CP France Status of Cancer Pain and Palliative Care

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France: Status of Cancer Pain 
and Palliative Care 
Z?ZtYOdUCtiOtl 
As in many countries, cancer pain has been 
poorly managed in France for a long time. 
However. pain management has been improv 
ing during the past few years. In 1993, Paris 
was the venue for the Seventh Congress of the 
International hsociation for the Study of Pain 
(IASP), and this helped LO support the devel- 
opment of previous national initiatives and 
promote new ones. Several achievements have 
occurred since our previous report.) but some 
problems remain. 
E$n&miolo~ of Caw Pain 
A multicenter survey of 601 cancer patients 
at different stages of dtsease was conducted in 
1991.’ More than one-half (57%) of these 
patients reported cancer-related pain: of the 
patients in pain, 69% rated their pain at a 
level that impaired their abiiity to function. 
This survey also revealed that 5 I % of patienrs 
reporting pain did not receive adequate pain 
medication. Younger patients, patients without 
metastatic disease. patients with a better per- 
formance status, and patients who rated their 
pain as more severe than the rating given by 
their doctors were at greater risk for under- 
treatment. 
Barriers to Efftiive Pain 
MUnagement 
A national survry of two representative 
samples of primary care physicians (PCPs. N= 
600) and medical oncologists (01~s. N = 300) 
&as conducted in 1992.’ This study confirmed 
the presence among both groups of attitudinal 
barriers and knowledge deficits previously 
reported in other countries, such as the fear of 
side effects and restrictive regulations on the 
prescription of morphine. It also identified 
more specific barriers: Morphine was less pre- 
scribed, because other drugs were perceived to 
be as efftctive and because of its (perceived) 
poor image in the public opinion. Finally. this 
study revealed discrepancies in physicians’ atti- 
tucks and knowledge about pain control. For 
example, although S5% of PCPs and 93% of 
oncologists expressed satisfaction with their 
own ability lo marrage cancer pain, 76% of 
PC!3 and 50% of oncologists reported being 
reluctant to prescribe morphine for cancer 
pain. Another large national survey confirmed 
that French physicians undertreat cancer 
pain.” Surveys of the genetal public and of 
pharmacists are currently being analyzed. Pre- 
liminary results indicate that more than one- 
half of the public has a negative image of mor- 
phine, and that pharmacists have a poor 
knowledge of pain treatment.“.” 
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Availability of Opioids fw the 
Mamgemrrnt cf Cancer Pain 
Compared to other European countries, 
France has bxn -anked “2” in terms of 
“opiophobia” on a scale where “0” represents 
the more liberal and “4” the most restricthe 
legislation regarding opioid analgesics.’ 
Morphine prescription is limited in daily 
dosage (180 mg hy mouth. 80 mg 
parenterally); hut this can be exceeded and tn 
duration. In 1995. the allowed duration for a 
single prescription of oral morphine sulfate or 
parenteral morphine (if administered continu- 
ously) wrs incrcasei to 28 days. Prescription of 
oral morphine chlorhydmtc, however. is still 
limited to 14 days. In x!dition. prescribing 
opioids still recluircs tilling out a pccial pt-e- 
scription form, which is seen a.r a signiticant 
impediment hy physician:.” 
Programs Addressing the Need for 
Symptom Conbvl and Qua&q of Life 
Among Patients with Cancer 
Fmnch National Poliq Against Pain 
For many years. the French .Winistry of 
Health has showt iuterest in improving the 
nagement of pain. 0ver the past fcuv yews. 
legislative and executive authorities developed 
several initiatives pertainiug to the identifica- 
tion of pain as a national health priority. to the 
definition of hospitals’ and professionals’ 
roles, to the improvement of meilicdl training. 
and to the cousidetatiou of pain-t-elated issues 
in the elaboration o!. regulations ronsrtaining 
opioid use. 
The Noxmbcr 1994 report of the “Haut 
Cornit de la SantG Pttblique” (High Commit- 
tee of Public bkahh) identified pain as one of 
the key health problems in France. This report 
set the objecthe that “by the year 2000, rile 
uumbcr of patients suffering front cancer or 
postofxrative pain must be halved.“” 
Following the world of a special study group 
constituted in the French .Senate in Octobet- 
1994, the Senatorial Commission on .Social 
A&its published a comprehensirc report and 
recommendations to improve the manage- 
mcnt of pain in France.” In February lYY5, an 
nmcndmcnt to the 1991 law defining French 
hospitals’ missions stipulated that health insti- 
tutions must adopt appropt-iatc means to man- 
age pain. individual health professionals are 
also required to contribttte to the adequate 
management of pain, The new Code of Ethics 
published in September 1995 by the French 
National Board of I’hpicians (0rdt.e Satuonal 
des Wdecins) pt-oclaims that “in all ckum- 
stances, every physician must endeavor to 
reliew the suffering of his,‘her patient. to prc- 
\ide mot-al support, and must a\-oid any excess 
in examination and treatment.” 
Pain management and palbatiw care were 
not previously taught in the course of medical 
studies. Both should soon he included in the 
core curriculum of all French medical srhools. 
according to a &lay 1995 administrative now 
hy the Ministry of tIc:alth and hy the Mnistr! 
of Higher Education and Research. 
Postgraduate training in pain man gement 
has been available since 1991 through an 
intcrunixrsi~ diploma set up at the initiative 
of the French chapter of the LXW. in 19%. a 
special Senatotial Fund of Sl .OOO,OOO was set 
up to support additional lrdiliing acrivitics of 
existing Rain Management Centers. 
In January 1996, a paitt expett joined .:.e 
Special Adt-isory Commission on opioid use in 
the .Ministry of Health. The composition of 
this commission *as, until then. limited to 
members of the national health administta- 
tion and to d;ug abuse experts. 
Specific efforts to improve cancer pain man- 
agement have been also developed by profes- 
sional aud nonprofessiottal organimtions. Spe- 
cial gt-oups on cancer pain were created in the 
French chapter of LGP and in the “~SociGtF 
Francophonc pour I’Etudc de la Doulcnr” 
(SOFRED). In 1995. the “Lipue Sationnle 
cuntre le Cancer,” d I trgc non-profit organiza- 
tion promoting research and care for cancer 
patients, declared pain management to be a 
pi-iotity. 
Clinical Praacticp Guld4itws 
II. IWi, the Sational Agcnc; for the Dcvel- 
optnent of Medical E\aluatton ptthlirlred 
guidelines for the management of rancor pain 
in ambttlatory prxtice.“’ l-he wme year. the 
National Fe&ration of Cancer Centers pub 
lishcd comprehensive guidelines, s\-,lilnhle in a 
referenced French journal ofoncolo~ and UII 
CD-ROM, which covered all componems 01 
oncological practice, including pai11 control 
a-ti pvcho+ncology.’ ’ 
The “Federation Qionale De 1.a Ai:ltditi 
Francaisc” (FNMF) provides con~plem~~nta~-y 
he;1 th insurance to one-half of the French 
pop&tion and dil-ectly manages more than 
50 health-care f:dcilities in France. In 1993, the 
FNMF declared the management of cancer 
pain and postopcrarive pain to he a priority. X 
pilot prcgram was developed to assess how 
quahty improvemenL procedure. derived 
from the American pain Society Quality hssur- 
ante Standards, could be implemented in all 
FNMF insdturions. This program is c-11rren11y 
in progress. 
There is no doubt that cancer pa;n manage- 
ment is improving in Frdnw. The increase in 
morphine consumption over the past decade 
in France (from 27 kg in 1984 IO 398 kg in 
1993) provides an indication RJf this esotulion. 
Evaluations of the quatiry 01. care received by 
cancer padcms should be repeated tn assessthe true cffcctivencss 01 p;liticat and insriw- 
cicnh.r ~.‘Foru. Media coverage of pain managc- 
mew issum has sometimes been inwnsive in 
the past few years. The effects of tiis informa- 
tion on the public pcrceplion of pain avd iu 
treatment should also be aswsced. 
Additional issues should stilt be considered. 
Further efforts shordd be made Lo facilit;ttc 
access to potent analgesics. The nllmhcr of 
opioids available in Fiance for pain manage- 
ment is limiwd: hydromorphone is not com- 
mt~ciatized and methadone is only available 
for treatment of drug abuseen. The limit on 
tie daily dowge of morphine allowed by cur- 
rent regulation is meaningless with respect to 
the pharmacolrgy of morphine and should IX 
removed. Avai!aYlity and ease of use of special 
prescription forms should lx improved. 
Appropriate pain management requires 
both skills and time. The implementation of 
planned improvements in Ihe medical schools 
curricula should be supported by consiswnr 
awl perrisdng effow. W%ite improved post- 
gl-aduate Lraining of’ hcatth professionals and 
[he disscmin;ction of pain management +dc- 
tines should alteviaw the current inadequacies 
in phyxicianc’ knowledgr, die current iinanc- 
ing syslcm ir Fiance does not promote spend- 
ing timr wi& paticnb. Mveover, crcdting new 
tms~~ious for wferial cenlcrs or experts in 
pain managcwwn~ may lx particularly difficult 
when strong cmphasib is placed on conrainirlg 
health esprnses.