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Charles S. Cleeland, PhD
I write this message in Guangzhou (Canton), China, as I participate in a training workshop for Chinese healthcare professionals. The workshop is a “train-the-trainer” program, focused on developing teachers of cancer pain management. Our U.S. teaching team is an all-APS group, including APS board member Judy Paice, PhD RN, of Rush-Presbyterian-St. Luke's Medical Center in Chicago, and Jim Cleary, MBBS FRACP, Paul Hutson, PharmD, and Xin (Shelley) Wang, MD, all from the University of Wisconsin. We are complemented by Chinese physicians and nurses who are knowledgeable about cancer and pain management. We Americans are learning that some of the problems of ensuring pain relief in China are unfortunately very similar to those that we face in the United States, and I think what we found is worth sharing with you.
The 30 participants at this workshop include teams of pharmacists, nurses, and physicians from three provinces in southern China. Combined, their hospitals have more than 6,500 patient beds and care for thousands of cancer patients each year. The venue for this meeting is a military hospital that has 60 beds dedicated to pain control and palliative care for a variety of military and nonmilitary patients. This unit is a “first” in South China-a unit that will function as a training and demonstration center for pain management and palliative care. The creation of this unit was strongly supported by both the provincial and national health administrations.
The unit has most of the medications that are needed for sophisticated pain management, although China currently lacks alternative opioids, such as oxycodone, hydromorphone, and the fentanyl patch. Compared with my previous visits, on this trip to China, the program participants seem more willing to use doses of morphine that are strong enough to manage pain. They are eager to learn about the use of adjuvants, the assessment of pain, and the management of analgesic side effects. They are also eager to hear about adjuvant psychological pain management methods.
The participants are spending 8 full days at this workshop. Mornings include 4 hours of lectures. Afternoons are spent with patients and in case discussion. The training is much more complete than any given in U.S. professional schools or postgraduate preparation. This high level of training is needed because these participants will become the resource teams to demonstrate aggressive pain and symptom control in their own hospitals and will constitute the teaching and consultation resource for their areas.
Adapting the World Health Organization (WHO) slogan, the sign outside this special hospital unit proclaims “Pain Relief by the Year 2000.” That goal is more realistic than many other “Year 2000” goals that have been set for health care around the world. There are several reasons to be optimistic that significant progress will occur.
First, the Ministry of Health of the People's Republic has made cancer pain relief a priority in health planning, a necessary step in a country with highly centralized healthcare programs. The Ministry of Health has made more opioids available and has begun the process of modifying the draconian regulations that, until recently, made adequate pain management difficult at best. The ministry has translated and published the WHO monograph, Cancer Pain Relief, and the synopsis of the Agency for Health Care Policy and Research (AHCPR) Clinical Practice Guideline: Management of Cancer Pain, as well as the companion AHCPR consumer guide for patients and families.
Second, Chinese health professionals seem quite willing to take symptom management seriously, perhaps because the goal of curing cancer is even more elusive in China than it is in countries with more developed healthcare technology. Third, attracted by a market that may include as many as 2 million patients with pain due to advanced disease, pharmaceutical companies are aggressively marketing analgesics and are supporting educational programs in pain management.
From a perspective of almost 20 years working in the pain area, I can see many current impediments to cancer pain relief in China that are similar to those we have observed in the United States. For example, the fear of addiction to analgesic drugs is a major barrier for both patients and health professionals. Even now, the fear of using opioid analgesics for children makes pain relief for young patients almost impossible. Aggressive treatment of severe pain in patients with metastatic, but not yet terminal, disease is still rare. Some physicians think that they need to let pain persist so that they can monitor the states of the disease. Patients are rarely asked if they have pain.
As in the United States, health care is not a universal right in China, and health costs (including the costs of analgesics) can be prohibitive. High-tech treatments, often less effective than oral analgesics, are often pressed on patients because they are more profitable for the hospital. Individual provincial (state) regulations are often more restrictive than national regulations and impede progress-especially by limiting outpatient access to analgesics (in most places, Chinese patients must stay in the hospital to receive adequate doses of opioids). The workshop participants have identified poor pain assessment as a major problem in all of their practice settings; they also recognize that few hospital staff have any sophisticated knowledge of pain management.
The participants have been extremely attentive to the presentations and seem eager to apply what they have learned when they work with the patients each afternoon. The lesson that we, the U.S. faculty, will take away is that the problems of improving pain relief are quite generic from one setting to the next, even when vast differences in culture, language, and social system are present. Adequate pain treatment is often the last frontier of good care. But, as in the United States, other countries have people strongly invested in crossing this frontier and eager to find a map to guide them.
