[Supply of opioid analgesics to outpatients with cancer pain].

INTRODUCTION: 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.
METHODS: In Germany special prescription forms, i. e. triplicate forms, have to be used for the prescription of strong opioids. At the time when our investigation took place prescriptions for outpatients had to be renewed every 7 days. For two observation periods of 6 months lasting from January to June 1988 and from January to June 1991 all of the opioid prescription forms that had been issued by general practitioners for clients of the AOK Hannover (one of the major medical insurance companies) were evaluated. The reasons for prescribing opioids were analysed by recording the diagnosis. The individual treatment period on an outpatient basis during these 6 months was determined, excluding, e. g. days of hospitalization.
RESULTS: During the two observation periods only 16.2 % (1988) and 19.5 % (1991) of the practitioners in the region of Hannover prescribed strong opioids to outpatients. The majority of the practitioners consisted of general practitioners and specialists in internal medicine. Although these two groups mainly function as family doctors who are responsible for the basic therapeutical needs of their patients, only 22.6-33.8 % of these doctors prescribed opioids to outpatients. In two-thirds of the patients, cancer pain was the reason for prescribing the drug. The total number of patients with a prescription for cancer pain was 164 in 1988 and 196 in 1991. Altogether 1002 prescription forms in 1988 and 1065 prescription forms in 1991 had been issued for these patients. Applied to the individual treatment period as an outpatient, only 36.0 % of the patients in 1988 and 32.1 % in 1991 received a regular prescription of strong opioids every 7 days. The mean time interval between separate prescriptions was 16.8 +/- 25.4 days in 1988 and 19.4 +/- 29.1 days in 1991. Accordingly, the majority of patients with chronic cancer pain had been supplied with opioids only occasionally.
CONCLUSION: 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.