Concerns About Pain and Prescribed Opioids in Taiwanese Oncology Outpatients

Rapid titration with oral sustained-release morphine plus subcutaneous morphine in a multi-center, randomized control study of cancer patients with moderate to severe cancer pain

BACKGROUND

Pain is one of the most common concomitant symptoms among cancer patients. Pharmacologic agents are regarded as a cornerstone of cancer pain management. 'Dose titration' with short-acting morphine is widely accepted. Such a titration method is very complicated. The analgesic background establishment is often delayed. Titration based on sustained-release opioids is also recommended, but the onset of analgesic effect requires hours, whereas the rescue analgesia is always needed. This study evaluated the optimized morphine titration scheme with a simultaneous combination of sustained-release morphine and subcutaneous morphine.

METHODS

In a multicenter, 7-day, randomized controlled study, patients with moderate to severe cancer pain were assigned to receive either sustained-release morphine and subcutaneous morphine simultaneously (rapid titration) or only subcutaneous morphine to dose titration. The primary outcome was the safety and the number of times of rescue therapy as needed in the first 24 h.

RESULTS

A total of 108 patients with moderate to severe cancer pain were included in the study. The number of times of rescue analgesics in the first 24 h significantly reduced in the rapid titration group (0.4 ± 0.48 vs. 2.3 ± 0.78, P = 0.000). No differences in the intensity of opioid-related symptoms were found between the two groups.

CONCLUSIONS

Rapid titration is safe and efficient, which could significantly decrease rescue analgesics in the first 24 h and achieve better analgesic efficacy for cancer pain patients.

Relationship between prescribed opioids, pain management satisfaction, and pain intensity in oncology outpatients

BACKGROUND

Pain is the most severe and commonest symptom for patients with cancer. Patients' pain management satisfaction is an essential indicator of quality care and further affects their willingness to seek care.

PURPOSE

This study aimed to examine the correlations between patients' prescribed opioids, pain management satisfaction, and pain intensity.

METHODS

This study adopted a cross-sectional correlation design, recruited a total of 123 patients with cancer pain through convenience sampling, and used two research scales, namely the Chinese version of the Pain Treatment Satisfaction Scale and the Brief Pain Inventory-Short Form.

RESULTS

The findings indicated that the correlations of prescribed opioid dosage with pain management satisfaction (r =  - .10, p > .05) and pain intensity (worst pain, least pain, average pain, and pain right now; r =  - .05 to .01, p > .05) were nonsignificant. The correlations of pain management satisfaction with pain intensity (r = .24 to .32, p < .01), pain interference (r = .32, p < .01), and pain relief (r =  - .25, p < .01) were all significant, but that with the worst pain (r = .06, p > .05) was nonsignificant.

CONCLUSIONS

Medical professionals providing cancer pain management should focus on medicines strategies and individuals' pain relief requirements. In particular, patients with the worst pain require extra investigations into their needs, and their satisfaction with their level of pain should be further evaluated.

Ethical Dilemma: Healthcare Surrogate Refusal of Opioid Administration

It is morally distressing when a healthcare provider sees patients with undertreated pain but is unable to provide adequate relief because of a surrogate's refusal of such treatment. This issue might occur when there is no clear advanced directive that represents patients' wishes for treatment, and can be further complicated when patients are of minority cultural backgrounds. This article presents a case where the surrogate of a Korean-American woman with severe somatic pain from metastatic pancreatic cancer requested only acetaminophen be given to control the patient's pain. The ethical issues associated with surrogate misconceptions on therapeutic use of opioids are reviewed. This case highlights the ethical dilemma of withholding opioid treatment in a patient with advanced cancer. We conclude that the obligation to treat pain should be understood beyond the authority of surrogate refusal, in favor of patient quality of life, when an advance directive is not in place.

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.

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.

Satisfaction with pain management and impact of pain on quality of life in cancer patients

AIM

To evaluate the prevalence of pain in cancer outpatients in Taiwan and to investigate the impact of pain on quality of life (QoL) and patient satisfaction. Results were compared to those of a similarly designed study conducted in 2008 to identify trends.

METHODS

Adult patients with cancer treated as outpatients in hospitals throughout Taiwan were recruited. Pain intensity and the extent to which pain interfered with QoL were self-reported using a modified version of the Brief Pain Inventory. Patients also indicated their level of satisfaction with their physician, as well as with their pain control.

RESULTS

A total of 2652 patients were enrolled from 16 sites. Of these, 1167 (44.0%) patients reported experiencing pain during the previous week. Prevalence and severity of pain were highest in patients with progressive disease. A higher pain severity score was significantly associated with greater interference in both physical and psychological functions. Overall, 86.0% of all participants expressed satisfaction with their physician and 84.8% were satisfied with their pain control; satisfaction rates were associated with pain severity. Compared with the findings from the 2008 study, pain prevalence was notably lower and patient satisfaction was significantly greater in the current study.

CONCLUSIONS

Prevalence and severity of pain were associated with disease stage. Pain interference on QoL correlated significantly with pain severity. Treatment of pain in cancer patients in Taiwan seems to have improved from 2008 to 2014, possibly attributable to new cancer pain treatment guidelines and the wider availability of novel analgesic therapies.

Cancer pain management needs and perspectives of patients from Chinese backgrounds: a systematic review of the Chinese and English literature

Objective

More than half of all cancer patients experience unrelieved pain. Culture can significantly affect patients’ cancer pain-related beliefs and behaviors. Little is known about cultural impact on Chinese cancer patients’ pain management. The objective of this review was to describe pain management experiences of cancer patients from Chinese backgrounds and to identify barriers affecting their pain management.

Method

A systematic review was conducted adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies were included if they reported pain management experiences of adult cancer patients from Chinese backgrounds. Five databases were searched for peer-reviewed articles published in English or Chinese journals between1990 and 2015. The quality of included studies was assessed using Joanna Briggs Institution's appraisal tools.

Results

Of 3,904 identified records, 23 articles met criteria and provided primary data from 6,110 patients. Suboptimal analgesic use, delays in receiving treatment, reluctance to report pain, and/or poor adherence to prescribed analgesics contributed to the patients’ inadequate pain control. Patient-related barriers included fatalism, desire to be good, low pain control belief, pain endurance beliefs, and negative effect beliefs. Patients and family shared barriers about fear of addiction and concerns on analgesic side effects and disease progression. Health professional–related barriers were poor communication, ineffective management of pain, and analgesic side effects. Healthcare system–related barriers included limited access to analgesics and/or after hour pain services and lack of health insurance.

Significance of results

Chinese cancer patients’ misconceptions regarding pain and analgesics may present as the main barriers to optimal pain relief. Findings of this review may inform health interventions to improve cancer pain management outcomes for patients from Chinese backgrounds. Future studies on patients’ nonpharmacology intervention-related experiences are required to inform multidisciplinary and biopsychosocial approaches for culturally appropriate pain management.

The impact of pain control on physical and psychiatric functions of cancer patients: a nation-wide survey in Taiwan

OBJECTIVE

To investigate the prevalence of pain in cancer patients at different disease statuses, the impact of pain on physical and psychiatric functions of patients and the satisfaction of pain control of patients at outpatient clinic department in Taiwan.

METHODS

Short form of the Brief Pain Inventory was used as the outcome questionnaire. Unselected patients of different cancers and different disease statuses at outpatient clinic department were included. The impacts of their current pain control on physical function, psychiatric function and the satisfaction of doctors were evaluated. Logistic regression analyses were performed to evaluate whether the interference scale performed identically in the different analgesic ladders. The dependent variables were satisfaction toward physician and treatment.

RESULTS

A total of 14 sites enrolled 2075 patients in the study. One thousand and fifty-one patients reported pain within the last 1 week. In patients whose diseases deteriorated, >60% of them need analgesics for pain control. Pain influenced physical and psychiatric functions of patients, especially in the deteriorated status. More than 80% of patients were satisfied about current pain control, satisfaction rate related to disease status, pain intensities and treatments for pain.

CONCLUSION

Our study found that different cancers at different statuses had pain at variable severity. Pain can influence physical and psychological functions significantly. More than 75% of subjects reported satisfaction over physician and pain management in outpatient clinic department patients with cancer pain in Taiwan.