Der Schmerz
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Treatment of chronic cancer pain with strong opioids is indicated in about 60-70 % of patients. Surprisingly, these very potent analgesics are prescribed with great reservations in many countries, including Germany. The aim of our investigation was to analyse the supply of opioid analgesics to outpatients with cancer pain in the region of Hannover, which has about 1.1 million inhabitants. ⋯ Our data indicate a significant undertreatment of outpatients suffering from cancer pain. Taking into account the estimated total number of patients suffering from cancer, only 14.5 % (1988) and 19.0 % (1991) of all outpatients in need of strong opioids were supplied sufficiently with those analgesics. Comparing the results from the observation period in 1988 with the results from 1991 it becomes obvious that the situation has not changed. There are different reasons for the insufficiency of opioid treatment: many physicians as well as their patients are still afraid of the side effects of strong opioids. Therefore, it is necessary to improve education concerning this issue. The legal restrictions on the use of narcotics and their complexity are another important reason for doctors not to prescribe strong opioids. In 1993 the regulations were simplified; nevertheless, this has not led to a profound change in the attitude of the prescribing practitioners. Thus, further changes in legislation seem to be necessary so that the requirements for the prescription of strong opioids do not differ from other drugs.
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According to WHO guidelines, morphine is the first choice for the treatment of chronic cancer pain, preferably as a controlled-release preparation administered orally. The WHO classifies the quality of pain management of a particular country by its morphine consumption for medical reasons. For this article, data from clinical and market research were collected. ⋯ The report also focuses on physicians' subjective viewpoints and prejudices. When strong opioids are only rarely prescribed, a general practitioner then has difficulties in assessing pain and possible side effects and treatment evaluation. Clinical research, too, is hampered by special regulations concerning controlled opioid administration.
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The present legal requirements for the prescription of controlled drugs remains an impediment to adequate therapy for chronic pain because of an abundance of legal regulations. The physician prescribing opioids must consider the permitted maximum amount per prescription, the period of time the drug is prescribed for, numerous cross references, and other special regulations, and he still cannot be sure that he does not violate certain legal requirements. Often these difficulties result in withholding necessary pain treatment. ⋯ It is important that the use of the narcotic be justified in the sense of paragraph 13 Abs. 1 of the drug control regulation, as judged by the responsible prescriber of the drug, and that any offence be punished. The use of triplicate prescriptions guarantees sufficient proof. Legislation is requested that will substitute for the present drug control regulations, which are difficult to handle.
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The prescription of strong opioid by general practitioners was studied, particularly for the treatment of chronic pain. In a medium-sized town (around 250 000 inhabitants) 17,839 prescriptions of strong opioids were issued by 455 doctors over 5 years (1 January 1990 until 31 December 1994) to 1,939 patients. Of these patients 37.8-48.3 % of them received only one prescription for 6 months, 60.5-75.8 % received between 1 and 4 prescriptions for 6 months, and only 20.9-35.7 % of all patients received 5 or more prescriptions for 6 months. ⋯ In order to safeguard the quality of medical care for pain treatment by strong opioid analgesics, unbiased training of physicians and a clear definition of narcotics is required. It is suggested that the expression "narcotic prescription" be changed related to the legislative terminology in the pharmacology-related expression "analgesic prescription". The prescribing regulations should not constrain medical treatment, but create a basic rule for the prescription of strong opioids.
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In spite of the fact that the treatment of pain is highly developed, outpatient care of patients suffering from chronic pain is frequently insufficient. In particular general practitioners often refrain from prescribing the necessary pain therapy with opioids. Because of the contract regarding medical treatment, however, the patient has a legal claim to adequate pain treatment, if necessary by administration of opioids. ⋯ Now that the legal and administrative conditions for prescribing opioids have been consolidated, the main objective is to exhaust the possibilities of prescription for the benefit of patients suffering from pain in a better way. This is first and foremost, an organizational and technical task of the medical professional group. In particular, training and continuing education in the field of pain therapy must be further developed without delay.