Treatment for cancer pain in France

EDITOR,--Francois Larue and colleagues draw attention to the persisting problem of undertreatment of cancer pain.1 In their French multicentre study of patients (most of whom were inpatients) 30% (84/279) of patients with cancer pain received no analgesic drugs. Of those patients given analgesics, 51% (137/270) received inadequate treatment for their pain. Discrepancy between physicians' and patients' pain ratings, young age of the patient, absence of metastatic disease, and better performance status were predictors for the undertreatment of cancer pain. The authors conclude that poor assessment of cancer pain is an important factor in the undertreatment of such pain.

The observation that less “seriously ill” patients with cancer are more likely to be undertreated prompts the speculation that physicians may be overcautious about using opioids in these patients owing to an ill-founded fear of addicition. We suggest that the poor assessment of pain described by Larue and colleagues is only one part of a widespread lack of knowledge on the part of physicians about managing cancer pain.

We have analysed the prescribing patterns of German physicians in the treatment of cancer pain.2 We found that only 322 of 16630 (1.9%) patients with cancer received strong opioids. In all, 191 of 328 (58.2%) practices did not prescribe a single strong opioid to their patients with cancer in three years; 295 (31%) of the prescriptions for morphine and buprenorphine were written for an inadequate intake schedule. Few patients who were receiving strong opioids received treatment for side effects of opioids (laxatives were given to 48 (14.9%) patients and antiemetics to 49 (15.2%). Only 75 (23%) patients receiving strong opioids also received non-opioid analgesics. We conclude that patients with cancer pain in Germany are severely undertreated.

Our data suggest that restrictive laws on prescribing strong opioids,lack of knowledge about health care providers, and prejudice against opioids impede effective management of cancer pain in Germany. While some European countries, particularly Britain and Denmark, have achieved a satisfactory level of care for patients with cancer pain, most European countries are still far behind this standard.1 2 3 4 Further education in the management of cancer pain and the dissolution of prejudice against opioids is warranted. Governments should be forced to liberalise restrictive laws on opioids. As long as penalties of up to DM50000 (£23000), as in Germany, impede the prescribing of opioids, the situation for patients with cancer pain will not change. We hope that Britain does not have to introduce laws on opioids similar to Germany's as a result of the European Union.