Concerns about medication and medication adherence in patients with chronic pain recruited from general practice

This study examines the concerns and beliefs about medication reported by patients with nonmalignant chronic pain encountered within general practice. Two hundred thirty-nine patients with chronic pain took part in this research. Patients completed the Pain Medication Attitudes Questionnaire, a measure of patient concerns and beliefs relating to addiction, withdrawal, side effects, mistrust in doctors, perceived need of medication, scrutiny from others, and tolerance. The data revealed that patient concerns and beliefs predicted general medication nonadherence. In addition, concerns were related to the direction of nonadherence: overuse of medication was related to increased perceived need for medication and greater concern over side effects; underuse was related to decreased concerns over withdrawal and increased mistrust in the prescribing doctor. Analyses also indicated that patient attitudes and concerns about medication were more predictive of nonadherence than both level of pain and the reported frequency of experienced side effects. This research contributes to the increasing evidence that patient attitudes and beliefs about pain medication are associated with adherence behavior. Training general practitioners to identify and address these concerns may reduce concerns, improve adherence, and facilitate the doctor-patient relationship.     

Pain medication beliefs and medication misuse in chronic pain.

This study assessed the influence of medication beliefs, symptom severity, disability, mood, and psychiatric history on opiate medication misuse behaviors in 288 chronic pain patients. Data were gathered by questionnaires and systematic reviews of electronic medical records. The results demonstrate that patients with a history of substance abuse, compared to those without, showed greater medication misuse despite similar dosages and self-rated opiate effectiveness. Misusers believed more strongly in the potential for opiate addiction and that they required higher doses than others, but also had greater belief in opiate effectiveness and the importance of free access. Although both anxiety and substance abuse history are related to medication misuse, a multivariate analysis indicated that these factors can be seen as mediated by medication beliefs. These data suggest important roles for historical, affective, and cognitive variables in understanding medication misuse. Patients with a history of substance abuse report stronger beliefs in opiate effectiveness while simultaneously showing awareness of their addiction potential. Providers may help patients by addressing these issues prior to prescribing opiates. PERSPECTIVE: History of substance abuse is associated with increased opiate medication misuse independent of differences in reported opiate effectiveness. Self-attributions regarding opiate treatment related to need for higher doses, dose control, and addiction potential, may be important mediators of this relationship and interact with anxiety to produce heightened risk of opiate misuse.     

Clinician beliefs about opioid use and barriers in chronic nonmalignant pain

A survey of the medical directors of multidisciplinary pain clinics and multidisciplinary pain centers listed in the American Pain Society Pain Facilities Directory was conducted to define those pain specialists' beliefs about the role of opioid analgesia in 14 types of chronic nonmalignant pain. Respondents also reported their perceptions of barriers to their prescribing opioids for chronic nonmalignant pain and what they perceived as barriers to opioid prescribing for chronic nonmalignant pain by other, non-pain specialist clinicians in their communities. The respondents are characterized by demographics, disciplines, specialties, and time in practice. The percentage of time that a pharmacist was available in the pain programs also is reported. There is increasing acceptance of opioids for most of the listed types of chronic nonmalignant pain, but the acceptance varies by types of pain syndromes. Opioids were most consistently accepted for sickle cell disease pain and least commonly endorsed for headaches, myofascial pain, and fibromyalgia. Factors that may influence clinicians' perceptions about opioids are discussed.     

Concerns about reporting pain and using analgesics among taiwanese postoperative patients.

The purpose of this study was to explore concerns about reporting pain and using analgesics and also to explore whether these concerns were related to the dosage of analgesics used among Taiwanese postoperative patients with pain. The three subscales receiving the highest scores on the BQT-S were time interval, tolerance, and injection. Patients who had hesitated to report pain had significantly higher scores on time interval, fear of tolerance, wound healing, fear of distracting one's physician from treating the disease, a desire to be a good patient, fatalism, and the total BQT-S score than those patients who had not hesitated to report pain. Patients who had hesitated to take medications reported significantly higher scores on time interval, wound healing, fear of distracting one's physician from treating the disease, a desire to be a good patient, fatalism, and the total BQT-S score than did those patients who had not hesitated to use analgesics. BQT-S scores were significant positively in relation to pain intensity and pain interference but were negatively related to dosage of analgesics used. PERSPECTIVE: This study documented postoperative patient concerns about reporting pain and using analgesics and their impact on adequate management of postoperative pain. Education about pain management for patients and clinicians could be an effective intervention to improve the management of postoperative pain in Taiwan.     

Antidepressant and anticonvulsant medication for chronic pain

Antidepressants and anticonvulsants have been shown to be efficacious in the treatment of neuropathic pain, chronic headache, and other chronic pain conditions. They may be useful in the treatment of disorders in which central nervous system hypersensitivity con-tributes to pain. They provide valuable alternatives or adjuncts to the use of opioid medications in the treatment of chronic pain. Antidepressants have several potential roles in the treatment of chronic pain in addition to their analgesic effects. Specifically, they effectively address the sleep disturbance, depression, and anxiety that are common in patients with chronic pain.     

Pain symptomatology and pain medication use in civilian PTSD

The comorbidity of pain syndromes and trauma-related syndromes has been shown to be high. However, there have been limited data, especially in civilian medical populations, on the role of trauma-related disorders such as posttraumatic stress disorder (PTSD) on chronic pain and pain medication use. We analyzed 647 general hospital patients in primary care and obstetrics and gynecological waiting rooms for the experience of trauma and PTSD-related stress disorders. PTSD symptoms were found to be significantly positively correlated with pain ratings (r = .282, P < 0.001) and pain-related functional impairment (r = 0.303, P < 0.001). Those with a current PTSD diagnosis had significantly higher subjective pain and pain-related impairment ratings than those with no PTSD. Furthermore, those with a current diagnosis of PTSD were significantly more likely to have used opioid analgesics for pain control compared to those without a diagnosis of PTSD (χ² = 8.98, P = 0.011). When analyzing the separate PTSD symptom subclusters (re-experiencing, avoidance, and hyperarousal), all symptom clusters were significantly related to pain and pain-related impairment ratings, but only the avoidance cluster was significantly related to prior opioid pain medication use. We conclude that PTSD and trauma-related disorders are common in impoverished medical populations and that their presence should be examined in patients with pain syndromes. Furthermore, these data suggest that PTSD and pain may share a vulnerability pathway, including the endogenous opioid neurotransmission systems.     

Multicultural influences on pain medication attitudes and beliefs in patients with nonmalignant chronic pain syndromes.

The objective was to develop an integrated review of quantitative and qualitative research regarding the influence of patients' beliefs and attitudes toward pain medication prescribed for the treatment of nonmalignant chronic pain on use of the pain medication. Studies involving patients at least 18 years old with nonmalignant chronic pain were included. Studies of patients with acquired immune deficiency syndrome, cancer, and acute pain were excluded. Medline, CINAHL, PsychInfo, and Cochrane databases from 1985 to 2005 were searched. Reference lists were screened for relevant articles. Abstracts were screened for compliance with the study criteria, and the articles were obtained for those that met criteria. By using a systematic process, each article was subjected to repeated review and data abstracted to the collection sheets. Evidence tables were created to assist with data review. High levels of concern positively correlate with nonadherence, preconceived ideas about when the drug should start working can cause the patient to discontinue it before it begins to work, and patients may perceive that if medication is taken on a regular basis to control pain it may not be effective in the future if the pain increases. Research also showed that if patients perceived the benefits of taking the pain medication to be high, they were willing to risk the side effects.     

Opioid use in the management of chronic pain.

Opioids are a necessary and effective component of the management of chronic non-cancer-related pain in some patients. Careful structuring, monitoring, and documentation of care are important, but the therapeutic use of opioids is uncomplicated in the majority of patients using opioids and is gratifying for both the patient and the treating physician when it results in significant reduction in pain, improvement in level of function, and a higher quality of life. Opioid therapy is most often successful when combined with other pharmacologic and nonpharmacologic interventions as indicated by the type of pain and the context in which it occurs.     

Medication use in patients with migraine and medication-overuse headache: the role of problem-solving and attitudes about pain medication

Excessive medication intake is a risk factor for the development of medication-overuse headache (MOH), a condition characterized by an increase of headache frequency to a daily or near-daily pattern. As yet, it is largely unknown why some patients overuse medication. In this study, we examined to what extent attitudes about pain medication, especially perceived need and concerns, and problem-solving are related to MOH. Patients with migraine (n = 133) and MOH with a history of migraine (n = 42) were recruited from a tertiary headache referral center and completed questionnaires measuring problem-solving and attitudes about pain medication. A problem-solving mode aimed at solving pain was associated with a higher need for and concerns about medication intake. Interestingly, in a model accounting for demographic factors and pain intensity, attempts to control pain, need for medication, and concerns about scrutiny by others because of medication intake all had a unique value in accounting for MOH. Results are discussed in terms of how repeated attempts to solve pain may trigger overuse of medication, even in the presence of clear negative consequences.     

Concerns and misconceptions about pain among Hong Kong Chinese patients with cancer

It is estimated that approximately 50% of patients with cancer experience pain, and this percentage increases to 80% in patients with terminal cancer. Misconceptions and concerns of patients with cancer regarding the use of opioid analgesics have been identified as one of the major barriers to achieving optimal pain control. Misconceptions and concerns regarding addiction and tolerance to opioid analgesics and patients' desire to be "good" have been reported in the United States. The aim of this survey was to determine if similar misconceptions and concerns exist in Hong Kong Chinese patients with cancer. The results indicate that Hong Kong Chinese patients have the same concerns regarding the use of opioid analgesics. The respondents' fatalistic beliefs are a major hindrance to optimizing pain control, with 79% indicating that pain is an inevitable aspect of hospitalization because they believe that cancer pain cannot be relieved by medications. Fear of addiction was a major concern for 52% of the respondents, and about the same number of respondents believed that opioid analgesics should be administered only as a last resort. Regarding a desire to be "good," more patients reported that they would prefer to disturb nurses rather than physicians. It is desirable that culturally specific education programs be provided to dispel patient misconceptions and concerns regarding the use of opioid analgesics.     

Validity of self-reported drug use in chronic pain patients.

OBJECTIVE: Previous researchers have reported that in psychiatric populations many patients provide incorrect self-report information on current drug use. Therefore, the purposes of the present study were to determine the percentage of chronic pain patients (CPPs) using illicit drugs (cannabis, cocaine), to determine the percentage of CPPs who provide incorrect self-report drug use information in the psychiatric examination, and to identify some variables that could help in identifying the CPP likely to provide an incorrect drug use history using drug urine toxicologies. DESIGN/SETTING/PARTICIPANTS/OUTCOME MEASURES: Two hundred seventy-four CPP consecutive admissions to a pain facility were psychiatrically examined according to criteria in the Diagnostic and statistical manual of mental disorders (3rd ed., rev; DSM-III-R), with special emphasis on all current drug use. Immediately after the psychiatric examination, all CPPs were asked to consent to urine toxicology. Urine was tested for benzodiazepines, opioids, tricyclics, propoxyphene, cannabinoids, barbiturates, amphetamines, methadone, methaqualone, phencyclidine, alcohol, and cocaine. CPPs were then segregated into three groups: negative toxicology, positive toxicology but concordant with self-report of current drug use, and positive toxicology discordant with self-report of current drug use. These groups were statistically compared with each other with regard to age, gender, race, workers' compensation status, and prevalence of individual DSM-III-R psychoactive substance use disorders. Sensitivities were also calculated for two conditions: accuracy of toxicology and accuracy of self-report. RESULTS: Toxicologies were obtained from 226 (82.5%) of the CPPs. Toxicologies were negative in 121 (53.5%) and positive in 105 (46.5%) of the CPPs. Of the 226 CPPs, 8.4% had illicit drugs in the urine (6.2% cannabis, 2.2% cocaine). Twenty (8.8%) of the CPPs provided incorrect self-report information about current drug use, the incorrect information most frequently about illicit drugs. Drug urine toxicology sensitivity results indicated that a significant percentage of CPPs was claiming to be taking a drug but was not taking it or taking it incorrectly. The psychiatric examination drug self-report sensitivity results indicated that a significant percentage of CPPs was withholding or providing incorrect information on current drug use. Lowest self-report sensitivity results were in reference to illicit drugs. CPPs who were more likely to provide incorrect psychiatric examination self-report information about current drug use were more likely to be younger, to be a workers' compensation CPP, and to have been assigned a DSM-III-R diagnosis of polysubstance abuse in remission. CONCLUSIONS: A significant percentage of CPPs appears to provide incorrect information on current illicit drug use. Urine toxicology studies may have a place in the identification of drugs for which incorrect information may be provided by CPPs. There are many possible reasons, such as assay error, that could lead to apparent misinformation. In the clinical setting, these possibilities should be considered if urine toxicology results appear to be incongruent with psychiatric examination drug use self-report.     

Concerns about pain management among adolescents with cancer: developing the Adolescent Barriers Questionnaire.

Investigators have examined barriers to pain management in adults with cancer, but these patient-related barriers have rarely been studied in adolescents. This article summarizes 2 studies used in the development and initial psychometric testing of the Adolescent Barriers Questionnaire (ABQ). Building on the Barriers Questionnaire-II, the ABQ is designed to measure the extent to which adolescents with cancer have concerns about reporting pain and using analgesics. Study 1 was a qualitative study investigating pain management concerns of 5 adolescents with cancer. Concerns emerged that could potentially impede pain management such as fear of addiction and worry about communicating pain to parents and providers. Each of the adolescents revealed at least 1 concern about pain management or held fatalistic beliefs that cancer pain cannot be relieved. In study 2, content validity of the preliminary ABQ (52 items assessing 13 barrier sub-scales) was assessed by 2 panels, adolescents with cancer and clinicians. Based on results, the ABQ was modified to contain 45 items that assess 11 barriers. Further examination of barriers in adolescents with cancer is warranted.     

Determinants of medication underuse and medication overuse in patients with chronic non-malignant pain: A multicenter study

Background

In chronic non-malignant pain, medication is often used as an important cornerstone of the treatment. Medication non-adherence is a frequent problem in chronic conditions. In patients with chronic non-malignant pain, medication non-adherence ranges between 8% and 53%. Two types of non-adherence can be identified: underuse and overuse of pain medication.

Objective

To examine determinants of both medication underuse and overuse non-adherence in patients with chronic non-malignant pain, with a focus on factors related to all five categories of determinants of medication non-adherence simultaneously, as proposed by the WHO.

Design

A multicenter cross-sectional study.

Settings

Three multidisciplinary outpatient pain centers in Flanders, Belgium.

Participants

A total of 265 patients with chronic non-malignant pain participated in the study.

Methods

Medication non-adherence was assessed by a self-report interview. Associations of socio-economic, treatment related, condition related, patient related and health care system related factors with medication underuse or overuse were determined by building two separate multivariable binary logistic regression models.

Results

Thirty eight percent of the patients were fully adherent. Based on multivariable analyses, underuse was significantly associated with more prescribed analgesics (OR = 2.303), self-medication (OR = 4.679), lower pain intensity (OR = 0.821), active coping strategies (OR = 1.132) and lack of information (OR = 0.268). Overuse of medication was associated with more prescribed analgesics (OR = 1.645) and current smoking (OR = 2.744).

Conclusion

Patients underusing or overusing their medication do have a different risk profile. The set of determinants of non-adherence, proposed by WHO, is suitable to study determinants of underuse, but the framework is less suitable to study determinants of medication overuse.