Cancer patients are suffering unnecessarily because they wrongly believe that morphine and other opioids are only used as "comfort for the dying" and as a "last resort" rather than seeing them as legitimate pain killers that can improve their quality of life.
In a study published online (Tuesday 11 December) in the cancer journal, Annals of Oncology experts in palliative care also say “the belief that opioids hasten death is widely held” amongst patients and this “has a significant impact on pain management, as patients felt that an offer of opioids signified imminent death”. Previous studies have estimated that between 40-70% of cancer patients may not have their pain properly controlled with the right medication for a variety of reasons.
Dr Colette Reid, the lead author of the study, said: “If we are to employ the range of available opioids in order to successfully manage pain caused by cancer, we must ensure that morphine does not remain inextricably linked with death. If this connection stays in place then morphine will continue to be viewed as a comfort measure for the dying rather than a means of pain control for the living.”
Dr Reid, a consultant in palliative medicine at the Gloucester Royal Hospital, Gloucester, UK, conducted in-depth interviews with 18 patients with metastatic cancer, aged between 55 and 82, who were asked to take part in a cancer pain management trial. She wanted to examine how patients reacted when first offered an opioid drug described as similar to morphine. Dr Reid also wanted to understand the factors that influenced patients' decisions whether to accept or to reject morphine. The interviews were analysed along with an experienced social scientist Rachael Gooberman-Hill, and Geoffrey Hanks, professor of palliative medicine, both from the University of Bristol.
The patients interviewed were all white and half of them were women. Their views and experiences about morphine fell into four distinct but inter-related categories: anticipation of death, morphine as a last resort, the role of the professional, and no choice but to commence.
Morphine as a “last resort” was the central theme to emerge from the interviews. The authors write: “We found that patients with cancer who were offered morphine for pain relief interpreted this as a signal that their health professional thought they were dying, because opioids were interventions used only as a ‘last resort'. Because participants themselves were not ready to die, they rejected morphine and other opioids as analgesics, despite the pain experienced as a consequence. Participants' descriptions of the role of professionals indicated that patients value professionals' confidence in opioids. Some patients may therefore become more frightened when offered a choice, since this indicates a lack of confidence in the opioid as an analgesic.”
It could be argued that the patients' belief that the use of morphine represented a ramping up of treatment in the face of approaching death and the associated pain is a reasonably held view, especially as most of the patients interviewed for the study have subsequently died.
However, Dr Reid said: “The World Health Organization guidelines for the management of cancer pain state that analgesic treatment choices should be based on the severity of the pain, not on prognosis. So patients at all stages of cancer could have morphine if their pain is sufficient. In reality, the patients most likely to experience pain, and likely also to have the most severe pain, are those with metastatic disease, i.e. their cancer cannot be cured. These patients may yet have many months to live, but their quality of life is adversely affected by pain, since unrelieved pain leads to social isolation, loss of role and depressed mood. This was the group of patients that we interviewed – patients with metastatic disease and life expectancy measured in months.
“The fear of these patients was that morphine suggested imminent death (and also possibly hastened death) and that once commenced would mean that they would not be able to function normally. However, morphine if used properly, can actually promote quality of life by allowing patients with pain to function better.”