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Structured and Patient-empowered Cancer Pain Control Program

Department of Surgery

Ospital ng Maynila Medical Center

 

Rolando  De Guzman, MD

Janix De Guzman, MD

Rodney Dofitas, MD

Reynaldo O. Joson, MD

 

Introduction:

 

Prior to May, 2003, the Department of Surgery of Ospital ng Maynila Medical Center (OMMC) has no structured cancer pain control program.  No residents have yellow prescription pads for opioid prescription.  The hospital pharmacy has no stocks of morphine because of absence of prescriptions by the physicians.  There was no monitoring of cancer pain control in the Department.

 

In May, 2003, the Department started a formal cancer pain control program.  This paper describes how the cancer pain control program was established in the Department of Surgery and how it is being implemented up to this time (July, 2003).

 

Methods:

 

The records of the Department of Surgery that pertained to its cancer pain control program were retrieved, reviewed, and systematically arranged and analyzed not only for assessment but also for feedback purposes.

 

The focus of the review and presentation was on the process of establishing and evaluating a cancer pain control program in a department of surgery.

 

Results:

 

In April, 2003, a situational analysis of the cancer pain control program of the Department was made.  The findings were as stated in the Introduction.

 

The situational analysis was immediately followed by a formulation of a cancer pain control program of the Department containing the three basic elements of a program, namely, objective, strategies, and evaluation.

 

The objective of the program was stated as follows: At the end of the year 2003, at least 90% of all admitted cancer patients in the Department of Surgery will have satisfactory control of their cancer pain.

 

The strategies consisted of the following:

 

  1. Formulation of a structured and patient-empowered cancer pain control program in the Department (See Appendix 1).
  2. Education of the surgical resident and parasurgical staff not only on the cancer pain control program but also on how to manage cancer pain and how to prescribe pharmacologic therapy, particularly, the opioids. (See Appendix 2).
  3. Imposition of a requirement that all surgical residents should have an S2 license and yellow prescription pads. (See Appendix 3).
  4. Insurance of availability of analgesic drugs, particularly, morphine, in the hospital pharmacy.
  5. Formulation of a system of oversight. (See Appendix 4).

 

The ultimate evaluation parameter used was a pain score of 3 or less for at least 2 days prior to discharge or death.

 

All the strategies mentioned above were accomplished by May, 2003.

 

From May to July, 2003, there were a total of ___ cancer patients admitted in the Department.

 

Table 1 shows the age and sex distribution of the admitted cancer patients with the age ranging from __ to __, with a mean age of ___.  There were ___ males and ___ females.  

 

Table 1. Age and sex distribution of admitted cancer patients, May to July, 2003, OMMC Department of Surgery.

 

Age

Male

Female

1-10

 

 

11-20

 

 

21-30

 

 

31-40

 

 

41-50

 

 

51-60

 

 

61-70

 

 

71-80

 

 

81-90

 

 

Total

 

 

 

 

Table 2 shows the distribution of different causes of cancer pain.

 

Table 2. Distribution of different causes of cancer pain.

 

Caused by cancer itself

Caused by treatment of cancer

(operative)

Caused by treatment of cancer (non-operative)

 Somatic

Visceral

Neuropathic

 

 

 

 

 

 

 

 

Table 3 shows the distribution of cancer diagnosis, stage, and average pain score by stage and by type of cancer on admission prior to treatment (pretx).

 

Table 3. Distribution of cancer diagnosis, stage, and average pain score by stage and by type of cancer on admission prior to treatment (pretx).

 

Cancer

 Stage I

Stage II

Stage III

Stage IV

Total no. by type of cancer

Ave. pain score  by type of cancer

(pretx)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Total no. by stage

 

 

 

 

 

 

Ave. pain score by stage

(pretx)

 

 

 

 

 

 

 

Table 4 shows the distribution of cancer diagnosis, stage, and average pain score by stage and by type of cancer posttreatment and 2 days prior to discharge.

 

Table 4. Distribution of cancer diagnosis, stage, and average pain score by stage and by type of cancer 2 days prior to discharge posttreatment (posttx).

 

Cancer

 Stage I

Stage II

Stage III

Stage IV

Total no. by type of cancer

Ave. pain score  by type of cancer

(posttx)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Total no. by stage

 

 

 

 

 

 

Ave. pain score by stage

(posttx)

 

 

 

 

 

 

 

 

 

 

Table 5 shows the overall pretreatment and posttreatment distribution of pain scores for the months of May, April, June, and July, 2003.  The posttreatment pain scoring results shows that the objective of the Department’s cancer pain control program has been achieved as of July, 2003

 

Table 5. Overall pretreatment and posttreatment distribution of pain scores by month.

 

 

0-3

n (%)

4-6

n (%)

7-10

n (%)

No.

May, 2003

 

 

 

 

Pretx

 

 

 

 

Posttx

 

 

 

 

 

 

 

 

 

April, 2003

 

 

 

 

Pretx

 

 

 

 

Posttx

 

 

 

 

 

 

 

 

 

June, 2003

 

 

 

 

Pretx

 

 

 

 

Posttx

 

 

 

 

 

 

 

 

 

July, 2003

 

 

 

 

Pretx

 

 

 

 

Posttx

 

 

 

 

 

 

 

 

 

Overall

 

 

 

 

Posttx

 

 

 

 

 

 

 

Table 6 shows the frequency and outcome of yellow prescriptions or use of morphine tablets in cancer pain control by type and stage of cancer.

 

 

Table 6. Frequency and outcome of morphine usage in cancer pain control by type and stage of cancer.

 

Cancer

 Stage I

Stage II

Stage III

Stage IV

Total no. of morphine usage by type of cancer

Ave. pain score  by type of cancer with morphine use

(posttx)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Total no.of morphine use by stage

 

 

 

 

 

 

Ave. pain score by stage with morphine use

(posttx)

 

 

 

 

 

 

 

Table 7 shows the frequency and outcome of non-morphine or non-opioid analgesic usage in cancer pain control by type and stage of cancer.   Non-morphine usage included use of paracetamol, nonsteroidal anti-inflammatory drugs (NSAIDs), and tramadol. 

 

 

Table 7. Frequency and outcome of non-morphine or non-opioid analgesic usage in cancer pain control by type and stage of cancer.

 

Cancer

 Stage I

Stage II

Stage III

Stage IV

Total no. of morphine usage by type of cancer

Ave. pain score  by type of cancer with non-morphine usage

(posttx)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Total no.of morphine use by stage

 

 

 

 

 

 

Ave. pain score by stage with non-morphine usage

(posttx)

 

 

 

 

 

 

 

 

Table 8 shows the results of control of postoperative pain for cancer patients undergoing operations.

 

Table 8. Results of control of postoperative pain.

 

Type of operations

No.

Ave. preop pain score

Ave. 1st day postop pain score

Ave. 2nd day postop pain score

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Total no.

Ave.

Ave.

Ave.

 

 

 Table 9 shows the side effects and adverse reactions of pharmacologic therapy.

The most common side effects and adverse reactions with opioid analgesics consisted of ………………………. While those of the non-opioid analgesics consisted of ………………………………

 

Table 9. Frequency of side effects and adverse reactions of pharmacologic therapy in cancer pain control.

 

 

paracetamol

nsaids

traumadol

morphine

others

Side effects

list

 

 

 

 

Adverse reactions

list

 

 

 

 

Frequency

N(%)

N(%)

N(%)

N(%)

 

 

 

 

 

 

 

 

Table 10 shows the mortality rate of cancer pain control by type of cancer and treatment with cause of death.

 

Table 10. Mortality rate and causes of death by type of cancer.

Type of cancer

Mortality

Cause of death

 

Operated

Not-operated

Operated

Not-operated

 

n

n

list

list

 

n

n

list

list

Mortality rate

 

 

 

Overall mortality rate

 

 

 

Table 11 shows the morbidity rate of cancer pain control by type of cancer and treatment with cause of death.

 

Table 11. Morbidity rate by type of cancer.

Type of cancer

Frequency of morbidity

Nature of morbidity

 

Operated

Not-operated

Operated

Not-operated

 

n

n

list

list

 

n

n

list

list

Morbidity rate

 

 

 

Overall morbidity rate

 

 

 

 

Table 12 shows the problems encountered in the cancer pain control program from May to July, 2003 and the status of resolution.

 

Table 12. Listing of problems encountered in the cancer pain control program from May to July, 2003 and the status of resolution.

 

Problems

When encountered

Month

Status

(Solved – not yet resolved)

List

 

 

 

 

 

 

 

 

 

 

 

Discussion:

 

In the Philippines, it was estimated in1988 that at least 200,000 Filipinos suffer from cancer pain every year (Laudico, 1988).

 

In a 2002 workshop report of The Cancer Pain Control Study Group under the auspices of the Department of Health entitled “For an organized implementation of the DOH-PCCP Cancer Pain Control Program in the Philippines,”  (Ref) the consensus is that “with high probability, may patients with cancer pain, are not being the appropriate treatment, and hence suffer unnecessarily.”  This consensus was based on findings derived from various studies on cancer pain control in the Philippines.  Among the major causes of inadequate cancer pain control in the Philippines were lack of education in cancer pain therapy among health professionals and problem with implementation of the strategies of the program.

 

In 2003, the Department of Surgery of OMMC has taken cognizant of the cancer pain problem in the Philippines and in its department and hospital.  It has decided to solve the problem existing in its home ground as well as to contribute to the solution of the cancer pain problem in the Philippines by setting an example and even a model for all departments of surgery in the country as well as clinical departments to follow.

 

A department of surgery can contribute much to the solution of the cancer pain problem in the Philippines because there are lots of such departments in the country and besides, majority of cancer cases are primarily handled by surgeons or put in another way, surgeons are the primary physicians of cancer patients since majority of cancers are solid tumors and primarily treated with operation.

 

The Department of Surgery of OMMC started from scratch with no cancer pain control program to talk about, with no residents having an S2 license and yellow prescription pad, and with no morphine in the hospital pharmacy.

 

Armed with a will and a mission, in a span of 4 months, the Department has come out with a structured and patient-empowered cancer pain control program, with all the residents having an S2 license and yellow prescription pad and having acquired the competency of cancer pain control, with the hospital pharmacy having adequate supply of opioid analgesics, and more than 90% of the admitted patients had adequate cancer pain control.

 

Though the five strategies formulated were relatively straightforward, the successful implementation required committed, focused, innovative, and perseverant leaders and followers. 

 

The formulation of the cancer pain control program was facilitated by the adoption and innovative modifications of the DOH Cancer Pain Control Program so as to make it suitable to the Department of Surgery’s setting which included its usual clients and existing activities as well as to make it more structured and explicit and patient empowerment (see Appendix 1).

 

The education of the surgical and parasurgical staff was facilitated by the presence of curriculum that is comprehensive in the sense that it included all treatment modalities for cancer pain control and structured in the sense that it included a formal curriculum with honest-to-goodness implementation. (See  Appendix 2).

 

The imposition of a requirement that all surgical residents should have an S2 license and yellow prescription pad was facilitated by the subsidy from the Department’s funds.(See Appendix 3).

 

The insurance of availability of analgesics in the hospital pharmacy was facilitated by the support and cooperation of the hospital director and hospital pharmacies.

 

Lastly, the formulation and implementation of an oversight system was facilitated by the presence of a volunteer parasurgical staff (nurse), a senior resident who served as chief executive officer of the program, cooperative residents, and the monthly progress reporting. (See Appendix 4).

 

DOH and other institutions have suggested establishment of pain clinics as a strategy in the cancer pain control. However, the Department did not take up this recommendation.  With establishment of pain clinics, there is a tendency for the expertise of pain control to be limited to a few health care professionals, particularly the anesthesiologists.   The Department decided that equipping all surgical residents with the competency of managing of cancer pain and that making pain management part and parcel of services offered in the Department’s Tumor and Cancer Clinic and other specialty clinics would be more effective and efficient. 

 

In the evaluation of a cancer pain control program of a department of surgery or even in the entire hospital, the Department deems it best to evaluate all forms of treatment modalities administered to a cancer patient in pain.  In almost all of the local papers dealing with cancer pain relief, the assessment was limited to the pharmacologic therapy.  In this paper, all forms of cancer pain treatment modality was evaluated.  Furthermore, it included not only the side effects and adverse reactions of pharmacologic therapy but also the complications of operative as well as other non-pharmacologic treatment

 

At present, the Department is focusing on the cancer pain control of admitted patients.  In the future, the cancer pain control monitoring and evaluation will be extended to the patients in the ambulatory clinics.

 

The authors hope that this report will serve as an example and model for other departments of surgery as well as other clinical departments dealing with cancer patient to follow and emulate so as to accelerate the achievement of objective of the cancer pain control program of the DOH as well as that of every health care institution and professional in the Philippines, for that matter.  The authors welcome adoption and will not impose copyrights restriction on the manuscripts seen in the appendices.

 

 

References:

 

Laudico AV, Ngelangel CA, de la Pena AS, et al.  Philippine Cancer Facts & Estimates, Philippine Cancer Society, Inc.  Manila, 1988.

 

 

For an organized implementation of the DOH-PCCP Cancer Pain Control Program in the Philippines.  The Cancer Pain Control Study Group.  Department of Health, Philippine Cancer Society, Inc., Pain Society of the Philippines, Dangerous Drug Board of the Philippines, Andres Soriano Foundation, Inc. 2002.

 

 

 

 

Appendix 1

 

Cancer Pain Control Program

Department of Surgery

Ospital ng Maynila Medical Center

 

 

Appendix 2

 

Cancer Pain Control Curriculum

Department of Surgery

Ospital ng Maynila Medical Center

 

 

 

 

 

 

Appendix 3

 

Department of Surgery

Ospital ng Maynila Medical Center

 

Ref. no: m03-89

Date: April 19, 2003

TO: All Residents and Consultants

FROM: Department Chair

RE: S2 License and Yellow Prescription Pads

 

Pursuant to our goal of establishing a cancer pain control program for our Department’s clients as well as for training of our residents, all residents are required to have an S2 license and yellow prescription pads during their entire period of residency.

 

Effective 2004, proof of an updated S2 license and acquisition of yellow prescription pads will form part of the requirements for acceptance of new residents.

 

For the present residents, the deadline for acquisition of the S2 license and yellow prescription pads will be on April 30, 2003.

 

The Department will subsidize 50% of the expense of the yellow prescription pads.

 

What are envisioned are the following:

 

  1. All residents of the Department of Surgery of OMMC will always have an S2 license and updated every 3 years and yellow prescription pads to be able to contribute to the success of the cancer pain control program of the department.

 

  1. All residents of the Department of Surgery are competent in comprehensive cancer pain control, inclusive of pharmacologic therapy and particularly the modified WHO’s cancer pain relief approach.

 

  1. The number of yellow prescriptions dispensed by the Department will be used as one of the parameters of adequacy of the cancer pain control program of the Department.

 

  1. The number of yellow prescriptions dispensed by a resident will be used as one of the parameters of competency in comprehensive cancer pain control.

 

  1. Number of yellow prescriptions dispensed by the Department and per resident will be monitored during the Department’s Monthly Service Performance Report.

 

 

 

Reynaldo O. Joson, MD, MHA, MHPEd, MS Surg

Chair

Department of Surgery

 

 

 

Appendix 4

 

Oversight System for Cancer Pain Control Program

Department of Surgery

Ospital ng Maynila Medical Center

 

 

Oversight System – Monitor, Assess, and Feedback

 

The implementation of the Cancer Pain Control Program of the Department of Surgery will be constantly monitored, periodically assessed (monthly and yearly), and given feedback for improvement.

 

An assigned senior resident (which may or may not be the chief resident) will be designated as the chief executive officer (CEO) of the program.  He/she will constantly monitor and presents a monthly progress report during the Monthly Service Performance Report of the Department.

 

All problems recognized will be resolved as soon as possible to ensure the objective of the program is achieved.