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Attitudes about cancer pain: A survey of Wisconsin's first-year medical students
vol. 5 No. 6- DecemberI990
Journal of Pain and SymptomManagement 345
*
Attitudes isconsin’s
ical
ents
David E. ~eiss~an, MD, and June L. Dahl, PhD 1piviskmof Hematology&2ncology(DE. W.), Depurtment ofMedicine, Medical College of Wisconsin, Milwaukee, Wisconsin; and Department of Pharmacology (J.L.D.), Universityof Wisconsin-Madison Medical School, Madison, Wisconsin
Abstract A brief questionnaire was administered to dl7
Cancer pain,
psy :hologicat
dependence, medical student education
During the past 20 years, increasing attentk3n has been paid to the undertreatment of cancer pain. It is now well documented that the pain 14 cancer is often inadequately treated and that a multitude of barriers result in unnecessa~ patient suffering. lb At least part of the problem is due to the fact that physicians often lack
Addressre@nt requestf a~: David E. Weissman, MD, Di~ion of ~ematolo~Oncolo~y~ Milwaukee County Medical Complex, 8700 West Wisconsin Avenue, Milwaukee, WI 53226.
Acceptedfor publication:April 9, 1990.
8 U.S. Cancer Pain Relief Committee, 1990 Published by Elsevier. New York, New York
knowledge of tbe methods for assessment and treatment of tamer pain, that they have excessive concerns about opioid ana!~e~ir stde effects and psychological dependence (addiction), and that they are concerned about regulatory scrutiny if they are “liberal” prescribers of opioids.6*7 In this study, we report the results of a survey administered to first-year medical students in Wisconsin to assess their attitudes about cancer pain and its management. The goal of this study, which is part of the physician education program of the Wisconsin Cancer Pain fnitiative, was to identify any negative attitudes held by these students that should be addressed by curricular changes.
346
Wt7bsmtm and Daht
A brief questionnaire was completed by S l7 (97%) entering medical students at the Medical C&ge of Wisconsin and the University of Wis#Amazon during an orientation session held prior to the start of the 1988-89 academic year. The questioner consisted of 11 multiple choice questions to assess attitudes about cancer pain and its treatment and eight additional questions to provide demographic information about the respondents (Tables 1 and 2). Gh$square and ManteCHaensael chi-square tests were used to as,sess correlations between student attitudes and demographic characteristics such as age, sex, size of horn2 town, history of cancer, chronic pain, or drug and alcohol abuse in themselves, family members, or a close friend.
Seven questions addressed general attitudes about the cause and treatment of pain. Students felt that cancer pain was very common (95% indicated that >60% of patients experience pain); that pain was often of long duration (79% indicated that >60% of patients with cancer experienced pain for >I mo); and that the cause of pain was the disease itself (7 1%) rather than the treatments (28%) or preexisting conditions (1%). Students were pessimistic about the possibility of providing pain relief: only 62% indicated that >60% cancer pain could be relieved. In the sample, 47% of the students felt most patients axe overmedicated. Only indicated that most patients are undermedicated. Most students (83%) felt that the patient is the best judge of pain intensity. However, only 35% felt that maximal analgesic therapy was appropriate at any time, and 44% felt martimal therapy should be reserved for patients with a prognosis of 62 mo. Four questions addressed attitudes about the use of opioid analgesics. Over one-half of the students (57%) felt that psychologic dependence (action) occurs frequentiy or very frequently when opioids are used to treat cancer pain. A boy high percentage indiited they would be moderately or extremely concerned about addiction if opioids were administered to a fam$’ member in pain. Students felt there was little tisit of suicide from opioids, wirh only 12% in-
Journal of Pain and Sympnn ?klanapwnt
dicating suicide was a frequent occurrence and none feeling it occurred very frequently. The students overwhelmingly assumed that increasing pain in a patient with cancer indicates analgesic tolerance (72%) rather than worsening disease (20%) or addiction (8%). Age was a major factor affecting attitudes. Compared to students age 26-25, students age 26 or older believed that (a) a greater percentage of cancer pain can be relieved (p = O.O~),(b) the majority of patients are undermedicated Q = O,~), (c) pain is more likely due to the cancer itself Cp= 0.004), and (d) increasing pain indicates wo~ening of the cancer &= 0.044). Older students were also less concerned about a family mem~r amine admits to morphine (p=O.OOl) and were more likely to believe that the patient is the best judge of pain fp = 0.01). Students from larger communities (> 100,000 ~pulation) were more likely to be concerns about addiction @=0.009) and also more concerned about the risk of suicide with opioids V,= 0.009). Students who had worked with cancer patients were iess concerned that their family members would become addicted to morphine Ip -0.004). Female students were more likely to indicate that maxima1 pain therapy was appropriate at any time during the course of the disease Cp=0.004). There were no significant correlations between responses to the questions and a history of cancer or chronic pain La the students themselves, a family member, or friend, or a history of drug or alcohol abuse in themselves, a family member, or friend.
Thii survey showed that students emer Wisconsin’s two medical schools with certain erroneous, indeed negative, attitudes about cancer pain and its treatment, including 1) the belief that maxima1 drug therapy should be dependent on prognosis: 44% thought that maximal drug doses should be reserved for patients with a prognosis of 3 mo or less; 2) an exaggerated fear of opioid psychologic dependence (addiction): 57% of students believed that this occurs frequently or very frequently when in fact the reported incidence of addiction is quite rare;’ 3) the belief that increasing pain is invariably
Vol. 5 No. 6 December 1990
Attituh
Ahut Cancer Pa&
_-
Table 1 Cancer Pain Attitude Questionnaire 1. What ~~en~~ a) 20% b) 40% c) 60% d) 80% e) 100%
of cancer patients suffer pain?
2. What percentage of cancer patients suffer pain for > i month? a) 20% b) 40% c) 60% d) 80% e) 100% 3. What percentage of pain can be relieved with treatment? a) 20% b) 140% c) 60% d) 80% e) 100% 4. Which of the following is true? a) Most patients receive adequate pain treatment. b) Patients receive more pain medication than necessary. c) The majority of patients are uiidermedicated, 5. Psychologic dependence to narcotics as a resuh of legitimate prescription to patients with cancer pain occurs a) very frequently (>l in 10) b) frequently ( 1: 10 to 1: 100) c) 0ccasionaHy ~l:lO~lOOO) d) rarely (< 1 in 1000~ 6. Suicide with an overdose of narcotics pIescribed for cancer pain occurs a) very frequently (> 1 in 10) b) frequently (1:lO to 1:lOO) c) occasionaliy (l:lOO-1000) d) rarely (< 1 in 1000) 7. The best judge of cancer pain intensity is a) the treating physician b) the patient’s nurse c) the patient d) the patient’s spouse or family 6. Your degree of concern about addiction if a family member is given morphine for cancer pain would be a) no concern b) mild concern c) moderate concern df extreme concern 9. At what time a) any time b) prognosis c) prognosis d) prognosis
is it appropriate for patients to receive m.aximal doses of analgesics?
10. Cancer pain is most Likelydue to a) cancer treatments b) cancer itself c) preexisting conditions unrelated to the cancer 11. Increasing requests for analgesics indicates a) psychological dependence (addiction) b) worsening cancer c) tolerance to the analgesic
347
Weis.wu
348
and Dahl
Journal of Pain and Symptom Management
Table 2 Medical Student Demographic Characteristics Characteristics Iikkal school Medical College of Wisconsin University of Wisconsin !kX
Male
Female Agt 20-25 26+ Townsize <25,000 ‘Lb 100,060 > 106,006 Family member health professional Yes No
n
6%
185 132
200 105
(63)
292 74
(73) (23)
WV
99 86 121 127 186
Self/relative/friend had cancer
180 134
(57) (42)
Selflrclativelfriend had pain for > I month Yes No
179 134
(57) (42)
Self/relative/friend abuse drugs/alcohol Yes No
100 213
(92)
WorWvolunteer with cancer patients Yes No
116 198
(57) (62)
Yes No
(67)
Note: In some categories. the totals do not equal 100% due to incomplete data.
related to drug tolerance: only 20% thought increasing pain was due to tumor ssion; and P lack of appreciation for the fact that cancer 4) pain is often undertreated: only 34% thought patients were undermedicated. Most students appropriately felt that the patient is the best judge of pain intensity and that suicide is uncommon in patients who receive opioids for pain. Furthermore, although stu-
dents had a realistic understanding of the incidence and durxion of cancer pain, they were imistic about the possibility of providing relief. Their views refiect those of the general public who feel that pain is to be expected with cartcerVthat it is often severe and that it is difficult to treaLS Age was the demographic characteristic that most a&c&d attitude. Older studenrs had
molyl positive attitudes than did their younger colleagues. This finding was unexpected and has no obvious explanation. Students from larger communities were more concerned about psychologic dependence (addiction) to opioids and about suicide with these drugs. Perhaps students from larger cities, with more visible illicit drug problems, are more sensitized to these issues. However, one cannot place any significance on these observations until they are replicated in other studies. Having a health professional as a family membet or having a family member or close friend have cancer did not influence survey responses. The negative attitudes toward cancer pain ant its treatment identified by this study should be addressed throughout the medical school curriculum, both in basic science and clinical courses. The time at which “attitude adjustments” can be made depends ou each
_Vol. 5 No. 6 December1990
Attitudes About Camm Pain
medical school’s unique curriculum design. Obvious courses that could emphasize cancer pain include neuroanatomy and neurophysiology (discussion ~‘f paiu pathways), pharmacology (discussion of opioid analgesics and drug abuse), and neoplastic diseases, if such a distinct course is ought in the basic science years. It will be essential to continue working with students in their clinical years and &uing their postgraduate training to overcome negative attitudes by providing good clinical rule models and by making relief of cancer pain an important, and therefore legitimate, treatment issue.
The authors are grateful for the excellent statistical assistance provided by Tanya ~urawicz of the University of Wis~~)~sin clinical Cancer Center and to Lesley Mack and Dr. Howard Stone for distributing and ensmmg completion of the questionnaires during the orientation meetings for the first-year medical students.
349
1. Bonica JJ. Cancer pain: a major national health problem. Cancer Nurs 1978;1:313-316. 2. Marks KIWI,Sachar EJ. Undertreatment of medical inpatients with narcotic rtnalgesics. Ann Interr Med 1973;78:173-181. 3. Levin DN, Cleeland CS, Dar R. Public attitudes coward cancer pain. Cancer 1985;56:2337-2339. 4. Weiss OF, Sriwatanakul K, Alloza JL, Weintrauh M, Lasagna L. Attitudes of patients, housestaff, and nurses toward postoperative analgesic care. Anesth Analg 1983;62:70-74, 5. Charap AD. The knowl~ge, attitudes, and expcrience of medical personnel treating pain in the ter. minally ill. Mt Sinai J Med 1978;45:561-580. 6. Cleeland CS, CltAnd LM, Dar R, Rinehardt LC. Factors influencing physician management of cancer pain. Cancer 1986;~~:79~8QO. 7. Jaffe J1-L Misinformation: ~u~iloria and addiction, In: Hill CS, Fields WS, eds. Advances in pain research and therapy. New York: Raven Press, 1989:163-174. 8. Porter J, Jick H. Addiction rare in patients treated with narcotics. N Engl J Med 1980;302:~23.
Journal of Pain and SymptomManagement 345
*
Attitudes isconsin’s
ical
ents
David E. ~eiss~an, MD, and June L. Dahl, PhD 1piviskmof Hematology&2ncology(DE. W.), Depurtment ofMedicine, Medical College of Wisconsin, Milwaukee, Wisconsin; and Department of Pharmacology (J.L.D.), Universityof Wisconsin-Madison Medical School, Madison, Wisconsin
Abstract A brief questionnaire was administered to dl7
Cancer pain,
psy :hologicat
dependence, medical student education
During the past 20 years, increasing attentk3n has been paid to the undertreatment of cancer pain. It is now well documented that the pain 14 cancer is often inadequately treated and that a multitude of barriers result in unnecessa~ patient suffering. lb At least part of the problem is due to the fact that physicians often lack
Addressre@nt requestf a~: David E. Weissman, MD, Di~ion of ~ematolo~Oncolo~y~ Milwaukee County Medical Complex, 8700 West Wisconsin Avenue, Milwaukee, WI 53226.
Acceptedfor publication:April 9, 1990.
8 U.S. Cancer Pain Relief Committee, 1990 Published by Elsevier. New York, New York
knowledge of tbe methods for assessment and treatment of tamer pain, that they have excessive concerns about opioid ana!~e~ir stde effects and psychological dependence (addiction), and that they are concerned about regulatory scrutiny if they are “liberal” prescribers of opioids.6*7 In this study, we report the results of a survey administered to first-year medical students in Wisconsin to assess their attitudes about cancer pain and its management. The goal of this study, which is part of the physician education program of the Wisconsin Cancer Pain fnitiative, was to identify any negative attitudes held by these students that should be addressed by curricular changes.
346
Wt7bsmtm and Daht
A brief questionnaire was completed by S l7 (97%) entering medical students at the Medical C&ge of Wisconsin and the University of Wis#Amazon during an orientation session held prior to the start of the 1988-89 academic year. The questioner consisted of 11 multiple choice questions to assess attitudes about cancer pain and its treatment and eight additional questions to provide demographic information about the respondents (Tables 1 and 2). Gh$square and ManteCHaensael chi-square tests were used to as,sess correlations between student attitudes and demographic characteristics such as age, sex, size of horn2 town, history of cancer, chronic pain, or drug and alcohol abuse in themselves, family members, or a close friend.
Seven questions addressed general attitudes about the cause and treatment of pain. Students felt that cancer pain was very common (95% indicated that >60% of patients experience pain); that pain was often of long duration (79% indicated that >60% of patients with cancer experienced pain for >I mo); and that the cause of pain was the disease itself (7 1%) rather than the treatments (28%) or preexisting conditions (1%). Students were pessimistic about the possibility of providing pain relief: only 62% indicated that >60% cancer pain could be relieved. In the sample, 47% of the students felt most patients axe overmedicated. Only indicated that most patients are undermedicated. Most students (83%) felt that the patient is the best judge of pain intensity. However, only 35% felt that maximal analgesic therapy was appropriate at any time, and 44% felt martimal therapy should be reserved for patients with a prognosis of 62 mo. Four questions addressed attitudes about the use of opioid analgesics. Over one-half of the students (57%) felt that psychologic dependence (action) occurs frequentiy or very frequently when opioids are used to treat cancer pain. A boy high percentage indiited they would be moderately or extremely concerned about addiction if opioids were administered to a fam$’ member in pain. Students felt there was little tisit of suicide from opioids, wirh only 12% in-
Journal of Pain and Sympnn ?klanapwnt
dicating suicide was a frequent occurrence and none feeling it occurred very frequently. The students overwhelmingly assumed that increasing pain in a patient with cancer indicates analgesic tolerance (72%) rather than worsening disease (20%) or addiction (8%). Age was a major factor affecting attitudes. Compared to students age 26-25, students age 26 or older believed that (a) a greater percentage of cancer pain can be relieved (p = O.O~),(b) the majority of patients are undermedicated Q = O,~), (c) pain is more likely due to the cancer itself Cp= 0.004), and (d) increasing pain indicates wo~ening of the cancer &= 0.044). Older students were also less concerned about a family mem~r amine admits to morphine (p=O.OOl) and were more likely to believe that the patient is the best judge of pain fp = 0.01). Students from larger communities (> 100,000 ~pulation) were more likely to be concerns about addiction @=0.009) and also more concerned about the risk of suicide with opioids V,= 0.009). Students who had worked with cancer patients were iess concerned that their family members would become addicted to morphine Ip -0.004). Female students were more likely to indicate that maxima1 pain therapy was appropriate at any time during the course of the disease Cp=0.004). There were no significant correlations between responses to the questions and a history of cancer or chronic pain La the students themselves, a family member, or friend, or a history of drug or alcohol abuse in themselves, a family member, or friend.
Thii survey showed that students emer Wisconsin’s two medical schools with certain erroneous, indeed negative, attitudes about cancer pain and its treatment, including 1) the belief that maxima1 drug therapy should be dependent on prognosis: 44% thought that maximal drug doses should be reserved for patients with a prognosis of 3 mo or less; 2) an exaggerated fear of opioid psychologic dependence (addiction): 57% of students believed that this occurs frequently or very frequently when in fact the reported incidence of addiction is quite rare;’ 3) the belief that increasing pain is invariably
Vol. 5 No. 6 December 1990
Attituh
Ahut Cancer Pa&
_-
Table 1 Cancer Pain Attitude Questionnaire 1. What ~~en~~ a) 20% b) 40% c) 60% d) 80% e) 100%
of cancer patients suffer pain?
2. What percentage of cancer patients suffer pain for > i month? a) 20% b) 40% c) 60% d) 80% e) 100% 3. What percentage of pain can be relieved with treatment? a) 20% b) 140% c) 60% d) 80% e) 100% 4. Which of the following is true? a) Most patients receive adequate pain treatment. b) Patients receive more pain medication than necessary. c) The majority of patients are uiidermedicated, 5. Psychologic dependence to narcotics as a resuh of legitimate prescription to patients with cancer pain occurs a) very frequently (>l in 10) b) frequently ( 1: 10 to 1: 100) c) 0ccasionaHy ~l:lO~lOOO) d) rarely (< 1 in 1000~ 6. Suicide with an overdose of narcotics pIescribed for cancer pain occurs a) very frequently (> 1 in 10) b) frequently (1:lO to 1:lOO) c) occasionaliy (l:lOO-1000) d) rarely (< 1 in 1000) 7. The best judge of cancer pain intensity is a) the treating physician b) the patient’s nurse c) the patient d) the patient’s spouse or family 6. Your degree of concern about addiction if a family member is given morphine for cancer pain would be a) no concern b) mild concern c) moderate concern df extreme concern 9. At what time a) any time b) prognosis c) prognosis d) prognosis
is it appropriate for patients to receive m.aximal doses of analgesics?
10. Cancer pain is most Likelydue to a) cancer treatments b) cancer itself c) preexisting conditions unrelated to the cancer 11. Increasing requests for analgesics indicates a) psychological dependence (addiction) b) worsening cancer c) tolerance to the analgesic
347
Weis.wu
348
and Dahl
Journal of Pain and Symptom Management
Table 2 Medical Student Demographic Characteristics Characteristics Iikkal school Medical College of Wisconsin University of Wisconsin !kX
Male
Female Agt 20-25 26+ Townsize <25,000 ‘Lb 100,060 > 106,006 Family member health professional Yes No
n
6%
185 132
200 105
(63)
292 74
(73) (23)
WV
99 86 121 127 186
Self/relative/friend had cancer
180 134
(57) (42)
Selflrclativelfriend had pain for > I month Yes No
179 134
(57) (42)
Self/relative/friend abuse drugs/alcohol Yes No
100 213
(92)
WorWvolunteer with cancer patients Yes No
116 198
(57) (62)
Yes No
(67)
Note: In some categories. the totals do not equal 100% due to incomplete data.
related to drug tolerance: only 20% thought increasing pain was due to tumor ssion; and P lack of appreciation for the fact that cancer 4) pain is often undertreated: only 34% thought patients were undermedicated. Most students appropriately felt that the patient is the best judge of pain intensity and that suicide is uncommon in patients who receive opioids for pain. Furthermore, although stu-
dents had a realistic understanding of the incidence and durxion of cancer pain, they were imistic about the possibility of providing relief. Their views refiect those of the general public who feel that pain is to be expected with cartcerVthat it is often severe and that it is difficult to treaLS Age was the demographic characteristic that most a&c&d attitude. Older studenrs had
molyl positive attitudes than did their younger colleagues. This finding was unexpected and has no obvious explanation. Students from larger communities were more concerned about psychologic dependence (addiction) to opioids and about suicide with these drugs. Perhaps students from larger cities, with more visible illicit drug problems, are more sensitized to these issues. However, one cannot place any significance on these observations until they are replicated in other studies. Having a health professional as a family membet or having a family member or close friend have cancer did not influence survey responses. The negative attitudes toward cancer pain ant its treatment identified by this study should be addressed throughout the medical school curriculum, both in basic science and clinical courses. The time at which “attitude adjustments” can be made depends ou each
_Vol. 5 No. 6 December1990
Attitudes About Camm Pain
medical school’s unique curriculum design. Obvious courses that could emphasize cancer pain include neuroanatomy and neurophysiology (discussion ~‘f paiu pathways), pharmacology (discussion of opioid analgesics and drug abuse), and neoplastic diseases, if such a distinct course is ought in the basic science years. It will be essential to continue working with students in their clinical years and &uing their postgraduate training to overcome negative attitudes by providing good clinical rule models and by making relief of cancer pain an important, and therefore legitimate, treatment issue.
The authors are grateful for the excellent statistical assistance provided by Tanya ~urawicz of the University of Wis~~)~sin clinical Cancer Center and to Lesley Mack and Dr. Howard Stone for distributing and ensmmg completion of the questionnaires during the orientation meetings for the first-year medical students.
349
1. Bonica JJ. Cancer pain: a major national health problem. Cancer Nurs 1978;1:313-316. 2. Marks KIWI,Sachar EJ. Undertreatment of medical inpatients with narcotic rtnalgesics. Ann Interr Med 1973;78:173-181. 3. Levin DN, Cleeland CS, Dar R. Public attitudes coward cancer pain. Cancer 1985;56:2337-2339. 4. Weiss OF, Sriwatanakul K, Alloza JL, Weintrauh M, Lasagna L. Attitudes of patients, housestaff, and nurses toward postoperative analgesic care. Anesth Analg 1983;62:70-74, 5. Charap AD. The knowl~ge, attitudes, and expcrience of medical personnel treating pain in the ter. minally ill. Mt Sinai J Med 1978;45:561-580. 6. Cleeland CS, CltAnd LM, Dar R, Rinehardt LC. Factors influencing physician management of cancer pain. Cancer 1986;~~:79~8QO. 7. Jaffe J1-L Misinformation: ~u~iloria and addiction, In: Hill CS, Fields WS, eds. Advances in pain research and therapy. New York: Raven Press, 1989:163-174. 8. Porter J, Jick H. Addiction rare in patients treated with narcotics. N Engl J Med 1980;302:~23.