WE’RE DELIGHTED TO PRESENT THIS MONTH’S ‘EDITOR’S CHOICE’ FROM PALLIATIVE MEDICINE, THE OFFICIAL RESEARCH JOURNAL OF THE EAPC
Each month, Professor Catherine Walshe, Editor-in-Chief of ‘Palliative Medicine’, chooses an article that readers may find particularly interesting or useful and invites the authors to draw out the key points on the EAPC blog. Focusing on research that is novel, a robust review, from a specific country or just slightly left of field, the ‘Editor’s Choice’ post aims to share experience and stimulate ideas. We hope you’ll read the longer article in ‘Palliative Medicine’, or EAPC members can access a free copy from the EAPC website.
Dr Julia Fee Voon Ho, Senior Manager, Supportive & Palliative Care Service, Sunway Medical Centre, Malaysia, gives the background to her longer article selected as Editor’s Choice in the May issue of ‘Palliative Medicine’.
“If the doors of perception were cleansed everything would appear to man as it is, infinite.” William Blake 1757-1827.
Suboptimal control of cancer pain has been reported in 43 per cent of patients with advanced cancer.1Although the use of morphine has been well established in the treatment of cancer pain,2 statistics from the International Narcotics Control Board (INCB) for 2015-2017 3 reported significantly lowerconsumption of opioid analgesics in Asia, as compared to countries like America and the United Kingdom. The Access to Opioid Medication in Europe (ATOME) project 4 further identified several barriers to the use of opioid analgesics, including fear of dependence, social stigma, economic burden, and insufficient knowledge among healthcare professionals on cancer pain management.
As a palliative care clinician, I frequently encounter patients who are reluctant to use morphine for cancer pain. In order to increase patients’ acceptance of morphine use, we will need to first understand what their concerns and fears surrounding morphine are, and the potential influence of their caregivers’ views.
We investigated the attitudes and perceptions about morphine use in cancer pain among our patients and their family caregivers using a qualitative approach. This study was conducted in Sunway Medical Centre, a tertiary private hospital in Malaysia. We thematically analysed the data obtained through semi-structured interviews of patients with advanced cancer and their family caregivers. Most participants in both groups thought morphine was a strong analgesic that was effective in reducing suffering and pain. However, concerns with morphine dependence, tolerance and side effects were prevalent. Many participants further associated morphine use with terminal stage of illness and hopelessness. Interestingly, despite these negative perceptions of morphine, most patient and caregiver participants were still open to the use of morphine to achieve optimal control of cancer pain. This was observed to be largely due to prioritizing the need to reduce suffering and achieve comfort. There was also an emphasis on placing their trust in their physicians to act in their best interest.
“Morphine in my impression is… it’s always equal to death. It’s [for] the terminally ill patients that have no more treatment, and it is used for them just to reduce their pain… and they will be given morphine just for the last few days of their lives… It’s like life is ending and the treatment is not effective anymore. So, you have no choice but to take morphine to control the pain.” (Patient Participant P5).
“If he is really in a lot of pain but is unable to sleep, then I feel that I will let him try it… Because I already had the impression that morphine is a drug, so I wonder if after he has been injected with it, will he become addicted? If he is ill, I don’t have a choice. If it makes him more comfortable, then I will continue to give it to him.” (Family Participant F16).
Findings from this study highlighted the multi-dimensional concerns and misperceptions about morphine use in cancer pain and its impact on participants’ acceptance of morphine. It also demonstrated the key role healthcare professionals play in educating our cancer patients and caregivers so as to improve compliance to opioid analgesics. Targeted education for healthcare professionals on cancer pain management could help to reduce barriers related to prescribing and administering opioid analgesics. Addressing these misperceptions and concerns in our clinical consultations might lead to more effective discussions and better patient adherence to opioid analgesics. Programmes to increase public awareness on the use of opioid analgesics for cancer pain might also help to reduce the stigma and misconceptions associated with its use.
We are grateful to all our participants for sharing their thoughts and opinions. I would also like to acknowledge the contributions of Prof Seng Beng Tan, Dr Hayati Yaakup, Dr Grace Low, Dr Lye Mun Tho and SN Siew Lih Wong in this rewarding research journey.
- Deandrea S, Montanari M, Moja L, et al. Prevalence of undertreatment in cancer pain. A review of published literature. Ann Oncol 2008; 19 (12): 1985-91.
- Caraceni A, Hanks G, Kaasa S, et al. European Palliative Care Research Collaborative (EPCRC); European Association for Palliative Care (EAPC). Use of opioid analgesics in the treatment of cancer pain: evidence-based recommendations from the EAPC. Lancet Oncol 2012; 13(2):e58-68.
- International Narcotics Control Board. Availability of narcotic drugs for medical use, https://www.incb.org/incb/en/narcotic-drugs/Availability/availability.html [accessed November 2019].
- Linge-Dahl L, Vranken M, Juenger S, North K, Scholten W, Payne Sand Radbruch L. Identificationof Challengesto the Availability and Accessibility of Opioids in Twelve European Countries: Conclusions from two ATOME Six-Country Workshops. J Palliat Med. 2015; 18(12): 1033-9.
- Contact Dr Julia Fee Voon Ho by email.
- Sunway Medical Centre, Malaysia.
- Read more posts about the ATOME project on the EAPC blog.
DOWNLOAD A FREE COPY OF THE FULL ARTICLE IN PALLIATIVE MEDICINE…
This post relates to the longer article, ‘Morphine use for cancer pain: a strong analgesic used only at the end-of-life? A qualitative study on attitudes and perceptions of morphine in patients with advanced cancer and their caregivers’ by Julia Fe Voon Ho, Hayati Yaakup, Grace Sook Hoon Low, Siew Lih Wong, Lye Mun Tho, Seng Beng Tan, published in Palliative Medicine 2020, 34 (5); pages: 619-629. Article first published online 27 February 2020. (https://doi.org/10.1177/0269216320904905) Issue published: 1 May 2020.
- Read earlier Palliative Medicine Editor’s Choice posts on the EAPC blog.
- Follow Palliative Medicine on Twitter @palliativemedj
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