kathy Foley MD.

I will be traveling to Shanghai this spring, and look forwards to sharing what I've learned from our Chinese colleagues upon my return.
ResearchBlogging.orgYanjun, S., Changli, W., Ling, W., Woo, J., Sabrina, K., Chang, L., & Lei, Z. (2009). A survey on physician knowledge and attitudes towards clinical use of morphine for cancer pain treatment in China Supportive Care in Cancer DOI: 10.1007/s00520-009-0768-2

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