Training primary care providers in opioid deprescribing and chronic pain management based on local guidance: a pre–post study of attitude change

Background. Local chronic non-cancer pain guidance recommends that general practitioners should consider opioid deprescribing and referral to multidisciplinary healthcare providers for behaviourally based treatments. We designed a training package called AIMM (Assess, Inform, Manage and Monitor) to reinforce this stewardship.Aim. To identify whether participation in AIMM training effectively aligned clinicians’ attitudes with local guidance for treating chronic non-cancer pain.Design and setting. In 2014–15, the AIMM training was tested using a pre–post-test non-randomised design at two sites in NSW, Australia. The primary outcome measure was an 11-item, study-specific, pain attitude questionnaire (PAQ).Method. Step one of AIMM training involved online completion of the PAQ and review of a specialist pain website. Step two involved attendance at two face-to-face, two-hour interactive workshops led by pain experts who addressed opioid deprescribing and switching to broader care. A repeat PAQ survey was completed at the conclusion of the second workshop.Results. Nineteen participants attended the workshops, including general practitioners (n = 7), nurses (n = 5), exercise physiologists (n = 2), a dietitian (n = 1), community pharmacists (n = 2) and psychologists (n = 2). Significant shifts in six attitudes occurred, including prescribing less pain medication, greater emphasis on social reconnection, increasing planned activity and adopting anti-inflammatory nutrition (p  .05). Responses to the item regarding expectations of a positive recovery was not aligned with local guidance and no significant attitudinal change was found. Four other attitudes were aligned with local guidance at baseline and did not change during the study.Conclusions. Online information and face-to-face training can achieve a change in healthcare provider attitudes towards non-pharmacological treatment of chronic non-cancer pain. Further work is needed to assess whether attitudinal changes are maintained and translate into behavioural change

All's well that ends well?: quality of life and physical symptom clusters in long-term cancer survivors across cancer types

Context: Little is known about the presentation of multiple concurrent symptoms (symptom clusters) in long-term cancer survivors, with few studies adequately powered to compare quality of life (QoL) and symptom presentation by cancer type. Objectives: This research aimed to 1) assess patient-reported QoL and 2) identify clusters of cancer-related physical symptoms by cancer type among long-term breast, prostate, colorectal, and melanoma cancer survivors. Methods: A population-based cross-sectional sample of 863 adult cancer survivors five to six years post-diagnosis completed the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30), assessing global QoL and frequency of presentation of cancer-related physical symptoms. Results: Long-term survivors reported higher levels of global QoL than 1) the general population (age-adjusted mean = 79.4 vs. 71.1, small clinical difference) and 2) cancer patients early in the care trajectory (age-adjusted mean = 77.1 vs. 61.3, moderate clinical difference). The majority (71%) did not report any cancer-related physical symptoms; 18% reported multiple (two or more) symptoms in the past month. Factor analysis found that cognitive functioning, fatigue, insomnia, pain, dyspnea, appetite loss, constipation, diarrhea, nausea, and vomiting formed a cluster (α = 0.48). No symptom clusters were identified that were specific to just one cancer type. However, individual symptoms (including diarrhea, pain, constipation, and insomnia) modestly discriminated between cancer types. Conclusion: Contrary to expectations, no symptom clusters specific to one type of cancer were identified and survivors reported few cancer-related symptoms and high QoL. These results convey a strong “good news” message, providing health professionals with a sound foundation for making encouraging predictions about their patients’ long-term physical recovery after cancer. Cancer patients also will welcome the news that only a minority of five-year survivors experience long-term and late effects

Rasch analysis of the Mini-Mental Adjustment to Cancer Scale (mini-MAC) among a heterogeneous sample of long-term cancer survivors: a cross-sectional study

Background: The mini-Mental Adjustment to Cancer Scale (mini-MAC) is a well-recognised, popular measure of coping in psycho-oncology and assesses five cancer-specific coping strategies. It has been suggested that these five subscales could be grouped to form the over-arching adaptive and maladptive coping subscales to facilitate the interpretation and clinical application of the scale. Despite the popularity of the mini-MAC, few studies have examined its psychometric properties among long-term cancer survivors, and further validation of the mini-MAC is needed to substantiate its use with the growing population of survivors. Therefore, this study examined the psychometric properties and dimensionality of the mini-MAC in a sample of long-term cancer survivors using Rasch analysis. Methods: RUMM 2030 was used to analyse the mini-MAC data (n=851). Separate Rasch analyses were conducted for each of the original mini-MAC subscales as well as the over-arching adaptive and maladaptive coping subscales to examine summary and individual model fit statistics, person separation index (PSI), response format, local dependency, targeting, item bias (or differential item functioning -DIF), and dimensionality. Results: For the fighting spirit, fatalism, and helplessness-hopelessness subscales, a revised three-point response format seemed more optimal than the original four-point response. To achieve model fit, items were deleted from four of the five subscales – Anxious Preoccupation items 7, 25, and 29; Cognitive Avoidance items 11 and 17; Fighting Spirit item 18; and Helplessness-Hopelessness items 16 and 20. For those subscales with sufficient items, analyses supported unidimensionality. Combining items to form the adaptive and maladaptive subscales was partially supported. Conclusions: The original five subscales required item deletion and/or rescaling to improve goodness of fit to the Rasch model. While evidence was found for overarching subscales of adaptive and maladaptive coping, extensive modifications were necessary to achieve this result. Further exploration and validation of over-arching subscales assessing adaptive and maladaptive coping is necessary with cancer survivors

Anxiety and depression among long-term survivors of cancer in Australia: results of a population-based survey

Objective: To assess the prevalence and predictors of anxiety and depression among a heterogeneous sample of long-term adult cancer survivors. Design and participants: Cross-sectional survey of 863 adults diagnosed with a new histologically confirmed cancer (local or metastatic) between 1 April and 30 November 1997 and still alive in 2002, living in NSW, able to read and understand English adequately, physically and mentally capable of participating, and aware of their cancer diagnosis, who were randomly selected from the New South Wales Central Cancer Registry. Main outcome measures: Prevalence of anxiety and depression assessed by the Hospital Anxiety and Depression Scale; and factors (patient, disease, and treatment characteristics; coping style; social support) predicting clinical or borderline levels of anxiety and depression. Results: Levels of anxiety and depression were low; only 9% of participants reported clinically important levels of anxiety and 4% reported depression. The strongest predictive factors of borderline or clinical anxiety were previous treatment for psychological illness, maladaptive coping styles (helplessness-hopelessness, anxious preoccupation) and poor social support. Borderline or clinical depression was most strongly predicted by previous treatment for psychological illness, being an invalid pensioner, maladaptive coping style (helplessness-hopelessness) and poor positive social interaction. Conclusions: By 5 years after diagnosis, most survivors had adjusted well to their cancer experience, with levels of anxiety and depression similar to those of the general population. Nevertheless, a small and important group of long-term survivors continue to experience adverse psychological effects and need assistance. Monitoring of psychological wellbeing and referring patients when appropriate need to be integrated into routine care for cancer survivors

Therapeutic alternatives for supporting GPs to deprescribe opioids: a cross-sectional survey

Background: GPs are central to opioid strategy in chronic non-cancer pain (CNCP). Lack of treatment alternatives and providers are common reasons cited for not deprescribing opioids. There are limited data about availability of multidisciplinary healthcare providers (MHCPs), such as psychologists, physiotherapists, or dietitians, who can provide broader treatments. Aim: To explore availability of MHCPs, and the association with GP opioid deprescribing and transition to therapeutic alternatives for CNCP. Design & setting: Cross-sectional survey of all practising GPs (N = 1480) in one mixed urban and regional Australian primary health network. Method: A self-report mailed questionnaire assessed the availability of MHCPs and management of their most recent patient on long-term opioids for CNCP. Results: Six hundred and eighty-one (46%) valid responses were received. Most GPs (71%) had access to a pain specialist and MHCPs within 50 km. GPs’ previous referral for specialist support was significantly associated with access to a greater number of MHCPs (P = 0.001). Employment of a nurse increased the rate ratio of available MHCPs by 12.5% (incidence rate ratio [IRR] 1.125, 95% confidence interval [CI] = 1.001 to 1.264). Only one-third (32%) of GPs reported willingness to deprescribe and shift to broader CNCP treatments. Availability of MHCPs was not significantly associated with deprescribing decisions. Conclusion: Lack of geographical access to known MHCPs does not appear to be a major barrier to opioid deprescribing and shifting toward non-pharmacological treatments for CNCP. Considerable opportunity remains to encourage GPs' decision to deprescribe, with employment of a practice nurse appearing to play a role