A concept analysis of analgesic nonadherence for cancer pain in a time of opioid crisis

Background Pain is one of the most common symptoms identified along the cancer trajectory. Among patients with moderate to severe cancer pain, nonadherence to prescribed analgesics may complicate treatment plans and exacerbate pain severity. Nonadherent behaviors are likely due to a number of individual/family, provider, and system level factors and may lead to negative pain-related outcomes. Purpose The purpose of this concept analysis is to clarify the concept of analgesic nonadherence for cancer pain and qualify its utility in the context of the opioid crisis. Method Walker and Avant's (2019) method for concept analysis was used. We integrated empirical evidence, relevant literature, and sociopolitical considerations related to the opioid crisis to provide critical and timely analysis. Data were collected from a search of PubMed, CINAHL, PsycINFO, and Scopus. The search yielded 418 individual records. Empirical articles using quantitative and qualitative methodologies pertaining to analgesic nonadherence for cancer pain in adult outpatient settings, written in English, with an abstract, and published between 2010 and 2018 were considered. Other relevant literature sources were used if additional criteria were met. A total of 33 records were selected for detailed review. Findings Few studies link analgesic nonadherence to patient outcomes highlighting a significant literature gap. Given the available evidence, a definition for analgesic nonadherence is proposed for future use in research, education, practice, and policy settings. Discussion The paucity of empirical data combined with the implications of the opioid crisis and conflicting pain management guidelines create uncertainty about the utility of analgesic nonadherence. The concept of analgesic nonadherence warrants further normative and empirical research to clarify the role of opioids and the meaning of nonadherence in shaping pain-related outcomes within the current sociopolitical environment

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

Abstract available at publisher's web site

Adherence to Analgesics for Cancer Pain: A Comparative Study of African Americans and Whites Using an Electronic Monitoring Device

Despite well-documented disparities in cancer pain outcomes among African Americans, surprisingly little research exists on adherence to analgesia for cancer pain in this group. We compared analgesic adherence for cancer-related pain over a 3-month period between African Americans and whites using the Medication Event Monitoring System (MEMS). Patients (N = 207) were recruited from outpatient medical oncology clinics of an academic medical center in Philadelphia (≥18 years of age, diagnosed with solid tumors or multiple myeloma, with cancer-related pain, and at least 1 prescription of oral around-the-clock analgesic). African Americans reported significantly greater cancer pain (P \u3c .001), were less likely than whites to have a prescription of long-acting opioids (P \u3c .001), and were more likely to have a negative Pain Management Index (P \u3c .001). There were considerable differences between African Americans and whites in the overall MEMS dose adherence, ie, percentage of the total number of prescribed doses that were taken (53% vs 74%, P \u3c .001). On subanalysis, analgesic adherence rates for African Americans ranged from 34% (for weak opioids) to 63% (for long-acting opioids). Unique predictors of analgesic adherence varied by race; income levels, analgesic side effects, and fear of distracting providers predicted analgesic adherence for African Americans but not for whites. Perspective: Despite evidence of disparities in cancer pain outcomes among African Americans, surprisingly little research exists on African Americans\u27 adherence to analgesia for cancer pain. This prospective study uses objective measures to compare adherence to prescribed pain medications between African American and white patients with cancer pain

SIO-ASCO Guideline on Integrative Medicine for Cancer Pain Management: Implications for Racial and Ethnic Pain Disparities

Racial and ethnic disparities in pain management pose major challenges to equitable cancer care delivery. These disparities are driven by complex interactions between patient-, provider-, and system-related factors that resist reductionistic solutions and require innovative, holistic approaches. On September 19, 2022, the Society for Integrative Oncology and the American Society of Clinical Oncology published a joint guideline to provide evidence-based recommendations on integrative medicine for cancer pain management. Integrative medicine, which combines conventional treatments with complementary modalities from cultures and traditions around the world, are uniquely equipped to resonate with diverse cancer populations and fill existing gaps in pain management. Although some complementary modalities, such as music therapy and yoga, lack sufficient evidence to make a specific recommendation, other modalities, such as acupuncture, massage, and hypnosis, demonstrated an intermediate level of evidence, resulting in moderate strength recommendations for their use in cancer pain management. However, several factors may hinder real-world implementation of the Society for Integrative Oncology and the American Society of Clinical Oncology guideline and must be addressed to ensure equitable pain management for all communities. These barriers include, but are not limited to, the lack of insurance coverage for many complementary therapies, the limited diversity and availability of complementary therapy providers, the negative social norms surrounding complementary therapies, the underrepresentation of racial and ethnic subgroups in the clinical research of complementary therapies, and the paucity of culturally attuned interventions tailored to diverse individuals. This commentary examines both the challenges and the opportunities for addressing racial and ethnic disparities in cancer pain management through integrative medicine

The Conceptualization and Measurement of Comorbidity: A Review of the Interprofessional Discourse

Copyright © 2013 Salimah H. Meghani et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Background. Chronic medical conditions often occur in combination. Understanding underlying mechanisms causing diseases and their interactions may make it possible to address multiple complex conditions with single or consolidated treatment approaches and improve patients’ health outcomes while reducing costs. Objectives. We present a synthesis of the current interprofessional discourse on the issues surrounding comorbidities. Methods. A targeted review of the literature was conducted using published editorials, commentaries, and review articles. Results. Errors in conceptualization and measurement plague our current understanding of comorbidities. Two potential paths to generating knowledge involve the use of etiological or epidemiological approach. An etiological approach investigates the risk factors and underlying mechanisms potentially leading to consolidation of diagnosis and treatments. Because of the rudimentary stage of knowledge development in this area, this approach will require time and significant research investments. In contrast, the epidemiological approach relies on statistical identification of disease entities that cooccur beyond random chance; this approach carries an accompanying risk of diagnostic and treatment proliferation. Discussion. The concept of comorbidity, its nature, and measurement is in need of meaningful debate by the scientific and clinical communities. Recommendations in the domains of conceptualization, research, and measurement are discussed

Identifying Distinct Risk Profiles to Predict Adverse Events among Community-Dwelling Older Adults

Preventing adverse events among chronically ill older adults living in the community is a national health priority. The purpose of this study was to generate distinct risk profiles and compare these profiles in time to: hospitalization, emergency department (ED) visit or death in 371 community-dwelling older adults enrolled in a Medicare demonstration project. Guided by the Behavioral Model of Health Service Use, a secondary analysis was conducted using Latent Class Analysis to generate the risk profiles with Kaplan Meier methodology and log rank statistics to compare risk profiles. The Vuong-Lo-Mendell-Rubin Likelihood Ratio Test demonstrated optimal fit for three risk profiles (High, Medium, and Low Risk). The High Risk profile had significantly shorter time to hospitalization, ED visit, and death (p \u3c 0.001 for each). These findings provide a road map for generating risk profiles that could enable more effective targeting of interventions and be instrumental in reducing health care costs for subgroups of chronically ill community-dwelling older adults

Perceptions, prevalence, and patterns of cannabis use among cancer patients treated at 12 NCI-Designated Cancer Centers

BackgroundThe legal climate for cannabis use has dramatically changed with an increasing number of states passing legislation legalizing access for medical and recreational use. Among cancer patients, cannabis is often used to ameliorate adverse effects of cancer treatment. Data are limited on the extent and type of use among cancer patients during treatment and the perceived benefits and harms. This multicenter survey was conducted to assess the use of cannabis among cancer patients residing in states with varied legal access to cannabis.MethodsA total of 12 NCI-Designated Cancer Centers, across states with varied cannabis-access legal status, conducted surveys with a core questionnaire to assess cannabis use among recently diagnosed cancer patients. Data were collected between September 2021 and August 2023 and pooled across 12 cancer centers. Frequencies and 95% confidence intervals for core survey measures were calculated, and weighted estimates are presented for the 10 sites that drew probability samples.ResultsOverall reported cannabis use since cancer diagnosis among survey respondents was 32.9% (weighted), which varied slightly by state legalization status. The most common perceived benefits of use were for pain, sleep, stress and anxiety, and treatment side effects. Reported perceived risks were less common and included inability to drive, difficulty concentrating, lung damage, addiction, and impact on employment. A majority reported feeling comfortable speaking to health-care providers though, overall, only 21.5% reported having done so. Among those who used cannabis since diagnosis, the most common modes were eating in food, smoking, and pills or tinctures, and the most common reasons were for sleep disturbance, followed by pain and stress and anxiety with 60%-68% reporting improved symptoms with use.ConclusionThis geographically diverse survey demonstrates that patients use cannabis regardless of its legal status. Addressing knowledge gaps concerning benefits and harms of cannabis use during cancer treatment is critical to enhance patient-provider communication

Factors affecting the negotiation of treatment for cancer pain among African Americans

Over the past decade, there has been a surge of literature related to disparities in pain treatment between minorities and non-minorities. Conspicuously lacking from this body of literature are the efforts to investigate the patient-level factors that might account for these ethnic differences. The present study, using QUAL-quant mixed-method, investigated the meaning of cancer pain, the preference for pain treatment, and the factors shaping negotiation of cancer pain treatment among African Americans. Symbolic Interactionism provided a framework for the inquiry. The sample (n = 32) was recruited from three outpatient oncology clinics in the mid-Atlantic region. Inclusion was based on self-identified African Americans, ≥18 years of age, diagnosed with solid tumors, with self-reported cancer pain of at least one month, and no history of major surgery in past three months. The data were gathered using demographics, the Brief Pain Inventory-Long Form, and in-depth semi-structured interviews. Qualitative findings revealed that despite having overt access to pain medications, considerable intra-cultural differences existed in the preference for analgesia among this group of African Americans. Pain treatment negotiations were largely the products of the meanings participants attributed to cancer pain and its treatment. From the interpretation of the interview data, a typology of negotiation was identified based on participants\u27 preference for analgesia: (1) non-believers, (2) centralists, and (3) strong believers. Non-believers comprised the group that expressed strong beliefs against using pain medications. They were futuristic, survival-oriented, and strongly believed that pain medication masked their ability to identify cancer progression. Contrarily, strong-believers expressed favorable beliefs towards taking pain medication, articulated fewer dilemmas in using analgesics, and reported fewer side-effects attributable to pain medication. Centralists comprised the group that did not believe in taking pain medications but resorted to taking them in favor of reduced pain severity or expectation of relief. The combined QUAL-quant analysis supported the qualitatively-derived typologies by demonstrating statistically significant differences in important quantitative variables, i.e., preference for pain medication, frequency with which pain medication was used, and degree of pain relief among these groups. The present study suggests that different subgroups of African Americans may benefit from different types and levels of interventions

Factors affecting the negotiation of treatment for cancer pain among African Americans

Over the past decade, there has been a surge of literature related to disparities in pain treatment between minorities and non-minorities. Conspicuously lacking from this body of literature are the efforts to investigate the patient-level factors that might account for these ethnic differences. The present study, using QUAL-quant mixed-method, investigated the meaning of cancer pain, the preference for pain treatment, and the factors shaping negotiation of cancer pain treatment among African Americans. Symbolic Interactionism provided a framework for the inquiry. The sample (n = 32) was recruited from three outpatient oncology clinics in the mid-Atlantic region. Inclusion was based on self-identified African Americans, ≥18 years of age, diagnosed with solid tumors, with self-reported cancer pain of at least one month, and no history of major surgery in past three months. The data were gathered using demographics, the Brief Pain Inventory-Long Form, and in-depth semi-structured interviews. Qualitative findings revealed that despite having overt access to pain medications, considerable intra-cultural differences existed in the preference for analgesia among this group of African Americans. Pain treatment negotiations were largely the products of the meanings participants attributed to cancer pain and its treatment. From the interpretation of the interview data, a typology of negotiation was identified based on participants\u27 preference for analgesia: (1) non-believers, (2) centralists, and (3) strong believers. Non-believers comprised the group that expressed strong beliefs against using pain medications. They were futuristic, survival-oriented, and strongly believed that pain medication masked their ability to identify cancer progression. Contrarily, strong-believers expressed favorable beliefs towards taking pain medication, articulated fewer dilemmas in using analgesics, and reported fewer side-effects attributable to pain medication. Centralists comprised the group that did not believe in taking pain medications but resorted to taking them in favor of reduced pain severity or expectation of relief. The combined QUAL-quant analysis supported the qualitatively-derived typologies by demonstrating statistically significant differences in important quantitative variables, i.e., preference for pain medication, frequency with which pain medication was used, and degree of pain relief among these groups. The present study suggests that different subgroups of African Americans may benefit from different types and levels of interventions