Relationship between Cancer Pain Self-management and Pain in Outpatients with Advanced Cancer Taking Opioid Analgesics

Background Each year in England and Wales, 150,000 people die from cancer, of whom 110,000 will suffer from cancer pain. Research highlights that cancer pain remains common, severe and undertreated, and may lead to hospital admissions. Objective To develop and evaluate pain self-management interventions for community-based patients with advanced cancer. Design A programme of mixed-methods intervention development work leading to a pragmatic multicentre randomised controlled trial of a multicomponent intervention for pain management compared with usual care, including an assessment of cost-effectiveness. Participants Patients, including those with metastatic solid cancer (histological, cytological or radiological evidence) and/or those receiving anti-cancer therapy with palliative intent, and health professionals involved in the delivery of community-based palliative care. Setting For the randomised controlled trial, patients were recruited from oncology outpatient clinics and were randomly allocated to intervention or control and followed up at home. Interventions The Supported Self-Management intervention comprised an educational component called Tackling Cancer Pain, and an eHealth component for routine pain assessment and monitoring called PainCheck. Main outcome measures The primary outcome was pain severity (measured using the Brief Pain Inventory). The secondary outcomes included pain interference (measured using the Brief Pain Inventory), participants’ pain knowledge and experience, and cost-effectiveness. We estimated costs and health-related quality-of-life outcomes using decision modelling and a separate within-trial economic analysis. We calculated incremental cost-effectiveness ratios per quality-adjusted life-year for the trial period. Results Work package 1 – We found barriers to and variation in the co-ordination of advanced cancer care by oncology and primary care professionals. We identified that the median time between referral to palliative care services and death for 42,758 patients in the UK was 48 days. We identified key components for self-management and developed and tested our Tackling Cancer Pain resource for acceptability. Work package 2 – Patients with advanced cancer and their health professionals recognised the benefits of an electronic system to monitor pain, but had reservations about how such a system might work in practice. We developed and tested a prototype PainCheck system. Work package 3 – We found that strong opioids were prescribed for 48% of patients in the last year of life at a median of 9 weeks before death. We delivered Medicines Use Reviews to patients, in which many medicines-related problems were identified. Work package 4 – A total of 161 oncology outpatients were randomised in our clinical trial, receiving either supported self-management (n = 80) or usual care (n = 81); their median survival from randomisation was 53 weeks. Primary and sensitivity analyses found no significant treatment differences for the primary outcome or for other secondary outcomes of pain severity or health-related quality of life. The literature-based decision modelling indicated that information and feedback interventions similar to the supported self-management intervention could be cost-effective. This model was not used to extrapolate the outcomes of the trial over a longer time horizon because the statistical analysis of the trial data found no difference between the trial arms in terms of the primary outcome measure (pain severity). The within-trial economic evaluation base-case analysis found that supported self-management reduced costs by £587 and yielded marginally higher quality-adjusted life-years (0.0018) than usual care. However, the difference in quality-adjusted life-years between the two trial arms was negligible and this was not in line with the decision model that had been developed. Our process evaluation found low fidelity of the interventions delivered by clinical professionals. Limitations In the randomised controlled trial, the low fidelity of the interventions and the challenge of the study design, which forced the usual-care arm to have earlier access to palliative care services, might explain the lack of observed benefit. Overall, 71% of participants returned outcome data at 6 or 12 weeks and so we used administrative data to estimate costs. Our decision model did not include the negative trial results from our randomised controlled trial and, therefore, may overestimate the likelihood of cost-effectiveness. Conclusions Our programme of research has revealed new insights into how patients with advanced cancer manage their pain and the challenges faced by health professionals in identifying those who need more help. Our clinical trial failed to show an added benefit of our interventions to enhance existing community palliative care support, although both the decision model and the economic evaluation of the trial indicated that supported self-management could result in lower health-care costs. Future work There is a need for further research to (1) understand and facilitate triggers that prompt earlier integration of palliative care and pain management within oncology services; (2) determine the optimal timing of technologies for self-management; and (3) examine prescriber and patient behaviour to achieve the earlier initiation and use of strong opioid treatment. Trial registration Current Controlled Trials ISRCTN18281271. Funding This project was funded by the National Institute for Health Research Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 15. See the NIHR Journals Library website for further project information.

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Morphine use for cancer pain: A strong analgesic used only at the end of life? A qualitative study on attitudes and perceptions of morphine in patients with advanced cancer and their caregivers

Palliative Medicine ◽

10.1177/0269216320904905 ◽

2020 ◽

Vol 34 (5) ◽

pp. 619-629

Author(s):

Julia Fee Voon Ho ◽

Hayati Yaakup ◽

Grace Sook Hoon Low ◽

Siew Lih Wong ◽

Lye Mun Tho ◽

...

Keyword(s):

Side Effects ◽

Qualitative Study ◽

Cancer Pain ◽

Advanced Cancer ◽

Pain Control ◽

Opioid Analgesics ◽

Tertiary Hospital ◽

Advanced Cancer Patients ◽

Attitudes And Perceptions ◽

Patients Acceptance

Background: The prevalence of undertreated cancer pain remains high. Suboptimal pain control affects quality of life and results in psychological and emotional distress. Barriers to adequate pain control include fear of opioid dependence and its side effects. Aim: To investigate the attitudes and perceptions of morphine use in cancer pain in advanced cancer patients and their caregivers and to examine the influence of caregivers’ attitudes and perceptions on patients’ acceptance of morphine. Design: Qualitative study involving semi-structured individual interviews transcribed verbatim and analyzed thematically. Setting/Participants: A total of 18 adult opioid-naïve patients with advanced cancer and 13 caregivers ( n = 31) were recruited at a private tertiary hospital via convenience sampling. Results: Attitudes and perceptions of morphine were influenced by previous experiences. Prevalent themes were similar in both groups, including perceptions that morphine was a strong analgesic that reduced suffering, but associated with end-stage illness and dependence. Most participants were open to future morphine use for comfort and effective pain control. Trust in doctors’ recommendations was also an important factor. However, many preferred morphine as a last resort because of concerns about side effects and dependence, and the perception that morphine was only used at the terminal stage. Caregivers’ attitudes toward morphine did not affect patients’ acceptance of morphine use. Conclusion: Most participants were open to future morphine use despite negative perceptions as they prioritized optimal pain control and reduction of suffering. Focused education programs addressing morphine misperceptions might increase patient and caregiver acceptance of opioid analgesics and improve cancer pain control.

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Self-management of Patients with Advanced Cancer: A Systematic Review of Experiences and Attitudes

10.26226/morressier.5c76c8b6e2ea5a7237612265 ◽

2019 ◽

Author(s):

Sophie van Dongen

Keyword(s):

Systematic Review ◽

Advanced Cancer ◽

Self Management

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Impact of individualized management of breakthrough cancer pain on quality of life in advanced cancer patients: CAVIDIOPAL study

Supportive Care in Cancer ◽

10.1007/s00520-021-06006-1 ◽

2021 ◽

Author(s):

Albert Tuca Rodríguez ◽

Miguel Núñez Viejo ◽

Pablo Maradey ◽

Jaume Canal-Sotelo ◽

Plácido Guardia Mancilla ◽

...

Keyword(s):

Quality Of Life ◽

Cancer Pain ◽

Advanced Cancer ◽

Low Doses ◽

Breakthrough Cancer Pain ◽

Eortc Qlq C30 ◽

Eortc Qlq ◽

Individualized Management ◽

The Impact

Abstract Purpose The main aim of the study was to assess the impact of individualized management of breakthrough cancer pain (BTcP) on quality of life (QoL) of patients with advanced cancer in clinical practice. Methods A prospective, observational, multicenter study was conducted in patients with advanced cancer that were assisted by palliative care units. QoL was assessed with the EORTC QLQ-C30 questionnaire at baseline (V0) and after 28 days (V28) of individualized BTcP therapy. Data on background pain, BTcP, comorbidities, and frailty were also recorded. Results Ninety-three patients completed the study. Intensity, duration, and number of BTcP episodes were reduced (p < 0.001) at V28 with individualized therapy. Transmucosal fentanyl was used in 93.8% of patients, mainly by sublingual route. Fentanyl titration was initiated at low doses (78.3% of patients received doses of 67 μg, 100 μg, or 133 μg) according to physician evaluation. At V28, mean perception of global health status had increased from 31.1 to 53.1 (p < 0.001). All scales of EORTC QLQ-C30 significantly improved (p < 0.001) except physical functioning, diarrhea, and financial difficulties. Pain scale improved from 73.6 ± 22.6 to 35.7 ± 22.3 (p < 0.001). Moreover, 85.9% of patients reported pain improvement. Probability of no ≥ 25% improvement in QoL was significantly higher in patients ≥ 65 years old (OR 1.39; 95% CI 1.001–1.079) and patients hospitalized at baseline (OR 4.126; 95% CI 1.227–13.873). Conclusion Individualized BTcP therapy improved QoL of patients with advanced cancer. Transmucosal fentanyl at low doses was the most used drug. Trial registration This study was registered at ClinicalTrials.gov database (NCT02840500) on July 19, 2016.

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Evaluation of an Educational Outreach Campaign (IMPACT) on Pain Management Delivered to General Practices in Walsall

International Journal of Pharmacy Practice ◽

10.1093/ijpp/riab015.059 ◽

2021 ◽

Vol 29 (Supplement_1) ◽

pp. i48-i49

Author(s):

S Visram ◽

J Saini ◽

R Mandvia

Keyword(s):

Data Analysis ◽

Pain Management ◽

Cancer Pain ◽

Educational Intervention ◽

Opioid Analgesics ◽

Educational Outreach ◽

Opioid Prescribing ◽

Prescribing Trends ◽

The Impact

Abstract Introduction Opioid class drugs are a commonly prescribed form of analgesic widely used in the treatment of acute, cancer and chronic non-cancer pain. Up to 90% of individuals presenting to pain centres receive opioids, with doctors in the UK prescribing more and stronger opioids (1). Concern is increasing that patients with chronic pain are inappropriately being moved up the WHO ‘analgesic ladder’, originally developed for cancer pain, without considering alternatives to medications, (2). UK guidelines on chronic non-cancer pain management recommend weak opioids as a second-line treatment, when the first-line non-steroidal anti-inflammatory drugs / paracetamol) ineffective, and for short-term use only. A UK educational outreach programme by the name IMPACT (Improving Medicines and Polypharmacy Appropriateness Clinical Tool) was conducted on pain management. This research evaluated the IMPACT campaign, analysing the educational impact on the prescribing of morphine, tramadol and other high-cost opioids, in the Walsall CCG. Methods Standardised training material was delivered to 50 practices between December 2018 and June 2019 by IMPACT pharmacists. The training included a presentation on pain control, including dissemination of local and national guidelines, management of neuropathic, low back pain and sciatica as well as advice for prescribers on prescribing opioids in long-term pain, with the evidence-base. Prescribing trends in primary care were also covered in the training, and clinicians were provided with resources to use in their practice. Data analysis included reviewing prescribing data and evaluating the educational intervention using feedback from participants gathered via anonymous questionnaires administered at the end of the training. Prescribing data analysis was conducted by Keele University’s Medicines Management team via the ePACT 2 system covering October 2018 to September 2019 (two months before and three months after the intervention) were presented onto graphs to form comparisons in prescribing trends of the Midland CCG compared to England. Results Questionnaires completed at the end of sessions showed high levels of satisfaction, with feedback indicating that participants found the session well presented, successful at highlighting key messages, and effective in using evidence-based practice. 88% of participants agreed the IMPACT campaign increased their understanding of the management and assessment of pain, and prescribing of opioids and other resources available to prescribers. The majority (85%) wished to see this form of education being repeated regularly in the future for other therapeutic areas. Analysis of the prescribing data demonstrated that the total volume of opioid analgesics decreased by 1.7% post-intervention in the Midlands CCG in response to the pharmacist-led educational intervention. As supported by literature, the use of educational strategies, including material dissemination and reminders as well as group educational outreach was effective in engaging clinicians, as demonstrated by the reduction in opioid prescribing and high GP satisfaction in this campaign. Conclusion The IMPACT campaign was effective at disseminating pain-specific guidelines for opioid prescribing to clinicians, leading to a decrease in overall prescribing of opioid analgesics. Educational outreach as an approach is practical and a valuable means to improve prescribing by continuing medical education. References 1. Els, C., Jackson, T., Kunyk, D., Lappi, V., Sonnenberg, B., Hagtvedt, R., Sharma, S., Kolahdooz, F. and Straube, S. (2017). Adverse events associated with medium- and long-term use of opioids for chronic non-cancer pain: an overview of Cochrane Reviews. Cochrane Database of Systematic Reviews. This provided the statistic of percentage receiving opioids that present to pain centres. 2. Heit, H. (2010). Tackling the Difficult Problem of Prescription Opioid Misuse. Annals of Internal Medicine, 152(11), p.747. Issues with prescriptions and inappropriate moving up the WHO ladder.

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Analysis of guidelines for chronic, non-cancer pain management with opioid analgesics

Journal of Pain ◽

10.1016/j.jpain.2013.01.764 ◽

2013 ◽

Vol 14 (4) ◽

pp. S25

Author(s):

J. Haddox ◽

J. Erensen

Keyword(s):

Pain Management ◽

Cancer Pain ◽

Opioid Analgesics ◽

Cancer Pain Management

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