Germany: Status of Cancer Pain and Palliative Care

Michael Strumpf, MD, Michael Zenz, MD, and Barbara Donner, MD

Department of Anesthesiology, Intensive Care and Pain Therapy
University Clinic - Bergmannsheil
Bochum (Germany)

Reprint from the Journal of Pain and Symptom Management,
Vol. 12 No. 2, August 1996

Epidemiology of cancer pain in Germany

Every cancer desease in Germany has to be included in a cancer desease register. In this register every information on the cancer itself, the progression, treatment, side effects are documented. But there is not even the word "pain" in any of these registers. The same is true for the criterion "quality of life". This lack of documentation leads to a lack of awareness about cancer pain and concomitant quality of life. If doctors were obliged to ask every patient, whether there is any concern of pain, the logical consequence would be to answer any question about the treatment of this pain and to improve the treatment efforts. Consequently, we can in Germany exactly give figures on different cancers but no exact figures on the incidence of pain in cancer.

Situation of palliative care

In Germany we have 216 hospices, which here work primarily on an outpatient basis. The physicians responsible for pain therapy in these institutions are the home physicians and they are not specifically trained in pain therapy or palliative care. So, a continuous and qualified pain treatment is not provided in these hospices. They are not to compare with the english or american hospices. In contrast to these outpatient and not hospital-bound hospices 26 palliative care units exist in hospitals distributed on the entire area of Germany (1). 16 institutions are supporte d by grants of the Ministry of Health and 3 by grants of iDeutsche Krebshilfei. A total number of 230 beds are provided. The need of palliative care beds has been accounted for about 4.000 in Germany to relate 10 beds to 200.000 inhabitants. So, the actual lack in Germany is 3770 beds. However, the situation has improved significantly over the last 6 years (2). An analysis of 16 palliative care units indicate that the most prominent reason to hospitalization was pain. A pain relief was achieved in 84 % of the cases. 16 % of the patients had the same pain or even more at the end of therapy. Certainly, these result can be improved as compared to other international data.

Availability of opioids

Weak opioids like codeine, dihydrocodeine, tramadol, or dextropropoxyphene are freely available on normal prescriptions. They are widely used for cancer and non-cancer pain (54.7 million defined daily dosages -DDD- per year). Whereas the total prescriptions of analgesics (opioids and non-opioids) decreased by 26 %, the prescription of weak opioids increased. In contrast to 54.7 million DDD of weak opioids only 9.6 million DDD of strong opioids were prescribed. This is 15 % of all opioids (3). Strong opioids like morphine or methadone are in Germany prescribed on triplicate prescription forms.

Barriers to effective cancer pain management

Treatment of chronic paini is a topic in the medical examination. But neither pain therapy nor palliative care is taught in german medical schools as a compulsory subject. Knowledge and education in pain therapy is up to the personal efforts of every physician in Germany. The most severe obstruction is the german opioid legislation regulating the prescription of strong opioids. Limits exist for the total amount of opioids, the daily amount, the duration of every priscription. These limits have been eased over the last years in certain steps. But limitations still exist suggesting that opioid use is dangerous. Our national health authorities support prejudices about strong opioids by imposing restrictive laws with marginal changes in legislation (Table 1). A questionnaire to the physicians of Bochum, Germany, demonstrated the following results: 54 % of the physicians stated the last opioid legislation change as an ease, but only 10 % changed their prescribing by this ease. 95 % of the doctors said they had no patients needing strong opioids. 30 % had no special opioid-prescription-forms. Although the legislation has been changed and eased 90 % of the physicians were not willing to increase prescribing of strong opioids (4). These results are coincident with earlier investigations indicating a severe undertreatment of cancer pain. Only 2 % of 16,630 cancer patients received an opioid prescription in a period of 3 years (5). But there must be additional barriers to effective cancer pain treatment, where the reasons are hard to explain. Analysing the data from our pain clinic cancer patients waited more than 2 years with pain, consulted more than 5 different physicians and had more than 60 inpatient days before consulting our pain clinic (6). These results are similar to those from other pain clinics (7).

Programs in Germany

As mentioned above 16 palliative care wards are supported by the government. Other programs do not exist as far as we know. In contrast, many programs on cancer diagnosis, prophylaxis and treatment are supported, whereas cancer pain plays a minor role in the official support. In 1995 a program has been started to publish and distribute guidelines for cancer pain therapy from the Ministry of Health in cooperation with the chamber of physicians. These guidelines have been developed on the basis of the old WHO guidelines and closely resemble their contents. It is hard to understand, why the Ministry did not just distribute the WHO guidelinesalready some years ago but developed own ones last year. The WHO should directly contact the national governments to increase the knowledge about the existing guidelinÖes and to prevent from national guidelines which possibly are not in accordance with the WHO ones. On the basis of the special german guidelines and others on headache and back pain the government has reserved grants for research with a total amount of 15 million DM. Although this amount seams to be minimal related to the extent of the problem, it has to be stated that for the first time in Germany the government has accepted chronic pain as a problem to support in clinical practice. The results of this 5-year-program are planned to conclude into general german guidelines for therapy of chronic cancer pain, headache and back pain.

Future developments

The major medical societies of Germany have recently been assembled to the German interdisciplinary society for pain therapyi with the goal to increase every societyis effort in improving the quality of education pain treatment and to develnope common rules for this education. As a result of these long lasting attempts at improving the quality of pain therapy an offical diploma ipain therapyi is going to be introduced in Germany. This diploma shall be open for every specialist phyicians, e. g. neurologist, anesthesiologist, oncologist etc. It demands a practical and theoretical training in specialized pain diagnosis and therapy over a period of 1 year, a theoretical interdisciplinary course and an examination. In this way the future development in pain therapy will improve in qualitative and quantitative respects in Germany.

References

1. Radbruch L: Personal communication

2. Zenz M. Germany: Status of Cancer Pain and Palliative Care. J Pain Symp Manage 1993;8: 416-418

3. Schmidt G. Analgetika. In: Schwabe U, Paffrath D, eds. Arzneiverordnungs-Report 95. Stuttgart Jena: Gustav Fischer Verlag, 1995: 29-41

4. Willweber-Strumpf A, Zenz M, Strumpf M: Verschreibung von BtM-pflichtigen Analgetika durch Bochumer niedergelassene Ärzte. Der Schmerz 1993;7: S 53

5. Zenz M, Zenz Th, Tryba M, Strumpf M: Severe Undertreatment of Cancer Pain: A 3-Year Survey of the German Situation. J Pain Symp Manage 1995;10: 187-191

6. Strumpf M, Zenz M, Willweber-Strumpf: Analyse der Therapie chronischer Schmerzen. Anästhesist 1993;42:169-174

7. Grond S, Zech D, Dahmann H, Schug SA, Stobbe B, Lehmann KA: Überweisungsgrund: "therapieresistente" Tumorschmerzen. Der Schmerz 1990;4: 193-200

Corresponding author: Prof. Dr. Michael Zenz
Department of Anesthesiology, Intensive Care and Pain Therapy
University Clinic - Bergmannsheil
Buerkle-de-la-Camp-Platz 1
D-44789 Bochum (Germany)
Tel. ++49 234 302 6825
Fax ++49 234 302 6834

Supported in part by grants from Mundipharma GmbH and Purdue Frederick