Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
Palliative Research Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
Cancer. 2024 Sep 1;130(17):3034-3042. doi: 10.1002/cncr.35299. Epub 2024 Apr 3.
Opioid pain management in cancer survivorship is a complex and understudied topic.
The authors conducted in-depth, qualitative interviews to understand clinician approaches to opioid pain management in chronic cancer pain and to generate ideas for improvement. They used a rigorous, inductive, qualitative, descriptive approach to examine clinician (n = 20) perspectives about opioid pain management in survivorship, including oncologists (n = 5), palliative care clinicians (n = 8), primary care clinicians (n = 5), and pain management specialists (n = 2).
The findings indicated that no consistent medical home exists for chronic pain management in cancer survivors and that there are fundamental differences in how each subspecialty approaches chronic pain management in survivorship (e.g., "Do we think of this as noncancer pain or cancer pain?… This is in this limbo zone-this gray zone-because it's cancer-related pain, right?"). Simultaneously, clinicians are influenced by their peers' perceptions of their opioid prescribing decisions, sparking intraprofessional tension when disagreement occurs. In these instances, clinicians described overthinking and doubting their clinical decision-making as well as a sense of judgment, pressure, and/or shame. Finally, clinicians acknowledged a fear of consequences for opioid prescribing decisions. Specifically, participants cited conflict with patients, sometimes escalating to aggression and threats of violence, as well as potential disciplinary actions and/or legal consequences.
Participants suggested that opportunities to improve chronic cancer pain care include developing clear, systematic guidance for chronic cancer pain management, facilitating clinician communication and consultation, creating tailored survivorship care plans in partnership with patients, and developing accessible, evidence-based, complementary pain treatments.
癌症幸存者的阿片类药物疼痛管理是一个复杂且研究不足的课题。
作者进行了深入的定性访谈，以了解临床医生在慢性癌症疼痛中管理阿片类药物疼痛的方法，并提出改进的想法。他们采用严格的、归纳的、定性的、描述性的方法，检查了临床医生（n=20）对癌症幸存者阿片类药物疼痛管理的观点，包括肿瘤学家（n=5）、姑息治疗临床医生（n=8）、初级保健临床医生（n=5）和疼痛管理专家（n=2）。
研究结果表明，癌症幸存者的慢性疼痛管理没有一个统一的医疗之家，每个亚专业在幸存者的慢性疼痛管理方面存在根本差异（例如，“我们是否认为这是非癌症疼痛还是癌症疼痛？……这处于这个中间地带——这个灰色地带——因为这与癌症相关的疼痛，对吧？”）。同时，临床医生受到同行对他们阿片类药物处方决策的看法的影响，当意见不合时，会引发专业内的紧张关系。在这些情况下，临床医生描述了过度思考和怀疑自己的临床决策，以及感到受到评判、压力和/或羞耻。最后，临床医生承认对阿片类药物处方决策的后果感到担忧。具体来说，参与者提到了与患者发生冲突的情况，有时会升级为攻击性和暴力威胁，以及潜在的纪律处分和/或法律后果。
参与者建议改善慢性癌症疼痛护理的机会包括制定明确、系统的慢性癌症疼痛管理指南，促进临床医生之间的沟通和咨询，与患者合作制定定制的生存护理计划，以及开发易于获得、基于证据的补充性疼痛治疗方法。
