April Hazard Vallerand

Knowledge of and barriers to pain management in caregivers of cancer patients receiving homecare.

Cancer treatment is increasingly being provided in outpatient settings, requiring many of the responsibilities for patient care to be undertaken by family caregivers. Pain is one of the most frequent and distressing symptoms experienced by cancer patients and is a primary concern for the family caregiver. Caregivers struggle with many issues that lead to inadequate management of cancer pain. The purpose of this study was to determine pain management knowledge and examine concerns about reporting pain and using analgesics in a sample of primary family caregivers of cancer patients receiving homecare. The Barriers Questionnaire and the Family Pain Questionnaire were administered to 46 primary caregivers. Between 46% and 94% of the caregivers reported having at least some agreement with the various concerns that are barriers to reporting pain and using analgesics, and up to 15% reported having strong agreement. The areas of greatest concern were about opioid-related side effects, fears of addiction, and the belief that pain meant disease progression. Results showed that caregivers with higher pain management knowledge had significantly fewer barriers to cancer pain management, supporting the importance of increasing caregivers knowledge of management of cancer pain.

The use of long-acting opioids in chronic pain management

The consensus statement from the American Pain Society and American Academy of Pain Medicine states that the undertreatment of pain is unjustified [6]. It has been suggested that opioid therapy can be used effectively to treat noncancer pain in a subset of patients [26], and this is becoming more acceptable [3]. Providing sustained analgesia is an important aspect of therapy, and medications should be administered on an around-the-clock basis, because regular administration of doses maintains a constant level of drug in the body and helps prevent recurrence of pain. Ideal treatment for persistent pain is a long-acting opioid administered around the clock to prevent baseline pain, with the use of short-acting opioids as supplemental agents for breakthrough pain. Controlled-release formulations can lessen the inconvenience associated with around-the-clock administration of short-acting opioids. Sustained analgesia also can be achieved with transdermal fentanyl, which combines a strong opioid with a 72-hour release profile and the benefits of a parenteral route, avoiding first-pass metabolism. Controlled-release formulations of morphine and oxycodone are available in the United States, and hydromorphone preparations are being reviewed for approval. Clinical experience with these formulations and transdermal fentanyl indicates that these agents are equally effective in controlling pain. Studies have demonstrated improved quality of life with the transdermal route and with controlled-release morphine and oxycodone. Because of patch reapplication every 72 hours, the transdermal route also enhances compliance. Use of an opioid without the need for oral or intravenous administration and the opportunity to improve compliance are among the advantages of the transdermal route in clinical practice. The nurse has an important role in the management of patients receiving long-acting opioids for chronic noncancer pain, Facilitation of the conversion from short-acting to long-acting opioids may be the initial step. Individualization of therapy to determine which route and product best suits the patients needs and lifestyle can be accomplished through a comprehensive nursing assessment. Titration of dose along with institution of a short-acting opioid for break-through pain may require frequent interventions that a nurse familiar with the patient can provide. Prevention and management of opioid-related adverse events are essential for effective opioid therapy. Providing patient and family education regarding administration, monitoring, and management of opioid therapy is an important nursing role. Lastly, documentation of pain level, functional status, and opioid-related adverse events is required for each contact with the patient, to make this information available to all who assist in the management of the patients pain. Chronic noncancer pain is an experience that affects all aspects of a patients life. Effective pain management with long-acting opioids may help the patient to focus on the positive aspects of life, decreasing the focus on pain.

Advancing a National Agenda to Eliminate Disparities in Pain Care: Directions for Health Policy, Education, Practice, and Research

BACKGROUND Pain is strongly associated with significant personal and societal costs. A crucial element of any initiative on pain must focus on eliminating pain care disparities that are pervasive throughout the United States health care settings. OBJECTIVES This report focuses on macro-level factors related to pain care disparities in the United States that may be amenable to policy interventions. METHODS We identify concrete opportunities for achieving equity in pain care, especially those occasioned by recent legislative changes in the United States health care system. An aggressive policy, advocacy, and research agenda is synthesized in five domains: 1) structural/system; 2) policy and advocacy; 3) workforce; 4) provider; and 5) research. RESULTS Inequities in pain care remain an important and neglected health policy concern. Many direct and indirect provisions within the Affordable Care Act (ACA) and other national initiatives that leverage on ACA offer opportunities to achieve equity in pain care. These include changes in insurance, in public, provider, and legislative education, in primary care and pain specialist training, improving workforce diversity, achieving uniformity in race/ethnicity data collection, emphasizing patient-centered outcomes research, and encouraging focus on pain care disparities within the comparative effectiveness research paradigm. CONCLUSIONS Recent national legislative initiatives within ACA are expected to generate multilevel efforts that will impact the flow of funding to address the pervasive issue of disparities. It is an opportune time for the pain community to take a lead in implementing a concerted agenda on pain care disparities in order to leverage these national initiatives.

Factors that affect functional status in patients with cancer-related pain

Abstract Cancer‐related pain in outpatient adult populations remains high and has a direct effect on functional status. Factors that affect functional status have been explored separately, but the inter‐relatedness of those factors has not been examined. Using a cross‐sectional design, the purpose of this study was to examine the relationships between pain level, beliefs about pain, symptom distress, perceived control over pain, and functional status in 304 ambulatory cancer patients who experienced cancer‐related pain within the past 2 weeks. Participants completed standardized questionnaires during regularly scheduled clinic visits. Patient’s pain level was positively related to increased distress and decreased perceived control over pain and functional status. Structural equation modeling indicated that symptom distress mediated the relation between pain level and functional status. Perceived control over pain had a direct effect on symptom distress and mediated the effect of beliefs about pain and pain level on symptom distress. Patients’ perceived control over pain may be an important component in pain management. The direct and mediating effects of perceived control and symptom distress suggest areas of further research. Interventions to increase knowledge and decrease barriers to pain control have the potential for increasing perceived control over pain.

The Use of Complementary/Alternative Medicine Therapies for the Self-Treatment of Pain Among Residents of Urban, Suburban, and Rural Communities

The use of complementary/alternative medicine (CAM) therapies has increased dramatically in the past decade.1,2 Frequently, these therapies are used to seek relief from pain, one of the most common health problems today. In the United States, 42% of adults experience pain daily, and 89% experience pain monthly.3 Many people frequently rely on self-treatment of their pain, often utilizing CAM therapies in addition to traditional medications without informing their health care practitioners.3–5 As the number of medications and herbal products/supplements an individual takes increases, so does the likelihood of experiencing drug interactions.6 This brief report describes the occurrence of pain among community residents and identifies the CAM therapies used for self-treatment of pain. Similarities and differences found in urban, suburban, and rural communities are described.

Challenges and Opportunities in Pain Management Disparities Research: Implications for Clinical Practice, Advocacy, and Policy

UNLABELLED Due to high profile initiatives at the national level, awareness of inadequate pain care affecting many groups in our society has never been greater. Nevertheless, increased awareness of pain disparities and the initiatives to address these disparities have yielded only modest progress, most notably in the form of growing appreciation that pain disparities likely result from multiple factors, including biological, psychological, environmental, health system, and cultural factors. Much less progress has been made in developing interventions that target these multiple determinants to reduce pain management disparities. In this paper we discuss key ethical and methodological challenges that undermine our capacity to investigate and develop meaningful interventions to improve pain outcomes among vulnerable populations. Key challenges in the areas of research engagement, recruitment, design, and measurement are discussed from both scientific and normative standpoints. Specific opportunities within emerging research paradigms to improve designs and measures are also discussed. Finally, we conclude with identifying potential synergies between the pain management disparities research agenda and the broader areas of clinical practice, advocacy, and policy that could help to move the field forward. PERSPECTIVE Researchers studying disparities in pain care face a number of ethical and methodological challenges that must be addressed to advance the field towards eliminating disparities. We discuss these ethical and methodological challenges and propose opportunities for paradigmatic revisions in areas of research engagement, design, measurement, advocacy, and policy.

Self-Treatment of Pain Among Adolescents in an Urban Community

Pain occurrence among adolescents, whether acute or chronic, persistent or intermittent, remains high, with potentially serious effects on quality of life, physical and emotional functioning, and psychosocial adjustment. The prevalence of pain in adolescents varies widely, and although discussed in the literature for more than two decades, data on adolescent knowledge and pain self-treatment is scarce. This descriptive-correlational study identified pain prevalence and intensity and pain self-treatment choices among adolescents in a diverse urban community. Almost 90% (n = 253) of high school students reported pain in the preceding 2 weeks and completed a series of study questionnaires (demographic data form, Brief Pain Inventory-Short Form, Adolescent Self-Treatment Survey). Respondents ranged in age from 14 to 19 years (mean 16) and were predominantly female (70%) and caucasian (75%). The sample was representative of all high school grades, and the majority (86%) reported participation in sports, dance, and physical activities. Mean pain scores ranged from 3.0 (current pain) to 6.5 (worst pain), with significantly higher scores among girls. A gender-related effect was also noted for pain interference in activities, mood, and sleep among the adolescent girls compared with the boys. Gender also predicted use of self-treatment methods, with girls more likely to use over-the-counter medications and nonpharmacologic therapies. Number of pain sites was also a strong predictor of use of self-treatment methods among adolescents. Knowledge of the pain experience during adolescence will help guide community-based nursing initiatives aimed at increasing awareness, promoting knowledge about pain and its treatment, and ensuring safety and positive outcomes related to self-treatment.

Home care nurses' perceptions of control over cancer pain.

This qualitative study examined home care nurses’ perceptions of control over cancer pain. Four major themes emerged: Being heard, feeling invisible in the pain management process; not knowing, a need for pain education; control through advocacy; and patient-related barriers to optimal pain management. This study documents the need for continued education in pain management and communication skills for home care nurses.

Nondrug Therapies for Pain Management Among Rural Older Adults

This quasiexperimental two-group pilot study tested an intervention aimed at educating older adults in rural communities about the appropriate use of nondrug treatments for pain. Earlier data reveal that older adults use significantly less nonpharmacologic modalities than their younger counterparts, and that pain self-treatment is prevalent in rural areas. Individuals aged ≥60 years who experienced pain in the preceding 2 weeks were recruited from rural Midwestern communities through the use of flyers and information sessions at hospitals, churches, and community organizations. Upon enrollment, participants selected a date for an educational session, which was randomized to the experimental or control condition. All participants (n = 53) completed a series of questionnaires (Brief Pain Inventory, Symptom Distress Scale, Perceived Control Scale) at the initial educational session (T1) and at a two-week follow-up session (T2). Participants in the control and experimental groups attended a 30-minute educational session on safe use of over-the-counter medications; the experimental group also received an additional 30-minute session on safe and effective use of heat, cold, and relaxation breathing. Hot and cold packs and relaxation breathing instruction were provided for use over the 2-week period. There was a significant increase in the use of all nondrug treatments and a decrease in pain-related distress and current pain scores in the experimental group compared with the control group. This study informs nurses and other health care providers on the value of education for use of nondrug therapies in conjunction with pharmacologic pain management among rural older adults.

Multimodal Analgesia for Acute Postoperative and Trauma-related Pain

: Multimodal analgesia, which combines analgesic drugs from different classes and employs analgesic techniques that target different mechanisms of pain, is recommended in the treatment of acute postoperative and trauma-related pain because its synergistic effect maximizes pain relief at lower analgesic doses, thereby reducing the risk of adverse drug effects. Using a case-based approach, this article reviews various multimodal analgesic therapies used in the treatment of acute pain; discusses their benefits; and summarizes findings from related research, recommendations from evidence-based practice guidelines, and expert consensus reports.