Germany: Cancer Pain and Palliative Care—Current Situation

Abstract

Guidelines of the World Health Organization (WHO) for cancer pain management have been adopted by several German medical societies. 1,2 In 1996, the drug commission of the German Medical Board produced guidelines on cancer pain management that follow the WHO recommendations closely. A second edition was published in 2000, also including an evaluation of the medical evidence behind these recommendations. 3 The Agency for Quality in Medicine, a central non-governmental organization supported by health insurance and German Medical Board, started a guideline evaluation program in 1998 and has chosen cancer pain as the second topic for this guideline clearinghouse. 4 The report produced in 2001 evaluated 13 guidelines for cancer pain management, including three published by German authors, and rated development, form and practicability with standardized scores. The guidelines of the German Medical Board received the highest ranking, with 33 of 40 points, closely followed by the guidelines of the Agency for Health Care Policy and Research (AHCPR) with the same score. The WHO recommendations were placed on rank 9 with a score of 25. The guideline clearing report also suggested areas and topics that should be included in cancer pain guidelines and gave examples from the existing guidelines for these areas. A catalogue of measures is currently in preparation. Although pain management, including cancer pain management, is not a specialty, it has been introduced as a subspecialty by the medical boards in most German states, with the exception of Bavaria, Brandenburg and Hessen. Despite these advances, the common practice of cancer pain treatment still shows serious deficiencies. In a recent survey among physicians not specializing in pain management, the majority reported knowledge of the WHO recommendations, though more than 15% rated transdermal fentanyl as a weak opioid or even a nonopioid analgesic. 5 In a representative survey from 1200 physicians in Lower Saxony, only 33.1% said that they know the analgesic ladder of the WHO. 6 Medical education also shows major deficits in pain management, which implies that no change will be achievable in near time. In a survey among medical students in the final term from six German universities, only 65% reported that they knew the analgesic ladder of the WHO, and onethird of these students did not even know the correct number of steps on this ladder. 7