Experience of barriers to pain management in patients receiving outpatient palliative care

Perceptions of prescription opioids among marginalized patients with hematologic malignancies in the context of the opioid epidemic: a qualitative study

PURPOSE

Opioids are essential for treating pain in hematologic malignancies (HM), yet are heavily stigmatized in the era of the opioid epidemic. Stigma and negative attitudes towards opioids may contribute to poorly managed cancer pain. We aimed to understand patient attitudes towards opioids for HM pain management, particularly among historically marginalized populations.

METHODS

We interviewed a convenience sample of 20 adult patients with HM during outpatient visits at an urban academic medical center. Semi-structured interviews were audio-recorded, transcribed, and qualitatively analyzed using the framework method.

RESULTS

Among 20 participants, 12 were female and half were Black. Median age was 62 (interquartile range = 54-68). HM diagnoses included multiple myeloma (n = 10), leukemia (n = 5), lymphoma (n = 4), and myelofibrosis (n = 1). Eight themes emerged from interviews that seemed to influence HM-related pain self-management, including (1) fear of opioid-related harms, (2) opioid side effects and harms to health, (3) fatalism and stoicism, (4) perceived value of opioids for HM-related pain, (5) low perceived susceptibility to opioid-related harms and externalizing blame, (6) preferences for non-opioid pain management approaches, (7) trust in providers and opioid accessibility, and (8) external sources of pain management support and information.

CONCLUSIONS

This qualitative study demonstrates that fears and stigmatized views of opioids can conflict with marginalized patients' needs to manage debilitating HM-related pain. Negative attitudes towards opioids were shaped by the opioid epidemic and reduced willingness to seek out or use analgesics.

IMPLICATIONS FOR CANCER SURVIVORS

These findings help expose patient-level barriers to optimal HM pain management, revealing attitudes, and knowledge to be targeted by future pain management interventions in HM.

Association of Race/Ethnicity, Persistent Poverty, and Opioid Access Among Patients with Gastrointestinal Cancer Near the End of Life

BACKGROUND

Social determinants of health (SDoH) can impact access to healthcare. We sought to assess the association between persistent poverty (PP), race/ethnicity, and opioid access among patients with gastrointestinal cancer near the end-of-life (EOL).

METHODS

SEER-Medicare patients with gastric, liver, pancreatic, biliary, colon, and rectal cancer were identified between 2008 and 2016 near EOL, defined as 30 days before death or hospice enrolment. Data were linked with county-level poverty from the American Community Survey and the US Department of Agriculture (2000-2015). Counties were categorized as never high-poverty (NHP), intermittent high-poverty (IHP) and persistent poverty (PP). Trends in opioid prescription fills and daily dosages (morphine milligram equivalents per day) were examined.

RESULTS

Among 48,631 Medicare beneficiaries (liver: n = 6551, 13.5%; pancreas: n = 13,559, 27.9%; gastric: n = 5486, 1.3%; colorectal: n = 23,035, 47.4%), there was a steady decrease in opioid prescriptions near EOL. Black, Asian, Hispanic, and other racial groups had markedly decreased odds of filling an opioid prescription near EOL (Black: OR 0.84, 95% CI 0.79-0.90; Asian: OR 0.86, 95% CI 0.79-0.94; Hispanic: OR 0.90, 95% CI 0.84-0.95; Other: OR 0.83, 95% CI 0.74-0.93; all p < 0.05). Even after filling an opioid prescription, this subset of patients received lower daily doses versus White patients (Black: -16.5 percentage points, 95% CI -21.2 to -11.6; Asian: -11.9 percentage points, 95% CI -18.5 to -4.9; Hispanic: -19.1 percentage points, 95%CI -23.5 to -14.6; all p < 0.05). The disparity in opioid access and average daily doses among was attenuated in IHP/PP areas for Asian, Hispanic, and other racial groups, yet exacerbated among Black patients.

CONCLUSIONS

Race/ethnicity-based disparities in EOL pain management persist with SDoH-based variations in EOL opioid use. In particular, PP impacted EOL opioid access and utilization.

Racial and Ethnic Disparities in Opioid Access and Urine Drug Screening Among Older Patients With Poor-Prognosis Cancer Near the End of Life

PURPOSE

To characterize racial and ethnic disparities and trends in opioid access and urine drug screening (UDS) among patients dying of cancer, and to explore potential mechanisms.

METHODS

Among 318,549 non-Hispanic White (White), Black, and Hispanic Medicare decedents older than 65 years with poor-prognosis cancers, we examined 2007-2019 trends in opioid prescription fills and potency (morphine milligram equivalents [MMEs] per day [MMEDs]) near the end of life (EOL), defined as 30 days before death or hospice enrollment. We estimated the effects of race and ethnicity on opioid access, controlling for demographic and clinical factors. Models were further adjusted for socioeconomic factors including dual-eligibility status, community-level deprivation, and rurality. We similarly explored disparities in UDS.

RESULTS

Between 2007 and 2019, White, Black, and Hispanic decedents experienced steady declines in EOL opioid access and rapid expansion of UDS. Compared with White patients, Black and Hispanic patients were less likely to receive any opioid (Black, -4.3 percentage points, 95% CI, -4.8 to -3.6; Hispanic, -3.6 percentage points, 95% CI, -4.4 to -2.9) and long-acting opioids (Black, -3.1 percentage points, 95% CI, -3.6 to -2.8; Hispanic, -2.2 percentage points, 95% CI, -2.7 to -1.7). They also received lower daily doses (Black, -10.5 MMED, 95% CI, -12.8 to -8.2; Hispanic, -9.1 MMED, 95% CI, -12.1 to -6.1) and lower total doses (Black, -210 MMEs, 95% CI, -293 to -207; Hispanic, -179 MMEs, 95% CI, -217 to -142); Black patients were also more likely to undergo UDS (0.5 percentage points; 95% CI, 0.3 to 0.8). Disparities in EOL opioid access and UDS disproportionately affected Black men. Adjustment for socioeconomic factors did not attenuate the EOL opioid access disparities.

CONCLUSION

There are substantial and persistent racial and ethnic inequities in opioid access among older patients dying of cancer, which are not mediated by socioeconomic variables.

Barriers and Facilitators of Pain Self-Management Among Patients with Cancer: An Integrative Review

BACKGROUND

Defining the main barriers and facilitators of cancer pain self-management are essential to improve patients' overall quality of life.

AIM

The main purpose of this review was to identify the main barriers and facilitators for cancer pain self-management.

METHOD

An integrative review guided by the five-stages framework that was identified by Souza et al. (2010) was used: (1) preparing the guiding question; (2) searching or sampling the literature; (3) data collection; (4) critical analysis of the studies; and (5) discussion of results. A comprehensive literature review was conducted using the electronic databases of PubMed/MEDLINE, CINAHL, Scopus, and Psych INFO.

RESULTS

Twenty-two studies were identified. The main facilitators that foster the process of cancer pain self-management were supportive ambiances including family caregivers as well as health care providers, active participation of patients with cancer in health care including self-discovery and self-awareness, acquiring pain knowledge, and using a pain diary. The main barriers include concerns regarding the use of pain medications, knowledge deficit, negative beliefs and attitudes, unsupportive ambiance, and psychological distress. Some patients' characteristics could be related to these barriers such as age, sex, race, marital status, educational level, level of pain, and presence of comorbidity.

CONCLUSIONS

Patients with cancer pain experience multiple barriers and facilitators when attempting to take on an active role in managing their pain.

Assessment of the Management of Patients with Chronic Pain Referred to a Specialized Pain Unit: A Cross-Sectional Multicenter Study (the DUO Project)

A multicenter cross-sectional study was designed to assess the quality of treatment of 1190 patients with chronic pain at the time of referral to a specialized pain unit. A total of 119 physicians from 77 pain units throughout Spain collected 23 indicators of the quality of care from 10 consecutive clinical records of chronic pain patients (5 men, 5 women). Degenerative spinal diseases (38.6%) and lumbosciatic pain (29.8%) were the most common etiologies. At the time of referral to the pain unit, 9.8% of patients were not receiving any analgesic treatment. Treatment was modified in 88.1% of the patients by adding adjuvant drugs, adding opioids or increasing the doses of analgesic medications, and using analgesic techniques. Women had higher percentages of osteoarthritis, headache and fibromyalgia as the cause of pain, longer duration of pain and severe pain intensity, and a higher proportion of changes in the diagnosis of the underlying condition with which they had been referred to the pain unit. Improvements should be made in the patient management and referral protocols not only in the clinics prior to patient referral to the pain unit, but also in the pain units themselves.

Does ethnicity affect pain management for people with advanced disease? A mixed methods cross-national systematic review of 'very high' Human Development Index English-speaking countries

BACKGROUND

Racial disparities in pain management have been observed in the USA since the 1990s in settings such as the emergency department and oncology. However, the palliative care context is not well described, and little research has focused outside of the USA or on advanced disease. This review takes a cross-national approach to exploring pain management in advanced disease for people of different racial and ethnic groups.

METHODS

Mixed methods systematic review. The primary outcome measure was differences in receiving pain medication between people from different racial and ethnic groups. Five electronic databases were searched. Two researchers independently assessed quality using JBI checklists, weighted evidence, and extracted data. The quantitative findings on the primary outcome measure were cross-tabulated, and a thematic analysis was undertaken on the mixed methods studies. Themes were formulated into a conceptual/thematic matrix. Patient representatives from UK ethnically diverse groups were consulted. PRISMA 2020 guidelines were followed.

RESULTS

Eighteen papers were included in the primary outcome analysis. Three papers were rated 'High' weight of evidence, and 17/18 (94%) were based in the USA. Ten of the eighteen (56%) found no significant difference in the pain medication received between people of different ethnic groups. Forty-six papers were included in the mixed methods synthesis; 41/46 (89%) were based in the USA. Key themes: Patients from different ethnically diverse groups had concerns about tolerance, addiction and side effects. The evidence also showed: cultural and social doctor-patient communication issues; many patients with unmet pain management needs; differences in pain assessment by racial group, and two studies found racial and ethnic stereotyping.

CONCLUSIONS

There was not enough high quality evidence to draw a conclusion on differences in receiving pain medication for people with advanced disease from different racial and ethnic groups. The mixed methods findings showed commonalities in fears about pain medication side effects, tolerance and addiction across diverse ethnic groups. However, these fears may have different foundations and are differently prioritised according to culture, faith, educational and social factors. There is a need to develop culturally competent pain management to address doctor-patient communication issues and patients' pain management concerns.

TRIAL REGISTRATION

PROSPERO- CRD42020167890 .

US Trends in Opioid Access Among Patients With Poor Prognosis Cancer Near the End-of-Life

PURPOSE

Heightened regulations have decreased opioid prescribing across the United States, yet little is known about trends in opioid access among patients dying of cancer.

METHODS

Among 270,632 Medicare fee-for-service decedents with poor prognosis cancers, we used part D data to examine trends from 2007 to 2017 in opioid prescription fills and opioid potency (morphine milligram equivalents per day [MMED]) near the end-of-life (EOL), defined as the 30 days before death or hospice enrollment. We used administrative claims to evaluate trends in pain-related emergency department (ED) visits near EOL.

RESULTS

Between 2007 and 2017, the proportion of decedents with poor prognosis cancers receiving ≥ 1 opioid prescription near EOL declined 15.5% (relative percent difference [RPD]), from 42.0% (95% CI, 41.4 to 42.7) to 35.5% (95% CI, 34.9 to 36.0) and the proportion receiving ≥ 1 long-acting opioid prescription declined 36.5% (RPD), from 18.1% (95% CI, 17.6 to 18.6) to 11.5% (95% CI, 11.1 to 11.9). Among decedents receiving opioids near EOL, the mean daily dose fell 24.5%, from 85.6 MMED (95% CI, 82.9 to 88.3) to 64.6 (95% CI, 62.7 to 66.6) MMED. Overall, the total amount of opioids prescribed per decedent near EOL (averaged across those who did and did not receive an opioid) fell 38.0%, from 1,075 morphine milligram equivalents per decedent (95% CI, 1,042 to 1,109) to 666 morphine milligram equivalents per decedent (95% CI, 646 to 686). Simultaneously, the proportion of patients with pain-related ED visits increased 50.8% (RPD), from 13.2% (95% CI, 12.7 to 13.6) to 19.9% (95% CI, 19.4 to 20.4). Sensitivity analyses demonstrated similar declines in opioid utilization in the 60 and 90 days before death or hospice, and suggested that trends in opioid access were not confounded by secular trends in hospice utilization.

CONCLUSION

Opioid use among patients dying of cancer has declined substantially from 2007 to 2017. Rising pain-related ED visits suggests that EOL cancer pain management may be worsening.

Opioid epidemic and prescribing in hospice and palliative care: a review of the literature

BACKGROUND

Rising rates of opioid abuse worldwide have led to the implementation of policies to curb opioid prescribing. It is unknown what impact these policies have on prescribing within the setting of hospice and palliative care.

OBJECTIVES

To determine the current state of the science of opioid prescribing in hospice and palliative care in relation to the opioid epidemic and associated policies.

METHODS

A systematic integrative literature review was conducted using the Cumulative Index of Nursing and Allied Health Literature (CINAHL), PubMed, ProQuest Central and SCOPUS.

RESULTS

Most of the existing literature examines physician perspectives related to opioid prescribing in primary care settings. Ample evidence exists that policies can and do affect rates of opioid prescribing in specialties outside of hospice and palliative care. There is limited evidence to suggest how these policies affect opioid prescribing in hospice and palliative care. However, the available evidence suggests that opioids are necessary in hospice and palliative care in order to manage pain.

CONCLUSION

Further research is necessary to examine the possible negative impact of the opioid epidemic on opioid prescribing in hospice and palliative care.

Revisiting patient-related barriers to cancer pain management in the context of the US opioid crisis

ABSTRACT

Patient fear of addiction is a well-documented barrier to the use of analgesic medications for cancer pain control. Over the past 2 decades in the United States, an "opioid crisis" has arisen, accompanied by risk messages delivered through news outlets, public health education, and patient-provider communication. The purpose of this study was to determine if patient-related barriers to cancer pain management-specifically, fears of addiction-and related pain outcomes (pain severity, pain interference with daily life, and adequacy of pain management) have worsened over the last 20 years. A sample of 157 outpatients with active recurrent or active metastatic cancer completed the Barriers Questionnaire-II (BQ-II) and measures of pain and analgesic use. We identified 7 comparison studies published between 2002 and 2020 that reported patient-related barriers using the BQ-II. Significant linear relationships were found between later year of publication and greater fear of addiction (harmful effect subscale score, B = 0.0350, R2 = 0.0347, F1,637 = 23.19, P < 0.0001) and between year of publication and more pain management barriers overall (total BQ-II score, B = 0.039, R2 = 0.065, F1,923 = 73.79, P < 0.0001). Relationships between BQ-II scores (harmful effect and total) and pain outcomes did not change over time. Despite worsening in patient-related barriers, the proportion of patients with adequate vs inadequate analgesic use did not differ over time. Notably, 40% of participants reported inadequate analgesic use, a statistic that has not improved in 20 years. Additional research is necessary to clarify factors contributing to changing beliefs. Findings indicate a continuing need for clinical and possibly system/policy-level interventions to support adequate cancer pain management.

Pain, symptom distress, and pain barriers by age among patients with cancer receiving hospice care: Comparison of baseline data

OBJECTIVES

Age group differences have been reported for pain and symptom presentations in outpatient and inpatient oncology settings, but it is unknown if these differences occur in hospice. We examined whether there were differences in pain, symptom distress, pain barriers, and comorbidities among three age groups (20-64 years, 65-84 years, and 85+) of hospice patients with cancer.

MATERIALS AND METHODS

Participants were recruited from two hospices. Half were women; 49% White and 34% Black. 42% were 20-64 y, 43% 65-84 y, and 15% 85+ y. We analyzed baseline data for 230 hospice patients with cancer (enrolled 2014-2016, mean age 68.2 ± 14.0, 20-100 years) from a stepped-wedge randomized controlled trial. Measures were the Average pain intensity (API, 0-10: current, least and worst pain intensity during the past 24 h), Symptom Distress Scale (SDS, 13-65), Barriers Questionnaire-13 (BQ-13, 0-5), and comorbid conditions. Descriptive, bivariate association, and multiple regression analyses were performed.

RESULTS

Mean API scores differed (p < .001) among the three age groups (5.6 ± 2.0 [20-64 years], 4.7 ± 2.0 [65-84 years], and 4.4 ± 1.8 [85+], as did the mean SDS scores (36.1 ± 7.3, 33.5 ± 8.1, and 31.6 ± 6.6, p = .004). BQ-13 mean scores (2.6 ± 0.9, 2.7 ± 0.8, and 2.5 ± 0.7) and comorbidities were not significantly different across age groups. In multiple regression analyses, age-related differences in API and SDS remained significant after adjusting for gender, race, cancer, palliative performance score, and comorbidities. Comorbidities were positively associated with SDS (p = .046) but not with API (p = .64) in the regression model.

CONCLUSION

Older hospice patients with cancer reported less pain and symptoms than younger patients, but all groups reported similar barriers to pain management. These findings suggest the need for age- and race-sensitive interventions to reduce pain and symptom distress levels at life's end.

Race and satisfaction with pain management among patients with HIV receiving long-term opioid therapy

INTRODUCTION

Management of chronic pain is an essential aspect of HIV primary care. Previous literature in the general population has elucidated racial disparities in the evaluation and treatment of pain. This study examined racial/ethnic differences in patient satisfaction and barriers to pain management among a cohort of PWH receiving LTOT.

MATERIALS AND METHODS

Patient-reported survey and EMR data were compared between non-white (n = 135; 81.3 %) and white (n = 31; 18.7 %) patients in a cohort of 166 PWH receiving LTOT in two clinics in Atlanta and Boston. Quantile and linear regression were used to evaluate the association between race and pain management outcomes: 1) satisfaction with pain management (0-10) and 2) patient-related barriers to pain management, including patient perceptions of pain medications, fatalism, and communication about pain. Models were adjusted for sex, age, clinical site, and baseline general health.

RESULTS

Non-white participants were noted to receive chronic opioids for a shorter mean duration of time than white participants (6.0 versus 11.0 years, p < 0.001) and lower mean morphine equivalent daily dose (MEDD) than white participants (28.1 versus 66.9 mg, p < 0.001). In adjusted analyses, there was no significant difference in satisfaction with pain management among non-white and white participants (p = 0.101). There was no significant difference in barriers to pain management in unadjusted (p = 0.335) nor adjusted models (p = 0.397).

CONCLUSION

While non-white PWH were noted to have received lower doses of chronic opioids and for shorter duration than white PWH, satisfaction with pain management was similar. Patient-related barriers to pain management were similar among non-white and white PWH.

Evaluating psychometric properties of the Short Form Brief Pain Inventory Sinhala Version (SF BPI-Sin) among Sinhala speaking patients with cancer pain in Sri Lanka

Background

Pain is one of the most common and unpleasant symptoms of patients with cancer. The Short Form Brief Pain Inventory (SF-BPI), has been psychometrically validated in several languages and widely used globally. Availability of a validated pain tool in Sinhala is a current requirement enabling the use among the majority of Sinhala-speaking cancer patients in Sri Lanka. The purpose of the study was to evaluate the psychometric properties of Sinhala translated version of SF BPI.

Methods

The translation was done by forward–backward translation method. Content and face validity were evaluated by a panel of experts and patients with cancer pain respectively. The study included 151 participants with cancer pain, registered at the Pain Clinic, Apeksha Hospital, Sri Lanka. The reliability, discriminant and convergent validity were assessed. The confirmatory factor analysis (CFA) was conducted and evaluated the two factor (severity, interference) and three factor models (severity, affective/ activity interference). In the three factor model-1, item ‘sleep’ was included within the affective interference along with mood, relationship with others and enjoyment of life. In the three factor model-2, item ‘sleep’ was included within the activity interference along with general activities, walking and normal works. Ethical approval was obtained from the Ethics Review Committee, Faculty of Medical Sciences, University of Sri Jayewardenepura, Sri Lanka.

Results

A total of 151 participants (79 males, 72 females) with a mean age of 54.6 (+/− 13.2) years were included. The composite reliability (0.902, 0.879), average variance extracted (AVE) (0.647, 0.568) and Cronbach’s alpha (0.819, 0.869) calculated for each severity and interference subscales were acceptable. The discriminant validity assessed with the heterotrait-monotrait criterion was 0.18. According to the Fornell–Larcker criterion, the square root of AVE of severity and interference factors (0.804, 0.753) greater than the correlation between the factors (0.140) demonstrated the discriminant validity. The CFA supported the three-factor model-2 (CFI—0.959, SRMR—0.0513, RMSEA—0.0699) and the values for two-factor and three-factor model-1 were marginally acceptable.

Conclusions

The Sinhala version of SF BPI is a reliable and valid instrument for the assessment of cancer pain among Sinhala speaking patients in Sri Lanka.

Factors That Hinder and Facilitate Cancer Patients' Knowledge About Pain Management-A Qualitative Study

CONTEXT

Pain management education may improve pain control for some patients, whereas individual differences exist.

OBJECTIVES

To evaluate possible critical components, facilitators, and hindrances for improved knowledge about pain management, in not hospitalized adult oncology patients with pain from bone metastasis participating in a pain management intervention.

METHODS

This substudy is a qualitative evaluation of the PRO-SELF Pain Control Program, tested in a randomized controlled trial. During six weeks, 87 participants in the intervention group received tailored coaching encounters by a trained oncology nurse. Three encounters for each patient were audio recorded. The encounter between patient's with the largest (n = 12) and lowest (n = 8) change in knowledge about pain management from before to after the intervention was transcribed verbatim and analyzed with qualitative content analysis.

RESULTS

The critical components of the intervention were repetition of information, struggling with resistance, use of peer experiences, and keeping track of variations. Facilitators of improvement were patients' trust and preparedness to try new procedures, the patient's self-awareness and body awareness, and taking active role in own care. Difficulties in processing complex information, culturally conditioned behaviors, fear, and lack of knowledge were the most important barriers to the success of the intervention.

CONCLUSION

Education in pain management in cancer patients requires repeated information, allowing time for overcoming resistance related to dysfunctional beliefs and fear. To facilitate the patient's involvement in their pain management, tailored and person-centered education is needed.

Non-pharmacological solutions to sleep and circadian rhythm disruption: voiced bedside experiences of hospice and end-of-life staff caregivers

Background

Sleep disturbance is a significant issue, particularly for patients with advanced terminal illness. Currently, there are no practice-based recommended approaches for managing sleep and circadian disruptions in this population. To address this gap, a cross-sectional focus group study was performed engaging 32 staff members at four hospices/end-of-life programs in three demographically diverse counties in New York State.

Methods

Participants responded to structured open-ended questions. Responses were transcribed and subjected to qualitative content analysis. The themes and recommendations for improved practice that emerged were tabulated using Atlas TI qualitative software.

Results

This report details the experiences of hospice and end-of-life care staff in managing sleep and circadian disruptions affecting patients and analyzes their recommendations for improving care. Caregivers involved in the study described potential interventions that would improve sleep and reduce circadian disruptions. They particularly highlighted a need for improved evaluation and monitoring systems, as well as sleep education programs for both formal and informal caregivers.

Conclusions

The voiced experiences of frontline hospice and end-of-life caregivers confirmed that disruption in sleep and circadian rhythms is a common issue for their patients and is not effectively addressed in current research and practice. The caregivers’ recommendations focused on management strategies and underscored the need for well-tested interventions to promote sleep in patients receiving end-of-life care. Additional research is needed to examine the effectiveness of systematic programs that can be easily integrated into the end-of-life care process to attenuate sleep disturbances.

Cancer pain management and the opioid crisis in America: How to preserve hard-earned gains in improving the quality of cancer pain management

Cancer pain remains a feared consequence of the disease and its treatment. Although prevalent, cancer pain can usually be managed through the skillful application of pharmacologic and nonpharmacologic interventions. Unfortunately, access to these therapies has been hampered by interventions designed to contain another serious public health problem: the opioid misuse epidemic. This epidemic and the unintended consequences of efforts to control this outbreak are leading to significant barriers to the provision of cancer pain relief. Oncologists and other professionals treating those with cancer pain will require new knowledge and tools to provide safe and effective pain control while preventing additional cases of substance use disorders (SUDs), helping patients in recovery to maintain sobriety, and guiding those not yet in recovery to seek treatment. How do these 2 serious epidemics intersect and affect oncology practice? First, oncology professionals will need to adopt practices to prevent SUDs by assessing risk and providing safe pain care. Second, oncology practices are likely to see an increased number of patients with a current or past SUD, including opioid misuse. Few guidelines exist for the direct management of pain when opioids may be indicated in these individuals. Third, modified prescribing practices along with the education of patients and families are warranted to prevent the exposure of these medications to unintended persons. Finally, advocacy on behalf of those with cancer pain is imperative to avoid losing access to essential therapies, including opioids, for those who might benefit. Cancer 2018;124:2491-7. © 2018 American Cancer Society.

Psychometric evaluation of the Chinese version of the revised American Pain Society Patient Outcome Questionnaire concerning pain management in Chinese orthopedic patients

The present study tested the clinical efficiency (item grouping, internal consistency of the subscales, construct validity, and clinical feasibility) of a widely used pain assessment system, the Mandarin version of the American Pain Society Patient Outcome Questionnaire (APS-POQ-R-C), in Chinese patients. We also attempted to investigate the current quality of pain management provided in orthopedic inpatient units in China and provide baseline data. First, we investigated the test–retest reliability of APS-POQ-R-C. In total, 236 orthopedic patients were evaluated. Our results showed that APS-POQ-R-C has satisfactory internal consistency and construct validity, although some items are not appropriate for orthopedic patients. Test–retest reliability outcomes indicated that APS-POQ-R-C is a satisfactory battery with acceptable validity and reliability, and is therefore recommended for pain management in future studies.

Desirable Information of Opioids for Families of Patients With Terminal Cancer

OBJECTIVE

The aims of this study are to clarify the state of information regarding opioids for families and what kinds of experiences they had with opioids while the patient was followed as an outpatient and inpatient.

PARTICIPANTS

This study was part of a cross-sectional nationwide survey of bereaved families of patients with cancer, namely, the Japan Hospice and Palliative Care Evaluation 2 study. The participants in this study comprised 572 bereaved families who had experienced the death of a family member during the period from January 2008 to December 2009 at 1 of 103 certificated palliative care units.

MAIN OUTCOME MEASURES

In response to the question of "how much improvement was needed for information regarding opioids," 41% answered "improvement is not necessary at all," 43% answered "improvement is slightly necessary," 14% answered "improvement is necessary," and 2% answered "improvement is extremely necessary." Regarding anxiety about the use of opioid, it was found that 14% of respondents indicated "opioids are very safe," 65% of respondents indicated "opioids are relatively safe," 19% of respondents indicated "opioids are not so safe," and 2% of respondents indicated "opioids are not so safe at all." from the information obtained for opioids. It was found that 90% of families agreed with the item, "I would like to be clearly explained that drugs for medical purposes are safe and that the patient will not develop a drug addiction and their life expectancy will not be reduced."

CONCLUSION

From this study, it is important for families of patients with cancer to be explained profound and careful information of opioid.

Changes in Perceptions of Opioids Before and After Admission to Palliative Care Units in Japan: Results of a Nationwide Bereaved Family Member Survey

This study aimed to clarify perspectives of bereaved family members regarding opioids and compare perceptions before admission and after bereavement. A cross-sectional questionnaire survey for bereaved family members in 100 inpatient palliative care units was administered. Participants were 297 bereaved family members of patients who used opioids. Many bereaved family members had misconceptions of opioids before admission. There was improvement after bereavement, but understanding remained low. Respondents less than 65 years old showed significantly greater decreases in misconceptions regarding opioids compared to older generations, after bereavement. Bereaved family members who were misinformed about opioids by physicians were significantly more likely to have misconceptions about opioids. Educational interventions for physicians are needed to ensure that they offer correct information to the general population.

Why people accept opioids: role of general attitudes toward drugs, experience as a bereaved family, information from medical professionals, and personal beliefs regarding a good death

CONTEXT

Many surveys have evaluated patient-related barriers to pain management.

OBJECTIVES

To explore associations between a preference for opioids and general attitudes toward drugs, the experience and information received as a bereaved family, and beliefs regarding a good death.

METHODS

A cross-sectional survey, performed in 2010, of bereaved families of patients with cancer in palliative care units across Japan. Questionnaires were sent to 997 families.

RESULTS

A total of 66% of families responded. Of these, 224 responses were excluded because the family declined to participate in the study (n = 38), the patient was not receiving any opioid analgesics, and there were missing data (n = 164), or data were missing for the primary end points (n = 22). Thus, 432 responses were finally analyzed (43%). In total, 26%, 41%, and 31% of family members stated that they strongly want to receive, want to receive, or slightly want to receive opioids if needed in the future, respectively. Determinants associated with a preference for receiving opioid treatment were the following: a general appreciation of the drugs (P = 0.005), witnessing an improvement in the patient's quality of life as a result of pain relief (P = 0.003), information provided by medical professionals that the opioid could be discontinued if side effects developed (P = 0.042), and the belief that a good death was one that was free from pain and physical distress (P < 0.001).

CONCLUSION

More than 90% of bereaved families whose relatives were treated with opioid analgesics reported a preference to receive opioid analgesics for the treatment of cancer pain, if necessary, in the future.

Frequency and Outcome of Neuroleptic Rotation in the Management of Delirium in Patients with Advanced Cancer

Purpose

The response to haloperidol as a first-line neuroleptic and the pattern of neuroleptic rotation after haloperidol failure have not been well defined in palliative care. The purpose of this study was to determine the efficacy of haloperidol as a first-line neuroleptic and the predictors associated with the need to rotate to a second neuroleptic.

Materials and Methods

We conducted a retrospective review of the charts of advanced cancer patients admitted to our acute palliative care unit between January 2012 and March 2013. Inclusion criteria were a diagnosis of delirium and first-line treatment with haloperidol.

Results

Among 167 patients with delirium, 128 (77%) received only haloperidol and 39 (23%) received a second neuroleptic. Ninety-one patients (71%) who received haloperidol alone improved and were discharged alive. The median initial haloperidol dose was 5 mg (interquartile ranges [IQR], 3 to 7 mg) and the median duration was 5 days (IQR, 3 to 7 days). The median final haloperidol dose was 6 mg (IQR, 5 to 7 mg). A lack of treatment efficacy was the most common reason for neuroleptic rotation (87%). Significant factors associated with neuroleptic rotation were inpatient mortality (59% vs. 29%, p=0.001), and being Caucasian (87% vs. 62%, p=0.014). Chlorpromazine was administered to 37 patients (95%) who were not treated successfully by haloperidol. The median initial chlorpromazine dose was 150 mg (IQR, 100 to 150 mg) and the median duration was 3 days (IQR, 2 to 6 days). Thirteen patients (33%) showed reduced symptoms after the second neuroleptic.

Conclusion

Neuroleptic rotation from haloperidol was only required in 23% of patients with delirium and was associated with inpatient mortality and white race.