CHAPEL HILL, NC--Although the health care professional is often to
blame when cancer pain management is inadequate, barriers to pain
control can also stem from patients forgetfulness, stoicism,
and fatalism. "A cancer pain management plan cannot be effective
if patients fail to report pain and adhere to treatment
Tracy Thomason, PharmD, and colleagues at the University of North
Carolina Hospitals, Chapel Hill; Duke University Medical Center,
Durham; and Rex Cancer Center, Raleigh.
To identify patient-centered issues in pain control, the North
Carolina researchers interviewed 239 patients with cancer who had
experienced cancer-related pain in the previous month or were
currently taking analgesics for cancer pain control.
Patients were asked to assess their pain severity, specify their pain
medication use, and assess their frequency of communication about
pain and pain control with physicians, nurses, and pharmacists. When
a concern about pain medication was identified, they were asked,
"Does this keep you from taking your medication on
schedule?" A yes answer was defined as a "barrier."
The concerns surveyed were fear of running out of pain medication,
side effects, addiction, tolerance, forgetfulness, stoicism (belief
they should tolerate pain), and dependence on medication to control
pain (see table)
The most frequently reported barrier to pain control was forgetting
to take pain medications, cited by one-third of patients surveyed (J
Pain Symptom Manage 15:275-284, 1998). "Forgetfulness
remains a difficult barrier to overcome even with the many tools
available to prompt patients to take their medicine," the
The second most frequent concern was the patients belief that
they should be able to tolerate pain without medication. "Over
one-half of the patients acknowledged concern with this question, and
one-third of the patients who expressed concern reported that this
belief results in noncompliance with prescribed analgesic
therapy," the investigators said. They speculate that this
concern stems from religious and moral beliefs that patients who need
opioid drugs are somehow weak in character.
Elimination of this belief is a high priority, but
"unfortunately, it may be far more difficult to design
interventions to eradicate this barrier than other more commonly
recognized barriers," the researchers said.
Although 58% of patients reported concerns about side effects such as
drowsiness and dizziness, only 18% said that these concerns prevented
them from taking their medication. "Education about the
development of tolerance to these side effects of opioid analgesics
could minimize this concern," the researchers said.
Concerns over the possibility of addiction and development of
tolerance were expressed by 27% and 30% of patients, respectively,
and led to noncompliance with the pain control regimen in 17% and 10%
of patients, respectively, suggesting the need for continued
educational efforts in these areas.
Answers to questions about how others perceived their pain suggest
that many cancer pain patients are fatalistic about their situation.
About 30% of patients agreed with the statement that "health
care professionals thought nothing more can be done about my
pain," and the same percentage agreed that family and friends
thought the same. Furthermore, about 15% felt that both health care
professionals and family and friends "did not understand the
extent of my pain."
These findings suggest the need for focus groups and other education
programs for both patients and families, the investigators said.
"When emphasis on overcoming fatalism occurs early in a
patients therapy, the ability to report pain to clinicians and
expectations of pain relief should be enhanced," they said.
In this study, 93% of patients reported talking most often to their
physician about pain control vs 68% who talked most often to a nurse
and 39% to a pharmacist. "This information should encourage
physicians to enhance their provision of information designed to
alleviate fears and eliminate barriers," the researchers said.
"Conversely, nurses and pharmacists should be encouraged to
become more involved in patient education regarding cancer pain and
Overall, 54% of patients reported they were satisfied with their pain
control. The researchers called this figure "promising, but the
goal of 100% satisfaction remains elusive. Only through patient and
healthcare provider education and minimization of identified barriers
can this goal be achieved."
Dr. Thomasons co-workers were Jeannine McCune, PharmD, Stephen
Bernard, MD, and Celeste Lindley, PharmD, from the University of
North Carolina Hospitals; Eric Winer, MD, from Duke University; and
Steve Tremont, MD, from Rex Cancer Center.