Intentional and unintentional nonadherence to antihypertensive medication

BACKGROUND: Hypertension is poorly controlled in the US due to medication nonadherence. Recent evidence suggests that nonadherence can be classified as intentional or unintentional and different patient characteristics, such as the experience of adverse effects, may be associated with each. OBJECTIVE: To examine associations between patient characteristics, including reported adverse effects, and both intentional and unintentional nonadherence among 588 hypertensive patients. METHODS: Baseline data from a clinical trial, the Veterans' Study To Improve the Control of Hypertension, were examined. Intentional and unintentional nonadherence were assessed using a self-report measure. Participants were presented with a list of adverse effects commonly associated with antihypertensive medication and asked to indicate which symptoms they had experienced. Logistic regression analyses were used to examine adjusted associations between patient characteristics and type of nonadherence. RESULTS: Approximately 31% of patients reported unintentional nonadherence and 9% reported intentional nonadherence. Non-white participants, individuals without diabetes mellitus, and individuals reporting > or = 5 adverse effects were more likely to report intentional nonadherence than their counterparts. Individuals with less than a 10th-grade education and non-white participants were more likely to report unintentional nonadherence than their counterparts. When symptoms of increased urination and wheezing/shortness of breath were reported, patients were more likely to report intentional and unintentional nonadherence compared with those who were adherent. Unintentional nonadherence was also associated with reports of dizziness and rapid pulse. CONCLUSIONS: Both intentional and unintentional nonadherence are common and related to perceived adverse effects. Furthermore, different interventions may be necessary to improve adherence in unintentionally and intentionally nonadherent patients.     

Determinants of patient adherence to an aerosol regimen

Patient adherence with prescribed inhaled therapy is related to morbidity and mortality. The terms "compliance" and "adherence" are used in the literature to describe agreement between prescribed medication and patient practice, with "adherence" implying active patient participation. Patient adherence with inhaled medication can be perfect, good, adequate, poor, or nonexistent, although criteria for such levels are not standardized and may vary from one study to another. Generally, nonadherence can be classified into unintentional (not understood) or intentional (understood but not followed). Failing to understand correct use of an inhaler exemplifies unintentional nonadherence, while refusing to take medication for fear of adverse effects constitutes intentional nonadherence. There are various measures of adherence, including biochemical monitoring of subjects, electronic or mechanical device monitors, direct observation of patients, medical/pharmacy records, counting remaining doses, clinician judgment, and patient self-report or diaries. The methods cited are in order of more to less objective, although even electronic monitoring can be prone to patient deception. Adherence is notoriously higher when determined by patient self-report, compared to electronic monitors. A general lack of adherence with inhaled medications has been documented in studies, and adherence declines over time, even with return clinic visits. Lack of correct aerosol-device use is a particular type of nonadherence, and clinician knowledge of correct use has been shown to be imperfect. Other factors related to patient adherence include the complexity of the inhalation regimen (dosing frequency, number of drugs), route of administration (oral vs inhaled), type of inhaled agent (corticosteroid adherence is worse than with short-acting beta2 agonists), patient awareness of monitoring, as well as a variety of patient beliefs and sociocultural and psychological factors. Good communication skills among clinicians and patient education about inhaled medications are central to improving adherence.     

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 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.     

Relationship between pain-specific beliefs and adherence to analgesic regimens in Taiwanese cancer patients: a preliminary study

This pilot cross-sectional study aimed to 1) explore pain beliefs and adherence to prescribed analgesics in Taiwanese cancer patients, and 2) examine how selected pain beliefs, pain sensory characteristics, and demographic factors predict analgesic adherence. Pain beliefs were measured by the Chinese version of Pain and Opioid Analgesic Beliefs Scale-Cancer (POABS-CA) and the Survey of Pain Attitudes (SOPA). Analgesic adherence was measured by patient self-report of all prescribed pain medicine taken during the previous 7 days. Only 66.5% of hospitalized cancer patients with pain (n = 194) adhered to their analgesic regimen. Overall, patients had relatively high mean scores in beliefs about disability, medications, negative effects, and pain endurance, and low scores in control and emotion beliefs. Medication and control beliefs significantly predicted analgesic adherence. Patients with higher medication beliefs and lower control beliefs were more likely to be adherent. Findings support the importance of selected pain beliefs in patients' adherence to analgesics, suggesting that pain beliefs be assessed and integrated into pain management and patient education to enhance adherence.     

Patient Patterns and Perspectives on Using Opioid Regimens for Chronic Cancer Pain

ContextWith increasing attention to the undertreatment of cancer pain in parallel with concerns about opioid misuse, little is known about how patients with advanced cancer adhere to opioid regimens for chronic cancer pain.ObjectivesWe explored patient approaches to managing chronic cancer pain with long-acting opioids.MethodsIn a multimethods study at an academic medical center, adult patients with chronic cancer pain (n = 17) used electronic pill caps to record adherence to prescribed long-acting opioid regimens. After eight weeks, patients viewed their adherence records and completed a semistructured interview about their opioid use. With a framework approach, we coded interview data (Kappa >0.95) and identified themes in how patients perceived and used opioids to manage cancer pain.ResultsPatients (59% female; 94% non-Hispanic white; median age = 65 years) felt grateful about pain benefit from opioids yet concerned about opioid side effects and addiction/tolerance. Main reasons for nonadherence included both intentional decisions (e.g., skipping doses) and unintentional barriers (e.g., missing doses due to inconsistent sleep schedules). Overall, patients set their own opioid adherence goals and developed routines to achieve them. Residual pain varied and was not consistently linked with opioid adherence.ConclusionPatients commonly felt conflicted about using prescribed long-acting opioids to manage cancer pain due to concurrent perceptions of their risks and benefits, and they set their own parameters for opioid-taking practices. Intentional and unintentional deviations from prescribed opioid schedules highlight the need to enhance adherence communication, education, and counseling, to optimize the use of long-acting opioids as a component of cancer pain management.     

Is There Gender Discrimination in Acute Renal Colic Pain Management? A Retrospective Analysis in an Emergency Department Setting

BackgroundPain is a widespread problem, affecting both men and women; studies have found that women in the emergency department receive analgesic medication and opioids less often compared with men.AimsThe aim of this study was to examine the administration and management of analgesics by the medical/paramedical staff in relation to the patients' gender, and thereby to examine the extent of gender discrimination in treating pain.DesignThis is a single-center retrospective cohort study that included 824 patients.SettingsEmergency department of tertiary hospital in Israel.Participants/SubjectsThe patients stratified by gender to compare pain treatments and waiting times between men and women in renal colic complaint.MethodsAs an acute pain model, we used renal colic with a nephrolithiasis diagnosis confirmed by imaging. We recorded pain level by Visual Analog Scale (VAS) scores and number of VAS examinations. Time intervals were calculated between admissions to different stations in the emergency department. We recorded the number of analgesic drugs administered, type of drugs prescribed, and drug class (opioids or others).ResultsA total of 824 patients (414 women and 410 men) participated. There were no significant differences in age, ethnicity, and laboratory findings. VAS assessments were higher in men than in women (6.43 versus 5.90, p = .001, respectively). More men than women received analgesics (68.8% versus 62.1%, p = .04, respectively) and opioids were prescribed more often for men than for women (48.3 versus 35.7%, p = .001). The number of drugs prescribed per patient was also higher in men compared with women (1.06 versus 0.93, p = .03). A significant difference was found in waiting time length from admission to medical examination between non-Jewish women and Jewish women.ConclusionsWe found differences in pain management between genders, which could be interpreted as gender discrimination. Yet these differences could also be attributed to other factors not based on gender discrimination but rather on gender differences.     

Impact of a Clinical Therapeutic Intervention on Pain Assessment,Management, and Nursing Practices in an Intensive Care Unit: A before-and-after Study

Background: Accurate pain assessment and management constitute a major challenge for medical and nursing staff in intensive care units (ICUs). A distinct recollection of pain is reported by high proportions of ICU patients. Purpose: A clinical therapeutic intervention directed at improving pain assessment and management in critically ill patients who are unable to communicate was implemented at an Italian ICU. Methods: In this before-and-after study, data were collected before (T₀) and after (T₁) the adoption of a protocol involving pain assessment with an ad hoc behavioral pain scale and the administration of analgesics, rather than sedatives, to patients with intermediate to high pain scores. Results: The main outcome measure was pain recollection a year after discharge; secondary outcome measures were the use and doses of sedatives and analgesics. A significantly (p = .037) smaller proportion of patients treated after protocol adoption recollected feeling severe pain compared with patients treated before the protocol was introduced. This group also received significantly (p < .001) fewer sedatives and significantly (p = .0028) more anti-inflammatory drugs and analgesics on an “as needed” basis. The administration of strong analgesics was similar in the two groups. The intervention was implemented in 70.5% of patients with intermediate to high pain scores. Conclusions: Appropriately trained ICU nurses have the potential to help adopt pain relief and prevention measures during nursing care and to contribute to the successful management of sedation and analgesia. Further studies of larger patient samples are needed to monitor the stability of results over time and to explore the efficacy of the approach in other populations, such as pediatric and neonatal ICU patients.     

Patient Trade-Offs Related to Analgesic Use for Cancer Pain: A MaxDiff Analysis Study

PurposeMany patients with cancer pain deviate from prescribed analgesic regimens. Our aim was to elicit the trade-offs patients make based on their beliefs about analgesic use and rank utilities (importance scores) using maximum difference (MaxDiff) scaling. We also investigated if there were unique clusters of patients based on their analgesic beliefs.MethodsThis was a secondary analysis of a three-month, prospective observational study. Patients (N = 207) were self-identified African Americans and Whites, >18 years, diagnosed with multiple myeloma or solid tumor, and were prescribed at least one around-the-clock analgesic for cancer pain. MaxDiff analysis allowed us to identify patients utilities. Second, a cluster analysis assisted in ranking how analgesic beliefs differed by groups. Third, clusters were described by comparing key sociodemographic and clinical variables.ResultsParticipants’ beliefs were a significant factor in choices related to analgesic use (chi-square = 498.145, p < .0001). The belief, ‘Pain meds keep you from knowing what is going on in your body’, had the highest patient endorsement. Two distinct clusters of patients based on analgesic beliefs were identified; ‘knowing body’ was ranked as top priority for both clusters. The belief that cancer patients become addicted to analgesics was moderately important for both clusters. Severity of side effects was the only key variable significantly different between clusters (p = .043).ConclusionsOur findings support tailored pain management interventions that attend to individual beliefs about cancer pain and analgesic use. Future research should explore the relationship between analgesic utilities, actual analgesic taking behaviors, and how they impact patients’ cancer pain outcomes.     

Understanding how patients use visualization during ablation of atrial fibrillation in reducing their experience of pain,anxiety, consumption of pain medication and procedure length: Integrating quantitative and qualitative results

BackgroundPatients who undergo radiofrequency ablation of atrial fibrillation with a light conscious sedation often feel pain during the procedure which can be difficult to relieve with pharmacological pain treatment alone. In a quasi-experimental study, it was found that visualization together with usual pain medication reduced the amount of analgesics used. In addition, patients spontaneously expressed pain significantly fewer times outside the scheduled measurements. No difference was found in the perception of pain intensity or anxiety and procedure length in the study. In a subsequent qualitative study with patients from the intervention group in the quantitative study, patients reported visualization as a positive experience which helped them manage pain and anxiety by supporting their individual strategies and without inconvenience.AimTo examine patients' experiences with the effect of visualization during ablation of atrial fibrillation and its association with pain intensity, anxiety, pain medication and procedure length.MethodsA mixed-method study with explanatory sequential design including a quasi-experimental study with a control and an intervention group and a qualitative interview study with semi-structured interviews. The results from the two studies in the mixed method study have been integrated by merging and constructing follow-up joint displays.ResultsThree themes were identified from the integration of the results from the quantitative and qualitative studies when analyzing and interpreting the results: “Zero pain is not always the goal”; “Not a real procedure time reduction but a sense of time shrinkage” and “Importance of the nurse's presence, visualization or not”.ConclusionVisualization can help patients to manage procedural pain when going through ablation of atrial fibrillation but the effect of an intervention such as visualization cannot be measured by pain intensity because the effect of visualization helps patients to cope with the pain and not to reduce the experience of pain intensity. It was shown that the patients had a feeling of reduced procedure time, although it was not reduced statistically significantly by using visualization. Finally, patients did not feel high anxiety during the procedure which was in line with very low values of anxiety measured in the quantitative study but at the same time the presence of the staff was of great importance to them in providing a feeling of security. A reduction of analgesics as found in the study is not only a matter of safety, it is also important in the patient's perception.     

出院患者使用强阿片类镇痛药物的随访分析

目的：了解我院中重度疼痛患者出院后使用强阿片类镇痛药物的依从性和不良反应。方法：采集我院2020年 8月-9月出院开具强阿片类镇痛药品（硫酸吗啡缓释片，规格30mg、10mg；盐酸羟考酮缓释片，规格40mg、10mg；芬太尼透皮贴剂，规格4.2mg、2.5mg、4.125mg）的患者信息，并对患者进行电话随访，比较各组临床资料及随访数据差异。结果：总计获得291例疼痛患者出院带药数据。三种强阿片类镇痛药物在患者个人一般情况、电话应答率、疼痛类型、合并使用其他镇痛药比例等方面存在显著差异。吗啡缓释片组存在用药顾虑的患者比例最高，为18.4%，显著高于另外两组（P＜0.001）。吗啡缓释片组、羟考酮缓释片组及芬太尼透皮贴剂组不良反应发生率分别为45.65%、24.14%及14.29%，差异有统计学意义(P=0.001)。三组药物在用药依从性和疼痛控制效果方面无明显差异。结论：疼痛的处理除了遵守“WHO三阶梯止痛应用原则”选择合适的镇痛药物控制疼痛外，还和患者个人生活习惯、规范用药和正确药物认知存在必然联系，药师应积极转变药学服务模式，指导服务覆盖出院后患者，促进合理、规范、有效地使用医生开具的镇痛药物，缓解疼痛的同时，减少和避免不良反应，提高患者生存质量。     

The incidence of postoperative pain in children

The incidence of pain in 170 children recovering from surgery was surveyed in two major teaching hospitals along with an analysis of analgesic medication prescribed and administered. Analgesic medication was not ordered for 16% of the patients and narcotic analgesic medication ordered was not given for 39% of the patients. In 29% of the patients, where an order for "narcotic or non-narcotic analgesic medication' was written, the non-narcotic drug was given exclusively. Irrespective of the treatments received, only 25% of the patients were pain free on the day of surgery and 13% reported severe pain. By the first postoperative day, 53% reported no pain but 17% still reported severe pain. There appeared to be no relationship between ages of patients and severity of pain reported. Analysis of orders written for postoperative analgesics revealed extremely variable prescribing habits of the medical staff and that doses frequently were too small and/or too infrequent. The majority of orders were written "PRN' which often was interpreted by nursing staff as "as little as possible.' Nursing staff also preferred not to give narcotic medications but substituted non-narcotic analgesics, even soon after surgery. Many of the children surveyed became withdrawn and this was interpreted as coping with pain. Others expressed a dread of "the needle' as a way of administering analgesics and preferred to suffer pain to an injection. We have concluded that there is considerable scope to improve pain management in children after surgery. This improvement must be based on improved education of medical and nursing staff in contemporary clinical pharmacology and on improved communication between staff, parents and patients.     

An individualized intervention to overcome patient-related barriers to pain management in women with gynecologic cancers

Concerns about reporting pain and using analgesics ultimately can contribute to poor pain management for many individuals. A nursing intervention to address these "patient-related barriers" was developed based on Johnson's self-regulation theory. The purpose of this pilot study was to determine whether provision of individually tailored sensory and coping information about analgesic side effects and specific information to counter misconceptions would enhance pain management in a sample of 43 women with gynecologic cancers. It was hypothesized that at 1-month post-test and 2-month follow-up, those subjects randomized to the information condition would (a) have lower barriers scores; (b) use more adequate analgesic medication; (c) have lower analgesic side effect scores; (d) have lower pain intensity scores; and (e) experience less pain interference with life and better overall quality of life compared to those in the care-as-usual control group. There was no main effect for group on any of the dependent variables. Rather, all women reported a decrease in barriers between baseline and 2-month follow-up (p<.05); all subjects experienced a decrease in pain interference with life scores between baseline and 1-month post-test (p<.05); and there was a significant shift of women from unacceptable pain management at baseline to acceptable pain management at 1-month post-test (p<.05). In addition, the majority of women reported that the intervention contained novel and useful information that helped them to feel more comfortable taking pain medication, to be less concerned about addiction, and helped them talk more openly about pain with a doctor or nurse.