Mediating Effect of Family Caregivers' Hesitancy to Use Analgesics on Homecare Cancer Patients' Analgesic Adherence

A Prospective Study to Compare Caregivers' Knowledge and Perception of Cancer Pain with Patients' Pain Assessment and to Evaluate their Quality of Life

OBJECTIVES

Family caregivers (FCGs) play a crucial role in the home care of terminally ill patients. Therefore, evaluating their comprehension of patients' symptoms and doctors' advice becomes crucial. Moreover, this might negatively impact their quality of life (QOL). Thus, the purpose of the study was to examine FCGs' perception and understanding of cancer pain in relation to patients' pain assessments, as well as the effect this has on their own QOL.

MATERIALS AND METHODS

The family pain questionnaire (FPQ) and patient pain questionnaire (PPQ) were used for both patient as well as their FCGs. The scores for each subscale, knowledge, and experience were calculated. Furthermore, FCGs' own QOL was assessed using the caregiver quality of life index-cancer (CQOLC) questionnaire. Results were statistically analysed.

RESULTS

The FCGs of 93 individuals were examined. The Cronbach alphas for the current dataset showed that the FPQ (0.754) and PPQ (0.759) overall reliability scales were satisfactory. The knowledge, experience, and total average scores for the PPQ (FPQ) subscales were reported as 35.91 (35.31), 27.19 (26.86), and 63.10 (62.17), respectively. The knowledge, experience, and overall scales of the PPQ (FPQ) were evaluated to provide median scores of 37 (36), 28 (25), and 65 (62) correspondingly. A t-test was used to determine the significance of the observed average differences (d) for knowledge (0.602), experience (0.333), and overall (0.935). The results showed that there were no significant differences (P > 0.05). An inverse relationship was elicited between the total QOL and the pain assessment scores of FCGs, as well as the age of the patient. The difference was, however, majorly statistically non-significant (P > 0.5). Further, statistical significance was found only between the burden component of the CQOLC and the age of the patients (P = 0.034), as well as total pain knowledge (P = 0.007) and total pain scores (P = 0.001) of the FCGs'.

CONCLUSION

As per our analysis, FCGs had less knowledge and experience of patients' pain, though statistically , it was not significant. The age of the patient, as well as total pain knowledge and total pain scores of the FCGs' were found to affect the QOL of FCGs'. Studies with large sample sizes might help in strengthening the findings.

Family Caregiver Challenges in Pain Management for Patients with Advanced Illnesses: A Systematic Review

Although pain management is integral to the caregiving role, there is a paucity of evidence synthesizing specific challenges family caregivers (FCs) face when managing pain for their care partners. This review comprehensively identified and summarized such challenges in the setting of advanced illnesses. Electronic databases (PubMed, CINAHL, PsycINFO, Scopus, and Health and Psychosocial Instruments) were searched using index and keyword methods for all articles published before April 2021. Fifty-five studies were included in this review. Most articles were published within the last 10 years (54%) in community settings, with home hospice care comprising the majority (50%). Most studies included patients with an advanced cancer diagnosis (84%), and 16% of the studies included patients with a noncancer diagnosis. Four major categories of challenges were identified: (1) caregiver-related issues (e.g., fears, beliefs, function), (2) caregivers' limited knowledge and skills in pain management (e.g., verbal and nonverbal pain assessment skills, pharmacological knowledge, documentation, safe management of medication), (3) communication challenges with health care providers, and (4) patient-related issues (e.g., inability to report pain). Many of these challenges have not been fully addressed in prior literature. Thus, this review provides a framework for needed future research to develop interventions that target FCs' specific challenges in providing pain management. The results also highlight a significant lack of research surrounding challenges faced by caregivers of care partners having a noncancer, dementia, or multimorbidity diagnosis.

The Prevalence and Potential Role of Pain Beliefs When Managing Later-Life Pain

OBJECTIVES

In this study of 154 community-dwelling older adults with chronic noncancer pain, we sought to assess participants' beliefs about pain as well as pain management treatments and to determine the influence of those beliefs on participants' willingness to undertake 3 physician-recommended pain treatments, that is, a pharmacologic, physical, and psychological therapy.

MATERIALS AND METHODS

A 16-item questionnaire was employed to ascertain participants' pain beliefs, divided into 4 subscales representing: (1) negative beliefs about pharmacological treatments, (2) positive beliefs about physical treatment approaches, for example, exercise, (3) positive beliefs about psychological treatments, and (4) fatalistic beliefs about pain. Participants were asked to rate their willingness to undertake a pharmacologic, physical, or psychological therapy if their physician recommended that they do so. Agreement with each belief was measured, and we examined willingness to undertake each treatment as a function of pain belief subscale scores after controlling for relevant covariates.

RESULTS

Positive beliefs about physical treatments (eg, benefits of exercise) were the most strongly endorsed items on the pain beliefs questionnaire. All 3 treatment-focused pain beliefs subscales were significantly associated with willingness to undertake that form of treatment (eg, negative beliefs about pain medication use were associated with decreased willingness to take pain medication). Fatalistic attitudes were significantly associated with a decreased willingness to undertake physical treatments.

DISCUSSION

These results support the notion that patients' beliefs about pain and pain treatments can have important effects on treatment engagement and, if assessed, can help guide clinical management of chronic pain in older adults.

Pain medication adherence in patients with cancer: a pragmatic review

OBJECTIVE

Adherence to pain medication in patients with cancer is crucial for successful pain therapy. This review aimed to investigate: the rate of adherence, which factors influence adherence, whether adherence differs in diverse patient populations, whether there are methods to improve adherence, and the relationship between adherence and pain relief.

METHODS

This review was performed following the PRISMA guidelines. MEDLINE/Pubmed, Embase, Web Of Science, Cochrane and ClinicalTrials.gov were searched. All types of studies investigating adherence of patients with cancer, factors influencing adherence, and methods to improve adherence to pain medication were included. They were first screened on title and abstract and thereafter on full text. Selected articles were subjected to a quality assessment according to the PRISMA checklist. From included articles, study characteristics and outcomes were extracted.

RESULTS

Out of 795 articles, 18 were included. Different methods were used to measure adherence, which led to adherence rates ranging from 8.9% to 82.0%. White Americans and men were found to be more adherent than African Americans and women. Due to various barriers, adherence is often suboptimal. Fear of addiction, physiological and harmful effects, tolerance, and disease progression are common concerns. Interventions, such as pain education booklets, pain consults, and specialised nurses, may be beneficial to increase the adherence. Lower adherence rates were associated with lower pain relief.

CONCLUSION

Adherence of cancer patients to pain medication is suboptimal. Health care workers should focus on barriers to increase the adherence in order to obtain a better pain relief.

The Association Between Analgesic Treatment Beliefs and Electronically Monitored Adherence for Cancer Pain

OBJECTIVES

To determine whether clusters based on analgesic treatment beliefs among patients with cancer predict objective analgesic adherence.

SAMPLE & SETTING

207 patients with cancer in the outpatient setting who were aged 18 years or older, self-identified as White or African American, were diagnosed with solid tumor or multiple myeloma, and were prescribed at least one around-the-clock analgesic prescription for reported cancer pain.

METHODS & VARIABLES

This study is a secondary analysis of an existing dataset. General linear modeling with a backward elimination approach was applied to determine whether previously identified analgesic treatment belief clusters, as well as sociodemographic, clinical, and pain variables, were associated with adherence behaviors.

RESULTS

Significant explanatory factors were experiential in nature and included sociodemographic, clinical, and pain-related variables, explaining 21% of the variance in analgesic adherence. Analgesic belief clusters were not predictive of adherence.

IMPLICATIONS FOR NURSING

Future research should examine sociodemographic and other clinical factors, as well as the influence of analgesic treatment beliefs, to better understand adherence behaviors among patients with cancer.

Factors influencing non-adherence to opioids in cancer patients: a mixed-methods cross-sectional study

Background: Strong opioids are mainly utilized to attenuate pain in cancer patients. Adherence to analgesic drugs significantly promotes adequate pain management and improves quality of life. We aimed to identify the factors influencing non-adherence to strong opioids in cancer patients. Methods: A descriptive, cross-sectional, two-phased, mixed methods design was conducted prospectively to evaluate a cohort of 101 cancer patients who are currently prescribed strong opioids from a pain clinic in Thailand between January and March 2018. Participants were asked to complete a questionnaire that included the following sections: general characteristics; the Medication Taking Behavior in Thai (MTB-Thai) for assessing adherence to medications; and factors influencing nonadherence, which were analyzed using multivariate logistic regression. In addition, face-to-face in depth interviews were conducted with patients showing non-adherence to strong opioids (MTB-Thai score ≤21) and analyzed using thematic content analysis.  Results: Of 101 cancer pain patients that completed the questionnaire, 39.6% showed non-adherence to strong opioids. Illness understanding (P=0.047) and the use of more than three types of pain medication (P=0.032) were significant factors influencing non-adherence. Qualitative analysis indicated that fear of long-term outcomes, opioid side effects, ineffective pain control, attempts to make the regimen more acceptable, poor understanding, and non-acceptance of disease related to non-adherence. Conclusion: Non-adherence to opioids for cancer patients is a common problem. Awareness of patient factors, medication-related factors, and illness-related factors will provide the knowledge and adequate advice that may enhance adherence to medications.

Factors influencing non-adherence to opioids in cancer patients: a mixed-methods cross-sectional study

Background: Strong opioids are mainly utilized to attenuate pain in cancer patients. Adherence to analgesic drugs significantly promotes adequate pain management and improves quality of life. We aimed to identify the factors influencing non-adherence to strong opioids in cancer patients. Methods: A descriptive, cross-sectional, two-phased, mixed methods design was conducted prospectively to evaluate a cohort of 101 cancer patients who are currently prescribed strong opioids from a pain clinic in Thailand between January and March 2018. Participants were asked to complete a questionnaire that included the following sections: general characteristics; the Medication Taking Behavior in Thai (MTB-Thai) for assessing adherence to medications; and factors influencing nonadherence, which were analyzed using multivariate logistic regression. In addition, face-to-face in depth interviews were conducted with patients showing non-adherence to strong opioids (MTB-Thai score ≤21) and analyzed using thematic content analysis.  Results: Of 101 cancer pain patients that completed the questionnaire, 39.6% showed non-adherence to strong opioids. Illness understanding (P=0.047) and the use of more than three types of pain medication (P=0.032) were significant factors influencing non-adherence. Qualitative analysis indicated that fear of long-term outcomes, opioid side effects, ineffective pain control, attempts to make the regimen more acceptable, poor understanding, and non-acceptance of disease related to non-adherence. Conclusion: Non-adherence to opioids for cancer patients is a common problem. Awareness of patient factors, medication-related factors, and illness-related factors will provide the knowledge and adequate advice that may enhance adherence to medications.

Management of Severe Pain in Terminally Ill Patients at Home: An Evidence-Based Strategy

The purpose of this article is to describe current evidence-based strategies to manage severe pain in patients living with terminal illnesses. A comprehensive pain assessment is a critical step in the initial development of a pain management plan and for ongoing evaluation of patients' pain. Although we have many effective clinical tools available for pain assessment, they are not always used consistently, which can negatively affect the pain management plan. Home care and hospice nurses need to be consistent in using the tools and documenting the patient's pain level and response to the pain management plan. Patients and caregivers have concerns and fears surrounding medication use, particularly with narcotic analgesics. It is vital that nurses provide thorough patient-centered teaching about medications to help address these concerns. Research has found that nurses who also provided validation to patients and families regarding their concerns, followed by education, were the most effective.

Patient Trade-Offs Related to Analgesic Use for Cancer Pain: A MaxDiff Analysis Study

PURPOSE

Many patients with cancer pain deviate from prescribed analgesic regimens. Our aim was to elicit the trade-offs patients make based on their beliefs about analgesic use and rank utilities (importance scores) using maximum difference (MaxDiff) scaling. We also investigated if there were unique clusters of patients based on their analgesic beliefs.

METHODS

This was a secondary analysis of a three-month, prospective observational study. Patients (N = 207) were self-identified African Americans and Whites, >18 years, diagnosed with multiple myeloma or solid tumor, and were prescribed at least one around-the-clock analgesic for cancer pain. MaxDiff analysis allowed us to identify patients utilities. Second, a cluster analysis assisted in ranking how analgesic beliefs differed by groups. Third, clusters were described by comparing key sociodemographic and clinical variables.

RESULTS

Participants' beliefs were a significant factor in choices related to analgesic use (chi-square = 498.145, p < .0001). The belief, 'Pain meds keep you from knowing what is going on in your body', had the highest patient endorsement. Two distinct clusters of patients based on analgesic beliefs were identified; 'knowing body' was ranked as top priority for both clusters. The belief that cancer patients become addicted to analgesics was moderately important for both clusters. Severity of side effects was the only key variable significantly different between clusters (p = .043).

CONCLUSIONS

Our findings support tailored pain management interventions that attend to individual beliefs about cancer pain and analgesic use. Future research should explore the relationship between analgesic utilities, actual analgesic taking behaviors, and how they impact patients' cancer pain outcomes.

Family Caregiving and Cancer Pain Management

Family caregivers are centrally involved in cancer pain management, especially for patients with advanced disease. This issue is becoming ever more important as care shifts to the outpatient setting and home care and as the aging population creates more patients who have multiple illnesses and family caregivers who often live with serious illnesses. This narrative review evaluated current knowledge and literature regarding family caregivers' involvement in cancer pain management and identified areas for future research and clinical practice. There is a need for additional research in this area and for clinical models of support for family caregivers as they provide pain management for patients with cancer.

Gender Difference in Cancer Patients' Adherence to Analgesics and Related Outcomes of Pain Management

BACKGROUND

Males and females have significant differences in certain medical outcomes. However, little research has explored the gender differences in cancer patient perceptions of analgesics, the relationship between gender and analgesic adherence, or the effectiveness of pain management.

OBJECTIVE

The objectives of this study were to compare gender differences associated with hesitancy to use analgesics, analgesic adherence, or pain management effectiveness and to examine whether gender can precisely predict analgesic adherence.

METHODS

The study was conducted in the outpatient oncology department of a medical center in Taiwan. A descriptive and cross-sectional design was used. The study samples were collected from 362 cancer patients. The participants completed the short version of the Barriers Questionnaire-Taiwan, the Morisky Analgesics Adherence Measure-Taiwan version, the Brief Pain Inventory-Chinese version, the Pain Management Index, and a demographic and disease questionnaire.

RESULTS

The pain intensity and hesitancy to use analgesics scores were significantly higher among females than among males. The Pain Management Index results indicated that a larger percentage of males had adequate pain management. In addition, being male was a significant predictor of higher analgesic adherence (odds ratio, 1.93; P < .05).

CONCLUSIONS

Gender could precisely predict cancer patients' medication adherence. Women experienced significantly greater pain than did men but also had more hesitancy to use analgesics, lower adherence, and inadequate pain management.

IMPLICATIONS FOR PRACTICE

Healthcare professionals should consider women as a high-risk group for inadequate pain control. It is crucial for health providers to consider the gender discrepancy when attempting to improve cancer pain management.

A nationwide survey of adherence to analgesic drugs among cancer patients in Taiwan: prevalence, determinants, and impact on quality of life

PURPOSE

Poor adherence to analgesic drugs is one of the most common barriers to adequate pain management. This prospective, cross-sectional, patient-oriented observational study aimed to explore the adherence rate, clinical factors, and impact of adherence to analgesic drugs on the quality of life (QoL) among cancer outpatients in Taiwan.

METHODS

Eight hundred ninety-seven consecutive adult outpatients with cancer who had reported tumor pain and received regular analgesic drug treatment were enrolled from 16 medical centers across Taiwan. The Brief Pain Inventory was used to assess pain intensity and QoL. Morisky's four-item medication adherence scale was used to assess adherence to analgesic drugs. Clinical factors possibly associated with good adherence to analgesic drugs were analyzed using multivariate logistic regression analyses.

RESULTS

Of the 897 patients, 26.9% met criteria for the good, 35.5% for the moderate, and 37.6% for the poor adherence groups. The good adherence group had significantly better QoL outcomes than the moderate and poor adherence groups (all p < 0.05). Age ≥ 50 years, head and neck or hematological malignancies, cancer-related pain, patients who agreed or strongly agreed that the side effects of analgesic drugs were tolerable, and patients who disagreed or strongly disagreed that the dosing schedule could be flexibly self-adjusted to deal with the actual pain were predictors of good adherence to analgesic drugs.

CONCLUSIONS

Awareness of the clinical factors associated with adherence to analgesic drugs may help clinicians to identify cancer patients at a greater risk of non-adherence, reinforce optimal pain management, and improve the QoL by enhancing adherence to pain medications.

Family caregivers for adult cancer patients: knowledge and self-efficacy for pain management in a resource-limited setting

Adult cancer patients (ACPs) in resource-limited settings disproportionately suffer from inadequate pain control despite advancements in pain management. Family caregivers (FCGs) can support optimal pain control for ACPs in these settings if they are knowledgeable and confident about the needed care. However, the status of FCGs' knowledge and self-efficacy (SE) for pain management in developing countries is not well established.

PURPOSE

To assess the FCGs' knowledge and SE levels for pain management among ACPs while at home in a resource-limited setting.

METHODS

Using a questionnaire that comprised a Family Pain Questionnaire and Chronic Pain Self-efficacy Scale, data were collected from 284 FCGs of ACPs receiving care from two cancer care centres.

RESULTS

The FCGs had moderate knowledge (mean = 41.70 ± 14.1) and SE (mean = 795.95 ± 301.3) levels for pain management at home for ACPs. Majority of the FCGs had low knowledge (52.1%), but expressed higher SE (52.5%). Poor self-rated health among FCGs was significantly associated with low knowledge levels (OR = 1.75; 95% CI 1.024-2.978, p = 0.041). SE was significantly associated with perceiving a low impact of caregiving on health (OR = 1.55; 95% CI 1.074-2.239, p = 0.019), hours of caregiving per week (OR = 0.52; 95% CI 0.315-0.854; p = 0.01) and receiving organisational support (OR = 0.388; 95% CI 0.222-0.679; p = 0.001).

CONCLUSION

The results show a need for deliberate interventions to enhance FCG knowledge and SE for pain management at home as one of the ways of improving cancer pain management in resource-limited settings.

Patient-clinician relationship seems to affect adherence to analgesic use in cancer patients: a cross sectional study in a Taiwanese population

Objectives

Patient satisfaction can provide a measure of service quality and serve as a predictor of health-related behaviors. Little is known about how patients' satisfaction with clinician-patient interactions affects their adherence to taking analgesics. The purposes of this study were to (1) investigate the predictors of patients' satisfaction with clinicians, and (2) examine whether patients' satisfaction with their clinicians can improve adherence to analgesic use.

Design

A cross-sectional and descriptive design was used.

Setting

Outpatient oncology clinic at a medical center in Taiwan.

Participants

A convenience sample (N = 309) was recruited.

Main outcome measures

The Medical Interview Satisfaction Scale 21 - Chinese Version, Short Version of the Barriers Questionnaire - Taiwan Form, Taiwanese version of the Morisky Medication Adherence Measure, and Interpersonal Physician Trust Scale - Chinese version, and Brief Pain Inventory Chinese Version.

Results

Variables that could significantly predict patients' satisfaction were patient age and trust in clinicians, which together accounted for 33% of the total variance. Patients' satisfaction with their clinicians significantly predicted patients' adherence to medication use (OR = 3.10, P < 0.05). There was an interactive effect (OR = 0.12, P < 0.05) between patients' satisfaction and barriers to analgesic use. Correlation coefficients between barriers to analgesic use and patients' adherence are -0.52 (P < 0.001) and -0.13 (P = 0.20) in the higher satisfaction and lower satisfaction patients, respectively.

Conclusions

Patients' satisfaction with their clinicians can have a positive effect on changing analgesics adherence behaviors when patients hold incorrect beliefs about analgesics. Patients' satisfaction has an important role in enhancement of analgesics adherence behaviors.