Original Article Barriers to Cancer Pain Management in Danish and Lithuanian Patients Treated in Pain and Palliative Care Units Ramune Jacobsen, PhD,* Jurgita Samsanaviciene, MSc, Zita Liubarskiene, PhD,‡ Per Sjøgren, MD, DMedSc,jj Claus Møldrup, PhD,# Lona Christrup, PhD,† Arunas Sciupokas, MD, PhD,§ and Ole Bo Hansen, MD{ ---



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From the *Department of Pharmacy; † Department of Drug Design and Pharmacology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; ‡ Department of Social and Humanitarian Sciences, Faculty of Public Health; § Department of Neurology, Faculty of Medicine, Lithuanian University of Health Sciences, Kaunas, Lithuania; jj Multidisciplinary Pain Center, Rigshospitalet, Copenhagen, Denmark; #Abbott Danmark, Copenhagen, Denmark; {Department of Anesthesiology, Holbæk Hospital, Holbæk, Denmark. Address correspondence to Ramune Jacobsen, PhD, Section for Social Pharmacy, Department of Pharmacy, Faculty of Health and Medical Sciences, University of Copenhagen, Jagtvej 160, DK 2100, Copenhagen, Denmark. E-mail: [email protected] Received September 28, 2011; Revised June 5, 2012; Accepted June 6, 2012. 1524-9042/$36.00 Ó 2014 by the American Society for Pain Management Nursing http://dx.doi.org/10.1016/ j.pmn.2012.06.002

ABSTRACT:

The prevalence of cancer-related pain is high despite available guidelines for the effective assessment and management of that pain. Barriers to the use of opioid analgesics partially cause undertreatment of cancer pain. The aim of this study was to compare pain management outcomes and patient-related barriers to cancer pain management in patient samples from Denmark and Lithuania. Thirty-three Danish and 30 Lithuanian patients responded to, respectively, Danish and Lithuanian versions of the Brief Pain Inventory pain scale, the Barriers Questionnaire II, the Hospital Anxiety and Depression Scale, the Specific Questionnaire On Pain Communication, and the Medication Adherence Report Scale. Emotional distress and patient attitudes toward opioid analgesics in cancer patient samples from both countries explained pain management outcomes in the multivariate regression models. Pain relief and pain medication adherence were better in Denmark, and the country of origin significantly explained the difference in the regression models for these outcomes. In conclusion, interventions in emotional distress and patient attitudes toward opioid analgesics may result in better pain management outcomes generally, whereas poor adherence to pain medication and poor pain relief appear to be more country-specific problems. Ó 2014 by the American Society for Pain Management Nursing The prevalence of acute and chronic pain in cancer patients is high: from 30% in patients with newly diagnosed cancer to 60%-80% in patients with advanced disease (Cherny, 2006). However, if adequate treatment is provided, sufficient pain relief can be obtained in the majority of these patients (Meuser, Pietruck, Radbruch, Stute, Lehmann, & Grond, 2001). Barriers to the use of opioid analgesics may cause undertreatment of cancer pain. Pain Management Nursing, Vol 15, No 1 (March), 2014: pp 51-58

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In most countries, opioid consumption is considered to be a criterion for evaluating the quality of management for cancer pain (Lindena & Muller, 1996; Mercadante, 1998). Until recently, Denmark has had the highest use of strong opioid analgesics per capita in the world. This was explained by an increased awareness of the importance of pain treatment, increased opioid consumption in chronic noncancer pain patients, earlier initiation of opioid treatment, and higher opioid doses for cancer patients with severe pain (Jarlbaek, Andersen, Hallas, Engholm, & Kragstrup, 2005). Lithuania, on the other hand, lies at the bottom of country lists regarding opioid use. The summary defined daily dose of morphine consumption in Lithuania is 20 times lower than in Denmark (End of Life Care, 2012; Hamunen, Paakkari, & Kalso, 2009). A comparison of these two countries with such differences in opioid consumption could help us to achieve a better understanding of the barriers to cancer pain management. In general, systemic (e.g., economic, legislative, health care organizations), health care professional, and patient-related barriers to cancer pain management have been identified (Schug & Gandham, 2006). The different economic potential of the two countries has an influence on differences in the magnitude of opioid use. Aside from that, legislation regulating opioid prescription may also explain the magnitude of opioid consumption. There are no legislative restrictions regarding prescribing analgesics for cancer patients in Denmark. In Lithuania, however, a 1997 regulation requires that physicians use a special prescription form for every opioid analgesic being prescribed. In addition, each opioid may be ordered for only a period of 7 days for patients believed to be terminally ill. The single exception is transdermal patches, which may be prescribed over a period of 30 days (Skorupskiene, 2004). A review of the literature on physician-related barriers to cancer pain management with opioids concluded that physicians from several countries, including Denmark, were clearly more knowledgeable regarding potential barriers. They were less concerned about addiction, tolerance, and side effects to opioids in cancer patients; prescribed strong opioids in effective doses more often; and were aware of the importance of rescue analgesia (Jacobsen, Sjogren, Moldrup, & Christrup, 2007). Physician-related barriers to cancer pain management in Denmark and Lithuania can not be compared, because no such studies exist in Lithuania. Patient-perceived pain relief is the final goal of cancer pain management. Studies to validate instruments for assessing patient barriers in the Danish

and in Lithuanian languages have been conducted previously (Jacobsen, Moldrup, Christrup, Sjogren, & Hansen, 2009a; Jacobsen, Moldrup, Christrup, Sjogren, & Hansen, 2009b; Jacobsen, Moldrup, Christrup, Sjogren, & Hansen, 2009c; Jacobsen, Samsanaviciene, Liuabarskiene, & Sciupokas, 2010). The aims of the present study were twofold: 1) to compare pain intensities and perceived pain relief in Danish and Lithuanian cancer patient samples; and 2) to compare patient-related barriers to pain management in these samples.

METHODS Definition of Patient-Related Barriers to Cancer Pain Management The most significant patient-related barriers to cancer pain management are patients’ reluctance to communicate about pain and adhere to treatment recommendations, as well as cognitive barriers, such as fear of addiction (Pargeon & Hailey, 1999). The understanding of patient-related barriers in the present study was expanded by using an idea from the multidimensional theory of pain, which states that cognitive, sensory, and affective factors constitute the intensity of pain that patients perceive and report (Melzack, 1988). Following this idea, patients’ knowledge and beliefs about pain medication (e.g., fear of addiction) were regarded as cognitive factors, the physiologic experiences related to pain treatment (e.g., opioid side effects) were regarded as sensory factors, and patients’ emotional experiences (e.g., symptoms of anxiety and depression) were considered to be affective factors. Measures Pain Severity and Pain Relief. The pain intensity scale of the Brief Pain Inventory (BPI) was used to evaluate pain intensity and perceived pain relief. In addition to their current pain intensity, patients were asked to report their worst pain, least pain, and average pain over the past 24 hours. Patients rated pain intensity on an 11-point numeric rating scale (NRS) ranging from 0 ¼ ‘‘no pain’’ to 10 ¼ ‘‘pain as bad as I can imagine’’. One item addressed pain relief; its response options ranged from 0 ¼ ‘‘no relief’’ to 100 ¼ ‘‘complete relief’’ on an 11-point NRS. The BPI has been used extensively and translated into a number of languages. Different versions of the BPI have been found to be both valid and reliable (Cleeland & Syrjala, 1992). Cognitive Barriers. The Barriers Questionnaire II (BQ-II) was used to evaluate cognitive factors. The BQ-II is a 27-item self-reporting instrument designed to measure the extent to which people hold beliefs

Barriers to Cancer Pain Management

about reporting cancer pain and use of analgesics that can act as barriers to pain management (Gunnarsdottir, Donovan, Serlin, Voge, & Ward, 2002). The BQ-II addresses: 1) maladaptive beliefs about pain communication, such as concerns that reports of pain distract the physician from treating the cancer and the belief that ‘‘good’’ patients do not complain; 2) concerns that analgesics may harm the immune system; 3) fears that analgesics mask changes in one’s body; 4) concerns about addiction; 5) fears of different opioid-related side effects; 6) fatalistic beliefs about cancer pain management; and 7) the belief that one becomes tolerant to the analgesic effect of pain medication. Participants rate the extent to which they agree with each item on an NRS with a range from 0 ¼ ‘‘do not agree at all’’ to 5 ¼ ‘‘agree very much.’’ Mean scores for the total scale and subscales are used for analysis, with higher scores indicating stronger barriers. The validity of the two versions of the barrier questionnaires used in the study has been reported previously in the literature (Jacobsen, Moldrup, Christrup, Sjogren, & Hansen, 2009a; Jacobsen, Samsanaviciene, Liuabarskiene, & Sciupokas, 2010). Affective Barriers. Patients’ symptoms of anxiety and depression were considered to be affective barriers to cancer pain management. Indications of anxiety and depression were evaluated with Hospital Anxiety and Depression Scale (HADS). The HADS is a self-assessment questionnaire with two seven-item subscales measuring symptoms of anxiety and depression, respectively. It has been validated in various studies, including Lithuanian ones, over the years and recommended for use in cancer research (Bjelland, Dahl, Haug, & Neckelmann, 2002). Each item has four descriptive response options to be scored on a scale of 0-3. A value of 0 corresponds to not having the symptom, 3 to having the symptom to a high degree. Scores for each of the two subscales are constructed by simple summations of its seven items. According to the developers, 0-7 points indicates a ‘‘noncase,’’ 8-10 a ‘‘doubtful’’ or ‘‘possible’’ case, and 11-21 a ‘‘definite’’ case of anxiety or depression (Zigmond & Snaith, 1983). Sensory Barriers. Medication side effects were considered to be sensory barriers to pain management when they hindered patients from using analgesics in a prescribed way. The influence of medication side effects on adherence was evaluated with a selfconstructed item asking the patients whether opioidrelated side effects have ever made them stop taking these analgesics. Response options on a 5-point verbal rating scale (VRS) were: ‘‘never,’’ ‘‘seldom,’’ ‘‘sometimes,’’ ‘‘often,’’ and ‘‘very often.’’

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Pain Communication. The modified version of the Patient Perceived Involvement in Care Scale (M-PICS) was used to evaluate pain communication. The MPICS is a brief, psychometrically sound, selfadministered measure of patients’ perceptions of physician-patient communication during the medical encounter in the context of chronic pain (Smith, Winkel, Egert, az-Wionczek, & DuHamel, 2006). The M-PICS measures patients’ evaluations of the following activities: 1) behaviors related to physician’s facilitation of the patient’s involvement; 2) behaviors related to information provision by patients; 3) patient participation in decision making; and 4) behaviors related to information provision by the health care provider. Participants rate the extent to which they agree with statements about communication behaviors on an NRS with a range of 0 ¼ ‘‘do not agree at all’’ to 5 ¼ ‘‘agree very much.’’ Mean scores for the total scale and subscales are used for analysis, with higher scores indicating better quality of communication. The shortened version of the M-PICS assessing the behaviors related to information provision by patients and their health care providers was used in the study. The validity of the pain communication questionnaires used in the study has been reported previously in the literature (Jacobsen, Moldrup, Christrup, Sjogren, & Hansen, 2009c; Jacobsen, Samsanaviciene, Liuabarskiene, & Sciupokas, 2010). Pain Medication Adherence. The Medication Adherence Report Scale (MARS) was used to assess pain medication adherence. The MARS is a medication adherence questionnaire assessing a range of adherence behaviors in different disease contexts (George, Kong, Thoman, & Stewart, 2005; Horne & Weinman, 1999). Several versions of the scale exist, but in all of them nonadherence is operationalized both by the tendency to avoid, forget, or stop taking medications and by the tendency to adjust or alter the dose from that recommended by the physician. Items are scored on a 5-point VRS and added to create a cumulative score, where a higher score indicates better adherence. The scale can be analyzed both continuously and categorically. The MARS has been found to have adequate reliability as well as good criterion and discriminative validity (Haynes, Taylor, Sackett, Gibson, Bernholz, & Mukherjee, 1980; Kravitz, Hays, Sherbourne, DiMatteo, Rogers, Ordway, & Greenfield, 1993). A four-item MARS, which is a valid instrument to measure medication adherence in chronic disease conditions, was translated and used in the present study (Horne & Weinman, 1999). The validity of the translations has been reported previously in the literature

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(Jacobsen, Moldrup, Christrup, Sjogren, & Hansen, 2009b; Jacobsen, Samsanaviciene, Liuabarskiene, & Sciupokas, 2010). Demographic and Disease-Related Variables. Participants answered questions regarding age, sex, education, and place of residence. Procedure The study in Denmark was approved by the Danish Data Protection Agency. The Center for Bioethics of the Lithuanian University of Health Sciences approved the study in Lithuania. Cancer patients in both countries were recruited from treatment programs in specialized pain management facilities. In Denmark, these were the Section of Acute Pain Management and Palliation Medicine at Rigshospitalet and the pain clinic at Holbaek Hospital. In Lithuania, recruitment was from the pain treatment unit of the Hospital of the Lithuanian Health Sciences University ‘‘Kauno Klinikos.’’ Inclusion criteria were: 1) diagnosis of cancer; 2) age $18 years; 3) ability to understand Danish or Lithuanian; and 4) willingness to participate in the study. The initial eligibility screening was conducted by telephone. A research assistant gave the cancer patients oral information about the study, but consent was not sought at this stage. Patients were told they would receive additional information by post. A questionnaire booklet was sent to those cancer patients who met the inclusion criteria. The questionnaires were mailed with an accompanying two-page letter explaining the purpose of the study, an informed consent sheet, and a prepaid return envelope. Data collection was conducted from June 2006 to February 2008. Statistical Analyses SPSS version 16.0 for Windows was used to conduct the data analyses. To compare patient barriers and pain management outcomes in the two countries, relevant bivariate analyses were conducted (Katz, 2006b). To assess the influence of the country of origin on pain management outcomes and patient barriers, relevant multivariate analyses (i.e., multivariate linear regression) were undertaken (Katz, 2006a). The multivariate linear regression models were run in three hierarchic steps: 1) in the first step, only demographic characteristics were included; 2) in the second step, pain management outcomes and the investigated patient-related barriers were added; and 3) in the third step, the country of origin was introduced; p values of #.05 were considered to be statistically significant.

RESULTS Patients Forty-five Danish patients were enrolled and 33 completed the study (77%). The Danish respondents varied in age from 41 to 80 years with a mean (SD) of 62 (9.4) years; 64% were male. The majority had a medium length (i.e., 1-3 years) of higher education (26.7%). Ninety-one Lithuanian patients met the inclusion criteria and 30 responded to the questionnaire (33%). The Lithuanian respondents varied in age from 29 to 77 years with a mean (SD) of 55.1 (2.35) years; 50% were male. The proportions of respondents with primary, secondary, higher, and academic education were 13%, 23%, 33%, and 30%, respectively. Those with primary education were significantly older than the remaining respondents (p < .001). The only statistically significant difference between the Danish and Lithuanian cancer patient samples was age: the Danish patients were significantly older than the Lithuanian ones (Table 1). Results of Bivariate Analyses The differences in pain management outcomes and investigated patient-related barriers to cancer pain management between the two countries are presented in Table 1. Statistically significant differences were observed regarding pain relief (p < .05) and pain medication adherence (p < .05). Patient outcomes regarding these two issues were better in the Danish patient sample. Results of Multivariate Analysis The results of multivariate linear regression models for pain intensity, pain relief, summary cognitive barrier score, summary anxiety and depression score, summary pain communication, and summary pain medication adherence scores are presented in Table 2. Pain intensity and anxiety/depression explained each other directly and significantly. The country of origin did not modify this relationship, nor did it contribute to pain intensity and anxiety/depression explanations. Pain relief, cognitive barriers, and adherence explained each other as follows: there was a reverse significant association between cognitive barriers and pain relief, as well as between cognitive barriers and adherence, and there was a direct significant relationship between adherence and pain relief. The country of origin modified this relationship slightly but not significantly. The country of origin did not contribute to the explanation of cognitive barriers but did contribute significantly to the explanation of pain relief and adherence. Both pain relief and adherence were better in patients from Denmark. Communication and adherence explained each

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TABLE 1. Results of Bivariate Analysis Patient Characteristics and Outcomes

Denmark

Lithuania

Age, y, mean (SD) 62.4 (9.44) 55.5 (12.85) Sex, men/women, n 21/12 15/15 Education, other/higher and academic, n 19/14 11/19 Pain intensity, BPI summary pain (scale 0-10), mean (SD) 3.6 (2.53) 3.9 (2.11) Pain relief, BPI, pain relief (scale 0-100), mean (SD) 70.8 (28.11) 55.0 (30.49) Cognitive barriers, BQ-II summary (scale 0-5), mean (SD) 2.3 (0.74) 2.5 (0.83) Affective barriers, HADS depression and anxiety (scale 0-42), mean (SD) 13.1 (9.58) 16.2 (9.34) ‘‘non-case’’ ‘‘doubtful case’’ Sensory barriers, stopping/not stopping taking opioids due to side 11/22 10/20 effects, n Pain communication, short M-PICS summary (scale 0-5), mean (SD) 3.6 (1.09) 3.1 (0.95) Adherence, MARS summary (scale 4-20), mean (SD) 17.8 (2.40) 13.0 (3.65)

Significance of Difference p < .05 n.s. n.s. n.s. p < .05 n.s. n.s. n.s. n.s. p < .001

BPI ¼ Brief Pain Inventory; BQ-II ¼ revised Barriers Questionnaire; HADS ¼ Hospital Anxiety and Depression Scale; M-PICS ¼ modified version of Patient Perceived Involvement in Care Scale; MARS ¼ Medication Adherence Report Scale; n.s. ¼ nonsignificant.

other directly and significantly, but the association disappeared when it was controlled for the country of origin. Thus, the country of origin was a confounder in the communication-adherence association.

DISCUSSION The aim of this study was to compare pain management outcomes and patient-related barriers to cancer pain management in patient samples from Denmark and Lithuania. The results of the analyses showed that pain intensities, anxiety/depression levels, and scores on the attitude questionnaire did not differ significantly between the patient samples from the two countries. Pain intensities were associated with anxiety and depression levels in the patient samples from both countries. Pain relief and pain medication adherence were better in the patient sample from Denmark, and the country of origin significantly explained the difference in the multivariable regression models for these outcomes. The common (i.e., cognitive and affective factors) and country-specific (i.e., pain relief and adherence to pain management regimens) cancer pain management outcomes and barriers are discussed below. Common Patient Barriers and Their Influence on Pain Management Outcomes Our findings regarding the influence of anxiety and depression on pain intensity are in line with the findings of other studies where research questions similar to ours have been raised. In 1995, Syrjala and Chapko examined cancer treatment-related pain with the use of a biopsychosocial model (Syrjala & Chapko, 1995).

According to those researchers, emotional distress was the strongest predictor of pain associated with bone marrow transplant. The results of that study suggested that nociception and distress were two main factors in the biopsychosocial model independently affecting the intensity of patient reported pain. According to the authors, nociception and distress should be addressed concurrently in pain treatment programs. In line with the conclusions of the Syrjala and Chapko study, the results of the present study also suggest that interventions in anxiety and depression, or affective patient-related barriers to cancer pain management, may result in better pain management outcomes, and this does not depend on a pain treatment facility. Our results regarding the importance of cognitive barriers are in line with a study by Elliot et al. (Elliott, Elliott, Murray, Braun, & Johnson, 1996), which showed that cognitive barriers significantly explained cancer pain intensity in the regression models. It is not possible to make a more precise comparison between the Elliot et al. study and the present one, because in our study both pain intensity and pain relief were treated as dependent variables in the regression models and cognitive barriers were operationalized differently. Moreover, in the Elliot et al. study, only cognitive barriers were used, and in the present study a barrier model including five different types of barriers was used. On the other hand, the results of our study are original, because they show an impact of cognitive barriers on pain relief, which is not dependent on a pain treatment facility. Nevertheless, both Elliot et al.’s and our conclusions support the notion regarding the need to focus on patients’ cognitive barriers when managing cancer pain (Ward, Donovan,

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TABLE 2. Results from Linear Multivariate Regression Models Dependent variable Pain intensity (n ¼ 54) Pain relief (n ¼ 52)

Cognitive barriers (n ¼ 52)

Communication (n ¼ 52)

Adherence (n ¼ 52)

R-Square Change (Significance)

R-Square Adjusted (Significance)

Demographics Barriers to CPM Country Demographics Barriers to CPM Country

0.103 (n.s.) 0.189 (n.s.) 0.002 (n.s.) 0.039 (n.s.) 0.179 (n.s.) 0.157 (p < .05)

0.049 (n.s.) 0.166 (p < .05) 0.149 (n.s.) 0.021 (n.s.) 0.072 (n.s.) 0.241 (p < .05)

Demographics Other barriers to CPM and pain outcomes Country

0.134 (n.s.) 0.239 (p < .05)

0.079 (n.s.) 0.239 (p < .05)

0.028 (n.s.)

0.255 (p < .05)

Significant Independent Variables Education* Anxiety and depression Anxiety and depression — Cognitive barriers Cognitive barriers Adherence Country† Gender‡ Pain relief

Standardized Regression Coefficients (Significance) 0.327 (p < .05) 0.480 (p < .05) 0.472 (p < .05) — 0.392 (p < .05) 0.410 (p < .05) 0.393 (p < .05) 0.529 (p < .05) 0.310 (p < .05) 0.328 (p < .05) 0.275 (p < .05)

Demographics Other barriers to CPM and pain outcomes Country Demographics Other barriers to CPM and pain outcomes Country

0.146 (n.s.) 0.244 (p < .05)

0.093 (n.s.) 0.259 (p < .05)

Influence of opioid side effects on adherence§ Adherence Pain relief Education* Pain intensity

0.005 (n.s.) 0.079 (n.s.) 0.201 (n.s.)

0.247 (p < .05) 0.013 (n.s.) 0.116 (n.s.)

Pain intensity — Adherence

0.393 (p < .05) — 0.322 (p < .05)

0.053 (n.s.)

0.160 (n.s.)

0.298 (p < .05)

Demographics Other barriers to CPM and pain outcomes Country

0.168 (p < .05) 0.166 (n.s.)

0.116 (p < .05) 0.190 (p < .05)

0.183 (p < .001)

0.398 (p < .001)

Influence of opioid side effects on adherence§ — Education* Communication Pain relief Cognitive barriers Country†

CPM ¼ cancer pain management; R-square ¼ explained variance in the model; n.s. ¼ nonsignificant. *Reference group: those without higher/academic education. † Reference group: Lithuania. ‡ Reference group: men. § Reference group: those who stopped taking pain medication owing to its side effects.

0.344 (p < .05) 0.405 (p < .05) 0.388 (p < .05) 0.395 (p < .05)

— 0.301 (p < .05) 0.295 (p < .05) 0.294 (p < .05) 0.278 (p < .05) 0.544 (p < .001)

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Anxiety and depression (n ¼ 52)

Independent Variable Groups

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Gunnarsdottir, Serlin, Shapiro, & Hughes, 2008; Ward, Hughes, Donovan, & Serlin, 2001). Finally, the results of the present study showed that, when the country of origin was controlled for, cognitive barriers were inversely related to pain medication adherence as well as to pain relief, and that adherence was directly related to pain relief. Such cognitive barriers–adherence–pain relief relationships have been previously hypothesized theoretically and shown empirically (Horne & Weinman, 1999). Again, our results were in line with the results of previously published studies. Facility-Related Patient Barriers and Their Influence on Pain Management Outcomes Adherence to analgesic regimens has recently become an active area in cancer pain management research (Liang, Yates, Edwards, & Tsay, 2008; Valeberg, Miaskowski, Hanestad, Bjordal, Moum, & Rustoen, 2008). In the present study, adherence to pain management regimens as well as the proportion of cancer patients with good self-reported adherence was significantly higher in the Danish pain management units. Moreover, the country of origin was one of the predictors of adherence in the multivariate regression models when the other variables were controlled for. A possible explanation for this result could be the differences in existing restrictions on opioid analgesic prescription between Denmark and Lithuania, which consequently could have caused the differences in the adequacy of prescribed opioid doses in the two countries. It has previously been reported that the use of strong opioid analgesics is a significant predictor of better self-reported adherence, because patients perceive strong opioid analgesics as having a better risk-benefit ratio than other types of analgesics (Valeberg, Miaskowski, Hanestad, Bjordal, Moum, & Rustoen, 2008). Consequently, Lithuanian patients were less likely to receive effective doses of opioid analgesics, which was reflected in their adherence as well as in their pain relief outcomes. This would suggest that in Lithuania, more attention should be paid to increase both patients’ and health care professionals’ awareness about the importance of effective opioid analgesic doses and opioid medication adherence.

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Study Limitations To do a power analysis and/or calculate a sample size, one needs to know the standardized differences of the variable of interest (Altman, 1999). In cases where data are continuous variables (i.e., the majority of outcomes in the present study), to determine standardized differences, standard deviations in a population as well as clinically relevant differences of these variables have to be obtained. In the present study, the outcome variables were scores of the questionnaires but not clinical measures, and the literature regarding clinically relevant differences as well as standard deviations of these scores was sparse. Therefore, to determine the minimum samples of the groups to be compared, we relied on a practice of social research that to analyze a group of respondents regarding any specific outcome, a minimum number of 30 persons is required (Babbie, 1992). Nevertheless, the relatively small and convenient samples of patients were the major limitations of this study, representing what was occurring in several specialized pain management units in two countries. Owing to this, the generalizability of the findings to a country-wide level is restricted. Conclusion and Suggestions for Further Research The results of this study suggest that interventions in emotional distress and patient attitudes toward opioid analgesics may result in better pain management outcomes generally, whereas poor pain medication adherence and poor pain relief appear to be more country-specific problems. The latter two problems could be a consequence of inadequate opioid doses being prescribed to cancer patients. Because the samples of cancer patients in this study were small, making the generalizability of the results questionable, a study on adequacy of opioid prescription (e.g., with the pain management index) in a representative Lithuanian patient sample is recommended. Additionally, it would be useful to investigate cancer pain management problems from the perspective of Lithuanian health care professionals. Such a study could assist exploring the level of adequacy of cancer pain management in Lithuania.

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Barriers to cancer pain management in Danish and Lithuanian patients treated in pain and palliative care units.

The prevalence of cancer-related pain is high despite available guidelines for the effective assessment and management of that pain. Barriers to the u...
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