Original Article Concerns About Pain and Prescribed Opioids in Taiwanese Oncology Outpatients ---

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From the *College of Nursing, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan; † Nursing Department, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan. Address correspondence to Shu-Yuan Liang, Associate Professor, College of Nursing, National Taipei University of Nursing and Health Sciences, 365 Ming Te Road, Beitou, Taipei 112, Taiwan. E-mail: shuyuan@ntunhs. edu.tw Received February 25, 2011; Revised August 11, 2011; Accepted August 12, 2011. 1524-9042/$36.00 Crown Copyright Ó 2013 Published by Elsevier Inc. on behalf of the American Society for Pain Management Nursing doi:10.1016/j.pmn.2011.08.004

Shu-Yuan Liang, PhD, RN,* Heng-Hsin Tung, PhD, RN,* Shu-Fang Wu, PhD, RN,* Shiow-Luan Tsay, PhD, RN,* Tsae-Jyy Wang, PhD, RN,* Kang-Pan Chen, MSN, RN,† and Yu-Yin Lu, PhD, RN*

ABSTRACT:

Pharmacologic agents are considered to be a cornerstone of cancer pain management. Patients’ concerns about use of analgesics are likely to lead to poor pain management. The purpose of this study was to describe participants’ responses to their beliefs regarding pain and prescribed opioids. Ninety-two outpatients age $18 years who had taken prescribed opioid analgesics for cancer-related pain in two teaching hospitals in the Taipei area completed the Pain Opioid Analgesics Beliefs Scale–Cancer. An important finding of this study is that large numbers of patients had misconceptions about using opioids for pain. Between 33.7% and 68.5% of the patients in this study held negative beliefs about opioids and beliefs about pain. Specifically, 68.5% of the patients agreed that ‘‘opioid medication is not good for a person’s body.’’ Many patients (62%) agreed that ‘‘the more opioid medicine a patient used, the greater the possibility that he/she might rely on the medicine forever,’’ and 61.0% agreed that ‘‘if a patient starts to use opioid medicine at too early a stage, the medicine will have less of an effect later.’’ Two-thirds (66.3%) of the sample agreed that adult patients should not use opioid medicine frequently. The findings provide empirical support for the need for better programmatic efforts to improve beliefs of pain and analgesics in Taiwanese oncology outpatients. Crown Copyright Ó 2013 Published by Elsevier Inc. on behalf of the American Society for Pain Management Nursing Despite the fact that 80%-90% of patients could be effectively treated with present pharmacologic therapies and advanced techniques (American Pain Society, 2008; Jacox et al., 1994; Reder, 2001; World Health Organization, 1996), studies estimate that 31%-85% of cancer patients in Taiwan suffer from pain (Chiu, 1997; Ger, Ho, Wang, & Cherng, 1998). Several reasons have been identified (Anderson, Mendoza, Valero, Richman, Russell, Hurley,.& Cleeland, 2000; Fazeny et al., 2000; Gunnarsdottir, Donovan, Serlin, Voge, & Ward, 2002), including key patient factors which contribute to the poor management of cancer pain (Liu, Lian, Zhou, Mu, Lu, Zhao,.& Ren, 2001). Pain Management Nursing, Vol 14, No 4 (December), 2013: pp 336-342

Concerns About Prescribed Opioids

Patients’ knowledge and beliefs about pain and prescribed opioids are critical components in pain management (Lai, Keefe, Sun, Tsai, Cheng, Chiou & Wei, 2002). Patients frequently possess negative beliefs regarding cancer pain (Lai, Dalton, Belyea, Chen, Tsai & Chen, 2003; Moore, 1999), for example, the idea that cancer pain cannot be relieved (Riddell & Fitch, 1997). On the other hand, some patients believe that the pain serves as a warning to protect the part that hurts and they might harm it if they were too comfortable (Coward & Wilkie, 2000; Gunnarsdottir, Donovan, Serlin, Voge, & Ward, 2002). These beliefs may affect patients’ expectation about cancer pain management and the effect of analgesics and therefore affect patients’ willingness to take analgesics for managing their pain (Gunnarsdottir et al., 2002; Lai et al., 2002). Other studies have demonstrated that many patients are concerned about the use of pain medication. The concerns include the risk of addiction and the fear of escalating tolerance and side effects (Coward & Wilkie, 2000; Gunnarsdottir et al., 2002, Ward, Goldberg, Miller-McCauley, Mueller, Nolan, Pawlik-Plank,.& Weissman, 1993). Patients’ fear of addiction was a key reason for not taking medication as often as scheduled in a number of studies (Coward & Wilkie, 2000; Gunnarsdottir et al., 2002; Paice, Toy, & Shott, 1998). In addition, there is also a common misconception that tolerance will develop if pain medications are taken too early and will therefore be ineffective if pain gets worse (Paice et al., 1998). Many participants tended to hold back on medication because they were concerned about side effects, such as nausea, constipation, and potential liver damage (Coward & Wilkie, 2000; Gunnarsdottir et al., 2002). This is despite the fact that many analgesic side effects can be prevented from occurring and others can be effectively managed with existing strategies (McNicol et al., 2003). Patients still hold the belief that side effects of analgesics are inevitable and unmanageable (Gunnarsdottir et al., 2002). The aim of the present study was to describe the beliefs about pain and opioid analgesics amongst Taiwanese oncology outpatients who had experienced moderate pain.

METHODS Study Population, Procedure, and Setting The sampling frame for this study comprised all cancer patients with pain who were admitted to the outpatient oncology units of two teaching hospitals in the Taipei area of Taiwan. Patients were eligible to enroll in the study if they met the following inclusion criteria: 1) had a cancer diagnosis; 2) had an average pain intensity score of $3 on a 0-10 scale in the past 24 hours; 3) had been prescribed opioid analgesics for cancer-

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related pain on an around-the-clock (ATC) and/or as needed (PRN) basis and had taken them for at least the past week; 4) were $18 years of age; and 5) were conscious and able to sign the consent form. The study was approved by the Ethics Committee of the institution in which the researcher works as well as the two teaching hospitals. Data were collected from a convenience sample during the period from October 2005 to June 2006. Information about the patients who had been prescribed opioid analgesics for cancer-related pain and patients’ ages were identified from medical charts. Potential participants who met eligibility criteria were invited to participate by the investigator. Patients who indicated interest in the study were screened to assess average pain levels in the past 24 hours, and eligible patients were provided further verbal information. If verbal consent was given, the patient information sheet, consent form, and self-administered questionnaire were provided so that the patients could decide whether to participate. After participants had finished the questionnaire, the researcher checked the questionnaire for any missing information. They were asked to complete items they had missed and then were thanked for their valuable contribution. The researcher collected information about relevant medical characteristics from the patients’ medical records. Measures Demographic and Medical Variables. Gender, age (years), education (years), and living with family/relative/friend were included as demographic variables. Diagnosis, metastases status, prescribed opioids, experienced side effects, and time that the patient has had pain (months) were included as medical variables. Pain and Opioid Analgesic Beliefs. Pain and opioid analgesic beliefs were measured by the Pain Opioid Analgesics Beliefs Scale–Cancer (POABS-CA), Chinese version (Lai et al., 2003). The POABS-CA was designed to assess the negative effect beliefs about opioids and pain endurance beliefs. The POABS-CA is a 10-item Likert-type scale, each item with a range of 0-4, such that 0 indicates ‘‘strongly disagree’’ and 4 indicates ‘‘strongly agree.’’ The higher the score on the POABSCA, the more concerns related to patients’ beliefs about cancer pain and opioids. The construct validity of POABS-CA was assessed by Lai et al. (2003) using factor analysis, confirming the two-factor structure identified by the original developers of the scale. The POABS-CA was reported to have an alpha coefficient or 0.84 for the total scale, 0.74 for negative effect beliefs, and 0.80 for endurance beliefs (Lai et al., 2003). Test-retest reliability of the scale was 0.94 over a 2-day period (Lai et al., 2003).

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Data Analysis The Statistical Package for the Social Sciences (SPSS for Windows) version 17.0 was used to analyze the data. Descriptive statistics (means and percentages) were used to characterize the total sample and beliefs about pain and prescribed opioids. The association between demographic/medical characteristics (continuous variables) and beliefs about pain and prescribed opioids (continuous variables) was assessed using Pearson product-moment correlations. Group differences for beliefs about pain and prescribed opioids were analyzed using independent-sample t test.

RESULTS Demographic Characteristics The sample consisted of 92 cancer outpatients, recruited from two teaching hospitals in Taipei. Most of the subjects were male (58.7%). Participants ranged in age from 30 to 92 years old with a mean age of 56.4 years (SD 12.2 y). The majority of subjects (89.1%) lived with others (families/relatives/friends), and the overall mean education level was 9.2 years (SD 4.5 y). Medical Characteristics The sample represented a heterogeneous group of individuals with various cancer diagnoses. Major groups of the 92 subjects were those with head and neck (35.9%), colon/rectum (18.5%), or breast (14.1%) cancer, and 66.3% had a diagnosis of metastatic disease. Participants reported having had pain for 1-70 months, with a mean duration of pain of 14.1 months (SD 19.5 mo). Types of opioids prescribed for this population included fentanyl (29.3%), tramadol (29.3%), morphine (25%), depain-x (15.2%), codeine (8.7%), buprenorphine (8.7%) and morphine-sulphate tablet (5.4%). The majority of subjects (78.3%) experienced side effects of opioids. The side effects most commonly knowledgeable by the patients were constipation (45.7%), dry mouth (40.0%), and drowsiness (33.7%). Beliefs About Pain and Analgesics Among Taiwanese Outpatients with Cancer Information on beliefs about analgesics was collected using the POABS-CA (Lai, 2003), which has a score range of 0-4. The scale indicates a person’s particular misconceptions about opioids. The scale includes subscales of negative effect beliefs and pain endurance beliefs. The higher the score, the more negative beliefs that patient has about using opioid analgesics for cancer pain. The mean of the total scale was 2.44 (SD 0.63), the mean for negative effect beliefs was 2.44 (SD 0.69), and the mean for pain endurance beliefs

was 2.43 (SD 0.82). Details of mean responses and categoric responses for the various beliefs about opioid analgesics measured by this scale are provided in Table 1. The misconceptions about using opioids for pain were at moderate levels, and a variable range of numbers of patients had misconceptions about using opioids for pain. Of these patients, one-half (49.0%) agreed that ‘‘if a patient starts to use opioid medicine, it means health is already in serious condition,’’ 26.1% disagreed, and 25.0% were unsure. However, many patients either disagreed (39.1%) or were unsure (27.2%) that ‘‘opioid medicine should only be used at the last stage of an illness,’’ with one-third (33.7%) agreeing. Moreover, many patients (68.5%) agreed that ‘‘opioid medication is not good for a person’s body,’’ and 58.7% agreed that ‘‘opioid medicine causes many side effects.’’ Many patients (62.0%) agreed that ‘‘the more opioid medicine a patient used, the greater the possibility that he/she might rely on the medicine foreve,’’ 61.0% agreed that ‘‘if a patient starts to use opioid medicine at too early a stage, the medicine will have less of an effect later,’’ and almost one-half of the sample (45.2%) agreed that ‘‘side effects caused by opioid medicine are not easy to handle.’’ Two-thirds of the sample (66.3%) agreed that adult patients should not use opioid medicine frequently. Similarly, 64.2% of the sample agreed that adults should not ask frequently for pain medicine. A total of 44.5% of the sample agreed that an adult should endure as much pain as possible. Such responses suggest that many patients in this study hold beliefs that may make them reluctant to take analgesics and that therefore act as barriers to effective pain management. Details of percentages of the participants relevant to the various beliefs about opioid analgesics are provided in Figure 1. Relationship Between Demographic/Medical Characteristics and Beliefs About Pain and Analgesics An independent-sample t test was conducted to examine differences in beliefs about pain and opioids between selected demographic and medical groups. However, there were no significant differences between the demographic (gender and living with others) and medical (experienced side effect) characteristics on beliefs about pain and opioids. Table 2 provides a detailed summary of the findings of these analyses. In addition, Pearson correlations were conducted to assess the relationships between age, years of education, prescribed opioid dosages, and the time the patient has had pain and beliefs about opioid analgesics.

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Concerns About Prescribed Opioids

TABLE 1. Participants’ Score on the Pain Opioid Analgesics Beliefs Scale (n ¼ 92) Level of Agreement (%)* Item Negative Effect Belief Opioid medicine is not good for a person’s body. Opioid medicine should only be used at the last stage of an illness. If a patient starts to use opioid medicine, it means health is already in serious condition. Opioid medicine causes many side effects. Side effects caused by opioid medicine are not easy to handle. The more opioid medicine a patient uses, the greater the possibility that he or she might rely on the medicine forever. If a patient starts to use opioid medicine at too early a stage, the medicine will have less of an effect later. Pain Endurance Belief Adults should not ask frequently for pain medicine. Adult patients should not use opioid medicine frequently. An adult should endure as much pain as possible.

0

1

2

3

4

0.0 8.7

6.5 30.4

25.0 27.2

51.1 23.9

17.4 9.8

3.3

22.8

25.0

37.0

12.0

3.3 2.2

9.8 15.2

28.3 37.0

47.8 35.9

10.9 9.8

4.3

19.6

14.1

45.7

16.3

1.1

14.1

23.9

43.5

17.4

2.2 1.1 7.6

15.2 15.2 25.0

18.5 17.4 22.8

53.3 50.0 39.1

10.9 16.3 5.4

Subscale

Mean

SD

Min.

Max.

Negative effect belief Pain endurance belief Total scale

2.44 2.43 2.44

0.69 0.82 0.63

0.57 0.00 1.10

4.00 4.00 4.00

*Level of agreement: 0 ¼ strongly disagree; 1 ¼ disagree; 2 ¼ neither agree nor disagree; 3 ¼ agree; 4 ¼ strongly agree.

that health professionals often underestimate (Ger, Chang, Ho, Lee, Chiang, Chao, Lai, Huang & Wang, 2004; Grossman, Sheidler, Swedeen, Mucenski, & Piantadosi, 1991) and undermedicate patients’ pain (Ger, Ho, & Wang, 2000; Lin, 2000; Lin & Ward, 1995; Wang et al., 1997). Specifically, in the present study,

0= I strongly disagree 1= I disagree

DISCUSSION

3= I agree 4= I strongly agree

80 Percent of participants

Level 4

70

Level 3

60 50 40 30 20

using at the last stage

enduring pain

side effects not easy to handle

using in serious condition

many side effects

relying on the analgesics

not asking frequently

0

not using frequently

10 analgesics not good

An important finding of this study is that large numbers of patients had misconceptions about using opioids for pain and that these misconceptions were at a moderate level. Between 33.7% and 68.5% of the patients in this study held negative beliefs about opioids and beliefs about pain. Several practical and research implications can be drawn from these findings. First, patients’ beliefs about the negative effects of opioids may influence their intention to report their pain (Lin & Ward, 1995; Wang et al., 1997) and adhere to their opioid regimen (Du Pen et al., 1999; Ferrell, Ferrell, Ahn, & Tran, 1994; Miaskowski et al., 2001), ultimately affecting their cancer pain control. These findings may help to explain one of the reasons

2= I neither agree nor disagree

less of an effect later

All opioid analgesics were converted to morphine equivalents for the relationship. Results indicate that no variable (age, education, prescribed opioid dosages, and the time the patient has had pain) was significantly correlated with beliefs about pain and opioid analgesics. Table 3 provides a detailed summary of these analyses.

FIGURE 1. - Percentage of the participants’ concerns about Pain and Prescribed Opioids.

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TABLE 2. Demographic/Medical Characteristics by Beliefs About Opioid Analgesics (n ¼ 92) Beliefs About Pain and Analgesics Total Scale Variable Gender Living with others Experienced side effect

Negative Effect Beliefs Subscale

Pain Endurance Beliefs Subscale

Group

Mean ± SD

t

df

Mean ± SD

t

df

Mean ± SD

Male Female Yes No Yes No

2.41  0.63 2.48  0.63 2.45  0.62 2.32  0.72 2.41  0.60 2.55  0.73

0.56

90

1.60

90

0.63

90

0.40

90

0.86

90

2.34  0.73 2.58  0.62 2.45  0.70 2.36  0.65 2.41  0.68 2.56  0.71

0.86

90

2.56  0.70 2.26  1.00 2.46  0.79 2.23  1.08 2.41  0.76 2.52  1.03

44.0% of the patients agreed that ‘‘an adult should endure as much pain as possible’’ and 34.0% agreed that ‘‘opioid medication should only be used in the last stage of an illness’’. Patients with such beliefs may tend to delay using analgesics and so endure pain for long periods. Many patients also agreed that ‘‘adult patients should not use opioid medicine frequently’’ (66.0%) and ‘‘adults should not ask frequently for pain medication’’ (64.0%). These beliefs suggest patients will use their opioid analgesics reluctantly. Such results indicate that misconceptions about opioid analgesics may be amongst the most problematic aspects of opioid treatment. Most of the patients in this study agreed that cancer pain needed to be endured, moreover they tended to agree with statements on the negative effects of opioids. These misconceptions about opioids include beliefs such as ‘‘opioid medicines are not good for a person’s body,’’ ‘‘the more opioid medicine a patient uses, the greater the possibility that he or she might rely on the medicine forever,’’ and ‘‘if a patient starts to use opioid medicines at too early a stage, the medicine will have less of an effect later.’’ Beliefs that ‘‘adult patients should not use opioid medicine frequently’’ and ‘‘adults should not ask frequently for pain medicine’’ were also common. It is therefore particularly important for clinicians to assess

t 1.60

df 63.52

0.82

90

0.50

90

the extent to which a patient has misconceptions about opioid analgesics, so that such misconceptions can be openly discussed and allayed. Compared with earlier studies, such as that by Lai et al. (2003), fewer patients in the present sample tended to agree that ‘‘an adult should endure as much pain as possible.’’ This difference is possibly due to the fact that the sample in this study may suffer from above-moderate levels of cancer pain and was already prescribed opioids. In Lai et al.’s research, the entry criterion was having cancer-related pain, but patients may not have suffered from cancer pain at the levels experienced by the sample in the present study. Similarly to Lai et al.’s study, however, most of the participants in the present study did not agree with the belief that ‘‘opioid medicine should only be used in the last stage of an illness.’’ The results of the present study are also consistent with findings of Lin and Gunnarsdottir et al., from patients in Taiwan and the United States, respectively, that fear of addiction continues to be one of the most prevalent concerns about analgesics (Gunnarsdottir et al., 2002; Lin, 2000). The levels of negative beliefs overall about pain and opioids are similar to those found by Lai et al. (2003), revealing that a majority of patients have misconceptions about opioids and their effects on disease outcomes. Similarly to other studies

TABLE 3. Demographic/Medical Characteristics by Beliefs About Opioid Analgesics (Pearson r; n ¼ 92) Scale Beliefs About Pain and Analgesics total scale Negative effect beliefs Pain endurance beliefs

Age

Education

Time Patient Has Had Pain

Prescribed Opioid Dosages

0.11

0.04

0.16

0.16

0.12 0.04

0.04 0.17

0.15 0.10

0.10 0.19

Concerns About Prescribed Opioids

in Taiwan (Lai et al., 2003), there was no difference in beliefs about opioid analgesics in relation to demographic characteristics and medical variables in the present study. The present study was limited in that it involved a cross-sectional survey and we recruited patients from two teaching hospitals in one urban setting only using a convenience sample of cancer patients. This may also limit generalizability of the findings.

CONCLUSIONS The results of this study highlight an important finding—large numbers of patients had misconceptions about using opioids for pain in this group of Taiwanese outpatients with cancer. The results suggest that patients report their pain and use their opioid analgesics

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reluctantly. Findings of this study suggest the need for improving poor pain control, and an effort to decrease patients’ misconceptions regarding cancer pain and opioid analgesics should be given high priority. On an individual basis, clinicians could use the POABS-CA to detect the concerns relating to patients’ beliefs about pain and opioids and target those beliefs during consultation. More generally, these results could be useful in improving the design of pain and opioid information sheets for patients. As well as allaying patients’ concerns regarding opioids and cancer pain, information sheets could include a discussion of the likely positive effects of opioid analgesics on cancer pain. Further studies need to explore related factors that may influence misconception in pain and opioids of cancer outpatients and the need for better programmatic efforts to improve beliefs about pain and opioid analgesics.

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Concerns about pain and prescribed opioids in Taiwanese oncology outpatients.

Pharmacologic agents are considered to be a cornerstone of cancer pain management. Patients' concerns about use of analgesics are likely to lead to po...
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