Opioids,Chronic Pain,and Addiction in Primary Care

Research has largely ignored the systematic examination of physicians' attitudes towards providing care for patients with chronic noncancer pain. The objective of this study was to identify barriers and facilitators to opioid treatment of chronic noncancer pain patients by office-based medical providers. We used a qualitative study design using individual and group interviews. Participants were 23 office-based physicians in New England. Interviews were audiotaped, transcribed, and systematically coded by a multidisciplinary team using the constant comparative method. Physician barriers included absence of objective or physiological measures of pain; lack of expertise in the treatment of chronic pain and coexisting disorders, including addiction; lack of interest in pain management; patients' aberrant behaviors; and physicians' attitudes toward prescribing opioid analgesics. Physician facilitators included promoting continuity of patient care and the use of opioid agreements. Physicians' perceptions of patient-related barriers included lack of physician responsiveness to patients' pain reports, negative attitudes toward opioid analgesics, concerns about cost, and patients' low motivation for pain treatment. Perceived logistical barriers included lack of appropriate pain management and addiction referral options, limited information regarding diagnostic workup, limited insurance coverage for pain management services, limited ancillary support for physicians, and insufficient time. Addressing these barriers to pain treatment will be crucial to improving pain management service delivery.     

A pilot survey of aberrant drug-taking attitudes and behaviors in samples of cancer and AIDS patients

The clinical assessment of drug-taking behaviors in medically ill patients with pain is complex and may be hindered by the lack of empirically derived information about such behaviors in particularly medically ill populations. To investigate issues surrounding the assessment of these behaviors, we piloted a questionnaire based on the observations of specialists in pain management and substance abuse. This preliminary questionnaire evaluated medication use, present and past drug abuse, patients' beliefs about the risk of addiction in the context of pain treatment, and aberrant drug-taking attitudes and behaviors. This instrument was piloted in a mixed group of cancer patients (N = 52) and a group of women with HIV/AIDS (N = 111). Reports of past drug use and abuse were more frequent than present reports in both groups. Current aberrant drug-related behaviors were seldom reported, but attitude items revealed that patients would consider engaging in aberrant behaviors, or would possibly excuse them in others, if pain or symptom management were inadequate. Aberrant behaviors and attitudes were endorsed more frequently by the women with HIV/AIDS than by the cancer patients. Patients greatly overestimated the risk of addiction in pain treatment. We discuss the significance of these findings and the need for cautious interpretation given the limitations of the methodology. This early experience suggests that both cancer and HIV/AIDS patients appear to respond in a forthcoming fashion to drug-taking behavior questions and describe attitudes and behaviors that may be highly relevant to the diagnosis and understanding management of substance use among patients with medical illness.     

Physicians' attitude and practices in sickle cell disease pain management

Many physicians believe that patients with sickle cell disease (SCD) are more likely to become addicted to pain medication than are other patient populations. This study hypothesizes that physicians' attitudes towards addiction in patients with SCD affects pain management practices. The Physician Attitudes Survey was sent to 286 physicians at seven National Institutes of Health-funded university-based comprehensive sickle cell centres. The survey assessed demographic information; and physician's attitudes toward and knowledge of pain, pain treatment, and drug addiction and abuse. Significant Pearson product-moment correlations were found between attitudes towards pain and beliefs regarding addiction to prescribed opioids. Physicians reported varied pain management strategies, however, many believe that attitudes toward addiction and to patients in pain crises may result in undertreatment of pain. These results indicate that physicians might benefit from additional education regarding sickle cell disease, addiction to pain medication, the pharmacology of opioids, and the assessment and treatment of pain.     

Identifying attitudinal barriers to family management of cancer pain in palliative care in Taiwan

The purpose of this study was threefold: (1) to examine attitudes held by Taiwanese family caregivers of hospice inpatients with cancer that serve as barriers to cancer pain management; (2) to determine the relationship of attitudinal barriers to family caregiver hesitancy to report pain and to administer analgesics; and (3) to determine the relationship of attitudinal barriers to the adequacy of analgesics used by the patient. A total of 80 pairs of palliative care inpatients and their primary family caregivers participated in this study. Family caregivers completed the Barriers Questionnaire-Taiwan (BQT) form and a demographic questionnaire. The instruments completed by patients consisted of the Brief Pain Inventory-Chinese version and a demographic questionnaire. The data revealed that Taiwanese family caregivers of palliative care patients with advanced cancer had concerns about reporting pain and administering analgesics, particularly as they related to disease progression, side-effects and p.r.n. analgesics. Older and less-educated family caregivers scored significantly higher on the BQT than did their younger, more educated counterparts. Family caregivers' concerns measured by the BQT were related to family caregivers' reluctance to administer analgesics to their patients. Implications for a broader understanding of analgesics in the advancement of pain management in palliative care in Taiwan are discussed.     

AIDS attitudes and attitudes toward caring for dying patients

This article reports on a survey of nursing staff working in AIDS residential health care facilities. More than two - thirds of respondents expressed non - punitive attitudes towards AIDS. Certified nursing assistants were more likely to report negative attitudes toward caring for dying patients than registered nurses. In general, respondents who had less punitive AIDS attitudes also reported less negative attitudes toward caring for dying patients. Nursing staff in AIDS residential facilities may benefit from further training that addresses issues involved in working with AIDS patients and caring for dying patients.     

Clinicians’ practice and attitudes toward cancer pain management in Korea

Objectives The purposes of this study were to assess clinicians’ (n = 250) current practices and attitudes about cancer pain management and to identify perceived concerns about and barriers to pain control in urban cancer-treatment settings in Korea. Materials and methods Survey data (20 items) were collected either by mail or interview. Approximately 40% of the sample were nurses. More medical clinicians than surgical clinicians had more than 5 years of experience with cancer care (43 vs 31%) and committed more than 30% of their working hours to palliation (61 vs 19%). Significantly more medical clinicians claimed to be somewhat more or much more liberal than their professional peers in using analgesics compared with surgical clinicians (54 vs 35%). The liberal sample was more likely to be male (OR = 3.3, p < 0.001) and to be more experienced with cancer care (OR = 1.2, p < 0.001). Medical clinicians also reported more adequate pain-management training and a more proactive approach to assessing and treating pain. Results Overall, the greatest concerns regarding opioid use were safety, side effects, and fear of addiction. Inadequate pain assessment and lack of staff knowledge and time were identified as barriers to pain management. Unrealistic expectations and denial from both patient and family were the most troublesome issues for delivery of care to dying patients. This study suggests a more conservative attitude toward cancer pain management in Korea than in other countries surveyed in a similar manner. Conclusion A combination of routine professional education and dissemination of guidelines is needed to bring about significant improvement in cancer pain control in Korea.     

Barriers to Pain Management in Hospice: A Study of Family Caregivers

Cancer-related pain not only affects the patient but the family/caregiver as well. The purpose of this study was to examine concerns about reporting pain and using analgesics in a sample of primary caregivers of cancer patients receiving care from a hospice program. The Barriers Questionnaire (BQ), an instrument designed to measure eight common barriers to adequate management of cancer pain, was administered to 37 persons identified as primary caregivers. Between 62 percent and 100 percent of the caregivers reported having at least some agreement with the various concerns that are barriers to reporting pain and using analgesics, and 3 percent to 43 percent reported having strong agreement. The subscales with the highest means were fear of opioid side effects, fear of addiction, the belief that increasing pain signifies disease progression, and the fear of injections. Caregivers who were older and less educated were more likely to believe that reporting pain may distract the physician from treating or curing the cancer. In addition, caregivers with lower educational levels had higher scores on the overall BQ. Finally, caregivers of patients who reported pain was not a problem on program admission had greater concerns about tolerance and were more likely to believe that “good” patients do not complain. The caregiver, often, with time and the declining abilities of the patient, becomes the first line decision maker regarding the patient’s care and treatment. Understanding caregiver perspectives is important for continued success with managing pain in hospice and, arguably, all settings. [Article copies available from The Haworth Document Delivery Service: 1-800-342-9678.]     

Do physical and sexual abuse differentially affect chronic pain states in women?

To evaluate the role of physical and/or sexual abuse on chronic pain symptoms and health care utilization in women, 104 consecutive female patients presenting to a multidisciplinary pain center for management of chronic pain were surveyed. Outcomes included a measure of sexual or physical abuse history (Drossman Sexual-Physical Abuse Survey), and measures of anxiety, health care utilization, substance abuse, and somatic symptoms. Forty-eight percent of the sample reported a history of physical abuse (PA) or sexual abuse (SA). Forty percent of the abused patients reported both PA and SA and the remainder reported SA (37%) or PA (23%) alone. The women who reported abuse had increased pain, physical symptoms, anxiety symptoms, and mental health care utilization compared to nonabused women. The women who reported abuse were also more likely to smoke and abuse street drugs. Women who reported both PA and SA were more likely to report head pain when compared to those who reported only PA or SA. Given the impact of abuse, particularly SA, on the presentation of chronic pain, queries regarding abuse should become a routine component of the patient interview. Abused patients should be referred to mental health care practitioners as a component of successful pain management if unresolved issues persist.     

Cancer pain management at home (II): does age influence attitudes towards pain and analgesia?

Goals of work  Older patients experience a higher prevalence of pain, including cancer pain, than other age groups and tend to receive poorer pain management. The reasons for unnecessary suffering resulting from pain among older patients are not well understood. This study aimed to identify barriers to cancer pain management for older patients living at home and to compare these with a younger control group. Patients and methods  Patients newly referred to community-based palliative care services were interviewed about their pain and related issues. Data included pain impact (BPI), mood (HAD), health (EuroQol), and barriers to reporting of pain and analgesic use (Barriers Questionnaire). Main results  Fifty-eight patients aged 75 or over and 32 people aged 60 or under were interviewed. Both groups reported that beliefs about the use of analgesics was the greatest barrier to effective pain management. Older patients reported that beliefs about the use of analgesics and communicating with medical staff were significantly more important barriers to pain management than for younger patients. Overall, factors such as communication with medical staff and fatalism were ranked lower than barriers related to medication. Younger patients reported significantly greater sleep disturbance due to pain and greater anxiety. Conclusions  Older age appears to influence attitudes towards pain and analgesia. Factors such as poorer knowledge about taking analgesia, reluctance to communicate with medical staff, poorer performance status, and being more likely to live alone suggest that older patients may require greater support in the management of their cancer pain than younger patients. Targeted interventions are needed to test this proposition.     

The role of childhood and adulthood abuse among women presenting for chronic pain management.

OBJECTIVE: This study investigated the association between repeated childhood and adulthood abuse and somatic symptom reporting, mental health care use, and substance use among women with chronic pain. DESIGN: A survey of a consecutive sample. PATIENTS: Ninety consecutive women patients presenting for chronic pain management at a multidisciplinary pain management center. OUTCOME MEASURES: The authors assessed the presence or absence of physical or sexual abuse (using the Drossman Physical-Sexual Abuse Survey), period of abuse, demographics, mental health care use, drug or alcohol use and substance abuse, and the presence or absence of physical, pain, and anxiety (somatic) symptoms. RESULTS: The response rate among patients surveyed was 64%. Of the 43 respondents (48%) who reported abuse, 17 (40%) cited childhood abuse, 12 (28%) cited adulthood abuse, and 14 (33%) cited repeated abuse. Women describing long-term abuse reported a significantly greater number of physical, pain, and anxiety symptoms and were more likely to report a history of substance abuse than women reporting abuse during childhood or adulthood alone. CONCLUSIONS: These data indicate a significant association between health status and reported abuse among women presenting to a multidisciplinary pain center for pain management. This finding is consistent with those of previous investigators, and emphasizes the importance of routine evaluation of the presence of long-term abuse as a possible predictor of the onset of chronic pain states.     

Palliative care in the management of advanced HIV/AIDS

The basic elements of palliative care can be translated into practice for patients with HIV/AIDS. More than half of clinical events and deaths occurring among patients on highly active antiretroviral therapy are classified as non-AIDS illnesses. Thus, end-of-life care for patients with late-stage AIDS needs to include any palliative measures that are used for patients without AIDS. This article reviews the epidemiology of HIV/AIDS, prognostic indicators, opportunistic infections, specific AIDS-defining and non-AIDS-defining malignancies, substance abuse/liver disease, and highly active antiretroviral therapy and comfort measures for late-stage AIDS patients.     

Barriers to the analgesic management of cancer pain: a comparison of attitudes of Taiwanese patients and their family caregivers

The purposes of this study were as follows: (1) to compare the attitudes which were considered to be barriers to cancer pain management held by Taiwanese cancer patients and their family caregivers; (2) to determine if these barriers were related to patient hesitancy to take analgesics and/or family caregiver hesitancy to administer analgesics: and (3) to determine if attitudinal barriers by patients and/or family caregivers predicted the adequacy of analgesics that patients used. A total of 159 dyads of oncology outpatients and their primary family caregivers (n = 318) participated in this study. The instruments completed by patients consisted of the Barriers Questionnaire-Taiwan form, the Brief Pain Inventory-Chinese version, the ECOG performance status scale, and a demographic and medication questionnaire. Family caregivers completed the Barriers Questionnaire-Taiwan form and a demographic questionnaire. The data in this study revealed that patients and family caregivers had attitudinal barriers to pain management and these concerns were positively correlated between patients and caregivers. Patient concerns were related to their hesitancy to take analgesics and, similarly, caregiver concerns were related to their hesitancy to administer analgesics. Most importantly, patient and caregiver concerns had an impact on how the patients' pain was managed: (1) patients and their family caregivers with higher levels of concerns used inadequate analgesics as compared to patients using adequate analgesics; (2) family caregiver barriers (concerns) were a significant predictor of inadequate management of cancer pain (after controlling for demographic and disease variables). Therefore, educational interventions for overcoming these barriers for both patients and their family caregivers may have potential for improving the management of cancer pain in Taiwan.     

Nursing students' attitudes towards HIV/AIDS patients in Finland, Estonia and Lithuania

This paper presents baseline data on attitudes towards HIV/AIDS patients and homophobic levels among nursing students in three Baltic Sea countries: Finland, Estonia and Lithuania. The aim is to describe and compare nursing students' attitudes in these three countries and to explore how attitudes towards HIV/AIDS correlate with background variables. The total sample comprised 471 nursing students. The respondents demonstrated average attitude scores towards patients with HIV/AIDS and rather positive attitudes towards homosexually oriented patients. Significant country differences were found, with Finnish nursing students showing the most positive attitudes towards HIV/AIDS patients and homosexually oriented patients. Previous experience of HIV/AIDS patients was the single factor with the greatest positive impact on nursing students' attitudes. Nursing students' willingness to provide care for an HIV/AIDS patient was associated with a positive attitude towards these patients. Length of employment experience correlated negatively with general attitude, and older nursing students with more work experience showed a more negative attitude towards homosexual patients. Proper education to achieve a sound knowledge base and good nursing skills promotes a more positive attitude to HIV/AIDS. It is important that nursing students are sensitive and show respect for the patient's human dignity. There is need for greater harmonization of education in the three countries.     

Pain and aberrant drug-related behaviors in medically ill patients with and without histories of substance abuse

OBJECTIVES: This study evaluated the prevalence and correlates of aberrant drug-taking behaviors in two populations: patients with HIV-related pain and a history of substance abuse (n = 73) and patients with cancer pain and no history of substance abuse (n = 100). METHODS: All patients completed a Drug-Taking Behaviors Interview, the Brief Symptom Inventory (BSI), Brief Pain Inventory (BPI), Memorial Symptom Assessment Scale (MSAS), and the Marlowe Crowne Social Desirability Scale (MCSDS). The Pain Management Index was calculated to assess the adequacy of opioid prescribing. RESULTS: The cancer sample comprised 38 men and 62 women, and the AIDS sample comprised 63 men and 10 women. Patients with AIDS-related pain had higher global distress on the MSAS (F1, 170 = 20.05, P < 0.001), greater pain-related interference in their daily functioning on the BPI (F1, 161 = 22.87, P < 0.001), and a lower percentage of relief from their current medications (F1, 156 = 76.14, P < 0.001). AIDS patients also reported more than twice as many examples of aberrant drug-related behaviors per patient (mean = 6.14, SD = 4.60) as the cancer patients (mean = 1.42, SD = 1.91). CONCLUSION: These data suggest that AIDS patients with histories of substance abuse receiving opioid therapy are more symptomatic, have more distress, experience more interference from residual pain, and engage in more problematic drug-related behaviors than patients with no history of drug abuse receiving opioids for cancer pain. Treatment of substance abusers with pain requires skills that complement best practices in opioid prescribing. Better approaches to the long-term treatment of these populations are needed.     

ISSUES OF WOMEN DUALLY DIAGNOSED WITH HIV INFECTION AND SUBSTANCE USE PROBLEMS IN THE CAROLINAS

A growing number of women are being dually diagnosed with HIV infection and substance use problems. Forty-two percent of all women diagnosed with AIDS have been infected through injection drug use. Many more women with HIV are exposed to nonintravenous drugs that potentially affect their quality of life and illness experience. This study sought to identify from the perspective of women factors that most influenced their ability to obtain treatment for their HIV infection and control their substance use. A focus group approach was used for data collection. Twenty-five HIV-infected women participated in one of four focus groups. Women were asked to identify and discuss their concerns and needs related to HIV/AIDS and substance use. Twenty-four women were African-American; one was white. All the women reside in South Carolina or North Carolina. Each focus group session was audiotaped and transcribed. Content analysis, following Krippendorff's (1980) methodology, was used to analyze the data. Five themes emerged: 1) AIDS as a life-altering event; 2) spirituality; 3) mental health issues; 4) barriers to health care services; and 5) environmental influences. It was concluded that the coexistence of HIV and substance abuse adds to the complexity of women's treatment needs. For these women, an HIV diagnosis can serve to alter their lives either positively or negatively. Dually diagnosed women have needs that require integration of physical and interventions. These women may benefit from services of psychiatric or mental health nurse who have the skills necessary to address the psychosocial issues women face as well as provide treatment. Additionally, drug treatment services to be expanded and made more comprehensive. Drug programs need to be developed specifically for and these services need to be made accessible to women with substance abuse problems. Further, drug programs need to provide comprehensive services can appropriately integrate the treatment of HIV and substance abuse.     

Insurance coverage, usual source of care, and receipt of clinically indicated care for comorbid conditions among adults living with human immunodeficiency virus

BACKGROUND AND OBJECTIVES: Associations of insurance coverage and source of care with use of human immunodeficiency virus (HIV)-related health, mental health, and substance abuse services are examined in a large, diverse, highly active antiretroviral therapy-era cohort. METHODS: Adults who were infected with HIV (n = 3818) were interviewed in clinics and community agencies in Los Angeles, Milwaukee, New York, and San Francisco regarding drug use behaviors, health status, and health care utilization. RESULTS: Most participants were insured by Medicaid. During the previous 3 months, 90% of privately insured, 87% of publicly insured, and 78% of uninsured participants had visited any provider. Publicly and privately insured participants were similar in receipt of antiretrovirals, prophylaxis against Pneumocystis carinii pneumonia, substance abuse services, and antidepressants. Uninsured participants were less likely to receive antiretrovirals but were more likely to use substance abuse services. Participants with no usual source of care were less likely to receive PCP prophylaxis. CONCLUSIONS: A lack of insurance is associated with barriers to care, but the advantage of private over public coverage appears smaller than in previous studies. PCP prophylaxis, substance abuse treatment, and antidepressants remain markedly underutilized. Educational initiatives about these treatments targeting providers and patients are indicated.     

The attitudes, concerns, gloving practices and knowledge of nurses in a Taiwanese hospital regarding AIDS and HIV

Many studies have documented nurses' attitudes and concerns regarding AIDS/HIV, but little is known about Taiwanese nurses. We documented attitudes, concerns, gloving practices and practical AIDS/HIV knowledge of 1090 nurses from one metropolitan hospital in Changhua City, Taiwan. The response rate was 80.9%. Both HIV and hepatitis contraction in the workplace was nurses' main concern. Two hundred and ten nurses (19.3%) were seriously considering leaving nursing because of fear of contracting AIDS/HIV. Virtually all nurses considered it their right to be informed of the presence of HIV-positive patients in their direct work area and many believed that HIV testing of patients should be mandatory. Practical AIDS/HIV knowledge was deficient. These Taiwanese nurses have concerns and fears that might be related to deficiencies in practical AIDS/HIV knowledge. Continuous educational programmes are recommended to alleviate these nurses' attitudes and concerns regarding AIDS/HIV.     

German nursing students' knowledge of and attitudes to HIV and AIDS: two decades after the first AIDS cases

German nursing students' knowledge of and attitudes to HIV and AIDS: two decades after the first AIDS case This study describes German nursing students' (n=180) knowledge and attitudes relating to HIV/AIDS, their homophobia level, willingness to care for people with AIDS, and their approach to possible sexual risk behaviours. A questionnaire was used to collect the data (response rate 97.8%). The results indicated that the nursing students had a rather high knowledge level concerning AIDS. However, there were gaps of knowledge, such as regarding AIDS immunopathology or the symptoms of the disease. Single nursing students and those having cared for a person with AIDS had a more thorough knowledge about the disease. In general, the attitudes towards AIDS and people with AIDS were tolerant and positive, and homophobia was only found with a small minority. Students having positive attitudes towards people with HIV/AIDS had less homophobia compared to those having negative attitudes towards persons suffering from AIDS. Those with positive attitudes were more willing to care for patients with HIV/AIDS, while those with a high homophobia level were less willing to do so. In addition, students having a high AIDS knowledge level tended less towards negative attitudes and homophobia than those with a low level of knowledge. The implications of the research for nursing education will be discussed.     

Modeling attitudinal antecedents of nurses' decisions to report impaired colleagues

Nurses whose professional functioning is impaired due to substance abuse represent a threat to the health and safety of patients, other health care staff, and themselves. The major means for identifying impaired nurses is nonimpaired coworkers. Yet, only 37% of nurses who have had experiences working with impaired colleagues reported them to supervisors. A cross-sectional correlational research design, employing structural equation modeling, was used to explicate the relationships among the latent attitudinal constructs: permissiveness, morality, treatment efficacy regarding substance abuse, and punitive attitudes toward impaired nurses. The influences of these attitudes on perceived severity of impairment in fictitious coworkers and subsequent intentions to report these coworkers to nursing supervisors were modeled in a sample of 126 nurses. Permissiveness and positive attitude toward treatment were significantly related to intentions to report nurses. Moralistic attitude was not related to intention. Moralistic attitude was, however, strongly associated with a punitive attitude toward impaired nurses.