Barriers to cancer pain management in Danish and Lithuanian patients treated in pain and palliative care units.

The prevalence of cancer-related pain is high despite available guidelines for the effective assessment and management of that pain. Barriers to the use of opioid analgesics partially cause undertreatment of cancer pain. The aim of this study was to compare pain management outcomes and patient-related barriers to cancer pain management in patient samples from Denmark and Lithuania. Thirty-three Danish and 30 Lithuanian patients responded to, respectively, Danish and Lithuanian versions of the Brief Pain Inventory pain scale, the Barriers Questionnaire II, the Hospital Anxiety and Depression Scale, the Specific Questionnaire On Pain Communication, and the Medication Adherence Report Scale. Emotional distress and patient attitudes toward opioid analgesics in cancer patient samples from both countries explained pain management outcomes in the multivariate regression models. Pain relief and pain medication adherence were better in Denmark, and the country of origin significantly explained the difference in the regression models for these outcomes. In conclusion, interventions in emotional distress and patient attitudes toward opioid analgesics may result in better pain management outcomes generally, whereas poor adherence to pain medication and poor pain relief appear to be more country-specific problems.

Optimal duration of combined psychotherapy and pharmacotherapy for patients with moderate and severe depression: a meta-analysis.

BACKGROUND: To investigate the most effective duration of combined psychotherapy and pharmacotherapy for achieving remission and preventing relapse in depressive patients as compared to pharmacotherapy alone. METHODS: A systematic review of English articles using PubMed, EMBASE, Web of Science, the Cochrane Library, and PsychINFO was performed in September 2009. Clinical studies comparing pharmacotherapy alone with pharmacotherapy in combination with a psychological intervention for depression treatment that reported response, remission or relapse as outcomes were included in the analysis. For each of the studies, clinical binary outcomes such as response, remission or relapse were extracted. RESULTS: All pooled analyses were based on random-effects models. Twenty-one article describing the influence of additional psychotherapy on remission and 15 articles reporting the influence on relapse in depression were included in the analysis. Patients receiving combined treatment experienced remission more often than those receiving pharmacotherapy alone, with the highest odds ratio OR, 2.36; 95% CI, 1.58-3.55 observed at 4months after commencing the treatment. Patients receiving pharmacotherapy alone also demonstrated a higher risk for relapse compared to those receiving combined treatment. LIMITATIONS: We restricted our search to only English language publications. Studies investigating relapse or recurrence rates are often of small size. CONCLUSION: Pharmacotherapy enhanced with psychotherapy is associated with a higher probability of remission and a lower risk of relapse, as compared to antidepressants alone for depression treatment. Receiving psychotherapy in both the acute and continuation phases is the most effective option. Further research is needed to investigate the influence of additional psychotherapy on different patients.

"Patients don't lie"; a view on adherence in asthma.

OBJECTIVE: The primary objective of this article is to examine the extent of self-reported non-adherence among patients participating in a controlled trial of an asthma compliance optimization intervention. The secondary objective is to introduce a two-question questionnaire that is, in wording and design, a neutral tool for disclosure of non-adherence behaviour. METHOD: Data in this study was obtained as part of a controlled trial on an SMS monitoring and compliance intervention developed for Danish asthma patients. The trial was conducted from November 2007 to May 2008. A total of 244 patients participated in the study. Two new designed nonadherence questions were asked in immediate succession. This practice, along with the wording of the questions and use of the Web as medium, constitute a new approach to self-reported adherence assessment. RESULTS: A total of 43.9% of the participants in the trial reported non-adherence to the medical dosage regime for which they had, only one question earlier, documented their awareness. CONCLUSION: This illustrates that at least 43.9% of the participants in the trial dared to report nonadherence to asthma medication.

Rationales behind the choice of administration form with fentanyl: Delphi survey among Danish general practitioners.

BACKGROUND AND AIM: The aim of this study was to describe the rationale behind the choice of fentanyl administration forms among Danish general practitioners (GPs). METHODS: Thirty-eight Danish GPs were contacted via an Internet survey system to perform a Delphi survey. In the brainstorming phase, the main reasons for prescribing and not prescribing fentanyl patches, oral transmucosal systems (OTFCs), and nasal sprays were identified. In the second phase, GPs were asked to rate the importance of each reason. RESULTS AND DISCUSSION: Thirty-three GPs responded in the brainstorming phase, and 33 and 31 in two rating rounds, respectively. The most important reason to choose fentanyl patches was that patients' clinical condition did not allow them to take analgesia orally. OTFCs were primarily seen as a self-administrative alternative to injections in case of breakthrough pain. The main reasons for not choosing OTFCs were intolerance to fentanyl and price. The most important possible rationale to choose fentanyl nasal spray was easy administration. The most important possible reasons to not choose fenanyl nasal spray were application side effects. CONCLUSIONS: The rationale behind the choice of administration form with fentanyl partly differed from those overviewed in the literature. Fentanyl nasal spray was seen as a better option for treatment of breakthrough pain among terminally ill patients if compared with OTFCs.

Psychological and behavioural predictors of pain management outcomes in patients with cancer.

To better understand the phenomenon of patient-related barriers to cancer pain management and address them more effectively in interventional studies, a theoretical model related to psychological aspects of pain experience and pain-related behaviours was elaborated. The aim of the study was to analyse the impact of patient-related barriers on cancer pain management outcomes following this model. Thirty-three patients responded to the Brief Pain Inventory Pain scale, the Danish Barriers Questionnaire II (DBQ-II), the Hospital Anxiety and Depression scale (HADS), the Danish version of Patient Perceived Involvement in Care Scale measuring the quality of patient-physician pain communication, and the Danish version of Medication Adherence Report Scale (DMARS-4). Statistical analysis was performed with SPSS 16.00. The results of the multivariable linear regression analyses showed that pain intensity was explained by patients' emotional distress (symptoms of anxiety and depression) and that pain relief was explained by cognitive barriers. In conclusion, interventions in emotional distress and patients' concerns may supposedly result in better cancer pain management outcomes.

Danish pain specialists' rationales behind the choice of fentanyl transdermal patches and oral transmucosal systems--a delphi study.

OBJECTIVE: The aim of this study was to describe the rationale behind the choice of fentanyl administration forms among Danish pain specialists. METHODS: Sixty Danish physicians specializing in pain management were contacted via an Internet survey system to perform a two-phase Delphi survey. Response rates were 45% in the brainstorming and 88% in the rating phases, respectively. Statistical analysis with SPSS for Windows 15.00 included descriptive statistics and factor analysis. RESULTS: The most important rationale to choose fentanyl patches was that patients' clinical condition did not allow them to take analgesia orally, while the main explanations for not choosing a fentanyl patch was a specific chronic pain condition such as nonmalignant or neuropathic pain origin, and price. The foremost rationale behind the choice of oral transmucosal fentanyl citrate (OTFC) were cancer patients' need for the alternative to oral, intravenous or subcutaneous rescue medication, followed by patients' wish and ability to administer pain medication independently. The main reasons for not choosing OTFC were price and the argument that OTFC administration requires much energy and healthy patients' mouth and therefore is inapplicable for terminal pain patients. CONCLUSION: The study had shown that the rationales behind the choice of administration form with fentanyl reported by a panel of Danish pain specialists partly differed from those overviewed in the literature and those thought to be important while developing fentanyl patches and OTFC.

Barriers to cancer pain management: a review of empirical research.

Patient-, physician-, and health care system-related barriers of cancer pain management in patients with malignant diseases are a recognized and widely investigated issue. The purpose of this review is to summarize the main findings of empirical research on these barriers in the literature. The most significant patient-related barriers were patient reluctance to report pain and adhere to treatment recommendations. Besides that, cognitive, affective, and sensory patient-related barriers to cancer pain management with opioid analgesics have been studied using quantitative and qualitative research methods. The Barriers Questionnaire and its shortened and modified versions were the most commonly used instruments in the context of research on patient-related barriers to cancer pain management. The most prominent physician-related barriers were insufficient physicians' knowledge about cancer pain management, inadequate patterns of pain assessment, and inadequate opioid prescription. The methodologies used to conduct the majority of the studies on physician-related barriers were weak. Nevertheless, physician knowledge of pain management guidelines, the quality of pain assessment and opioid prescription have been shown to be obviously better in a few Western countries. Institutional and health care system-related barriers were relevant only in countries with restrictive opioid prescription regulations. The evaluation of the influence of cultural-social-economical background on cancer pain management could probably help to obtain better insight into the problems of unrelieved cancer pain.

The Danish Barriers Questionnaire-II: preliminary validation in cancer pain patients.

OBJECTIVE: The objective of this study was to examine the psychometric properties of the Danish version of the Barriers Questionnaire-II (DBQ-II). METHODS: The validated Norwegian version of the DBQ-II was translated into Danish. Cancer patients for the study were recruited from specialized pain management facilities. Thirty-three patients responded to the DBQ-II, Hospital Anxiety and Depression Scale, and Brief Pain Inventory pain severity scale. RESULTS: A factor analysis of the DBQ-II resulted in six scales. Scale one, Fatalism, consisted of three items addressing fatalistic beliefs regarding cancer pain management. Scale two, Immune System, consisted of three items addressing the belief that pain medications harm the immune system. Scale three, Monitor, consisted of three items addressing the fear that pain medicine masks changes in one's body. Scale four, Communication, consisted of five items addressing the concern that reports of pain distract the physician from treating the cancer, and the belief that "good" patients do not complain. Scale five, Addiction, consisted of two items addressing the fear of becoming addicted to pain medication. Finally, scale six, Tolerance, consisted of three items addressing the fear of getting tolerant to analgesic effect of pain medicine. Items related to medication side effects were analyzed as separate units. The DBQ-II total had an internal consistency of 0.87. The DBQ-II total score was related to measures of pain relief and anxiety. CONCLUSIONS: The DBQ-II seems to be a reliable and valid measure of the barriers to pain management among Danish cancer patients.

Application of pharmacogenomics to clinical problems in depression.

The goal of this article is to review the literature for evidence supporting an association between polymorphisms within drug target genes and clinical outcomes for treating depression, with a purpose to identify a research area having the most promising potential to be introduced into clinical settings, and thus, discussing the perspectives of genotyping in antidepressant therapy. A total of 67 articles were identified. Polymorphic sites within the serotonin transporter gene promoter, 5-HTTLPR, were the most studied polymorphisms. All except three articles were designed as cohort studies. The other three articles included two meta-analyses and one decision-analytic model. The main finding from these meta-analyses was that the l variant was associated with a better response to selective serotonin reuptake inhibitors. The main conclusion from the decision-analytic model study was that performing genetic testing before prescribing antidepressant treatment may lead to greater numbers of patients experiencing remission early in treatment. Clinical outcomes of genotyping this polymorphism were evaluated by improvement of depression score, odds ratio and absolute risk reduction.

Patient-related barriers to cancer pain management: a systematic exploratory review.

The aim of this review was to systemically explore the current evidence regarding patient-related barriers to cancer pain management to find new areas that might be important for better understanding of patient barriers' phenomenon. The method used in this study was a computerised literature search, carried out in Cochrane Library, Medline (through PubMed), Web of Science and EMBASE databases for the period 1994-2005. Thirty-seven studies, dealing with cognitive, sensory and affective patient-related barriers, as well as studies, describing patients' pain communication and their adherence to analgesic regimen were included and analysed. The dominant part of articles studied cognitive patient-related barriers to cancer pain management, while affective, sensory barriers, as well as pain communication and pain medication adherence were studied in much less extend. However, the findings from different studies regarding relationships between cognitive barriers and pain intensity were not consistent. On the contrary, the quality of pain communication was consistently found to be not satisfactory in some key areas. The associations between more expressed attitudinal as well as sensory barriers and less optimal adherence were also consistent. In conclusions suggestion for the new research areas on patient-related barriers to cancer pain management are made. Firstly, further research is needed to differentiate the role of cognitive, affective and sensory factors with respect to their impact on pain relief, pain communication and medication adherence. Besides that, validated instruments to assess patients' pain communication and adherence to analgesic regimen are lacking.

The Danish version of the Medication Adherence Report Scale: preliminary validation in cancer pain patients.

OBJECTIVE: To examine the psychometric properties of the Danish version of the Medication Adherence Report Scale (DMARS-4) adapted to measure adherence to analgesic regimen among cancer patients. METHODS: The validated English version of the Medication Adherence Report Scale was translated into Danish following the repeated back-translation procedure. Cancer patients for the study were recruited from specialized pain management facilities. Thirty-three patients responded to the DMARS-4, the Danish Barriers Questionnaire II, The Danish version of Patient Perceived Involvement in Care Scale measuring the quality of patient-physician pain communication, and the Danish Brief Pain Inventory pain severity scale. RESULTS: A factor analysis of the DMARS-4 resulted in one factor. Mean (SD) score on the cumulative scale ranging from 4 to 20, with higher scores indicating better medication adherence, was 17.8 (0.42). The DMARS-4 scores were related to the measures of patients' concerns about pain management and patients' pain communication. The internal consistency of the DMARS-4 was 0.70. CONCLUSIONS: The DMARS-4 seems to be a valid and reliable measure of self-reported adherence to analgesic regimen in the context of cancer pain.

Clinical rationale for administering fentanyl to cancer pain patients: two Delphi surveys of pain management experts in Denmark.

OBJECTIVE: To describe the rationale behind the choice of fentanyl administration forms as reported by Danish nurses and physicians specializing in pain management. METHODS: Sixty nurses and 60 physicians specializing in pain management in Denmark were contacted via an Internet survey system to perform two Delphi surveys. In the brainstorming phase, the main reasons for administering and not administering fentanyl patches and oral transmucosal fentanyl citrate (OTFC) were identified. In the second phase, the nursing and medical experts rated the importance of these reasons on an 11-point Numerical Rating Scale. RESULTS: Responses from 10 pain nurses and 14 pain doctors were used for the final analysis. Impossible or difficult oral intake of analgesia was the most important reason to administer fenantyl patches, whereas patients' dermatological problems and neuropathic pain origin were the most important reasons for not administering fenantyl patches in both panels. OTFC was presented as an alternative or second choice administration form for breakthrough cancer pain by both nurses and doctors. A damaged mouth, the high cost, and energy required for administration of this medication were reported as the main reasons why OTFC was only rarely prescribed to cancer pain patients in Denmark. CONCLUSIONS: The reasons for administering fentanyl in different administration forms reported by Danish pain nurses and pain specialists partly differed from those derived from the literature. Studies of pain management traditions could improve the understanding of the reasons for analgesic administration.

Physician-related barriers to cancer pain management with opioid analgesics: a systematic review.

OBJECTIVE: The purpose of this review is to summarize the results of studies on physician-related barriers to cancer pain management with opioid analgesics. METHODS: A literature search was conducted in PUBMED, using a combined text word and MeSH heading search strategy. Those articles whose full texts were not available in PUBMED were retrieved from the electronic databases of specific journals. RESULTS: Sixty-five relevant articles, published in the period from 1986 to 2006, were identified. Physicians' barriers to cancer pain management were studied in questionnaire surveys and in the reviews of drug prescribing documents. The results of the articles found were analyzed with respect to (a) knowledge, beliefs, concerns, problems endorsed or acknowledged by physicians treating cancer pain, (b) physicians' skills in pain assessment, and (c) adequacy of opioid prescription. CONCLUSIONS: This review revealed mostly general and common physician-related barriers to cancer pain management: concerns about side effects to opioids, prescription of not efficient doses of opioids, and very poor prescription for the treatment of side effects from opioids. In the future, the evaluation of the influence of cultural-social-economical background, as well as the differences between the various specialists involved in the care of patients with cancer, should be explored to better understand physicians' barriers and more effectively address them in interventional and educational programs.

The diffusion of innovation: factors influencing the uptake of pharmacogenetics.

BACKGROUND: Inspired by diffusion research, this paper examines how perceived need, health status, experiences with medicine and testing, consumption of mass media and sociodemography influence the public's familiarity, knowledge, attitudes and intentions regarding pharmacogenetics. The objective is to identify factors affecting the adoption pattern of pharmacogenetics in the public. METHOD: The paper is based on an Internet-based questionnaire survey conducted in March 2005. A total of 3,000 representative Danes aged 18-70 years were included in the survey, representing a response rate of 58.9%. RESULTS/CONCLUSION: Knowledge of pharmacogenetics, and thus the diffusion of the technology, is influenced by medicine consumption, experienced lack of effect and side effects, use of medical testing and perception of societal need. Increased knowledge is seen in all cases. The general perception of and attitude to pharmacogenetics is related to prior use of medical tests and perception of societal need for pharmacogenetics, which in both cases indicates an increased positive approach.

Public acceptance of drug use for non-disease conditions.

OBJECTIVE: This article deals with the issue of ordinary healthy people using drugs to improve or enhance non-disease conditions. The objective is to illuminate the extent of public acceptance of this practice. RESEARCH DESIGN AND METHODS: The results are based on two studies: a classically structured telephone interview with 961 Danes in 1999 and an Internet questionnaire survey of 2735 Danes in 2003. The two studies cannot be compared due to differences in recruitment and methodology. RESULTS: Based on basic descriptive statistics, the studies show substantial public acceptance of the use of drugs for non-disease conditions. Men in particular look favourably on the use of drugs by healthy individuals. People with less education find this type of drug use unacceptable to a greater extent than those with more education, who are more positive. If we look at political affiliation, a pattern emerges. People who did not vote or voted for one of the left-wing parties are less likely to accept this type of drug use. The extent to which people work with drugs professionally does not seem to influence the extent to which they are positive or negative about this type of drug use. CONCLUSION: The implications of this development encompass a wide range of concerns, from the individual risk of side effects to general issues concerning the prioritisation of health care resources. The results need more attention, including further studies, professional consideration and health policy decisions.

Lay perspective on pharmacogenomics: a literature review.

The lay attitude to pharmacogenomics is crucial to successful implementation. The intention of the present literature review is to delineate the considerations, expectations, fears, and so on, described in the literature regarding pharmacogenomics seen from a lay perspective. The literature review was conducted in Medline and EMBASE in March 2005. The combined search in databases, reference lists, and so on, produced a total of 30 relevant articles, of which seven are included in the literature review. Other literature reviews on this issue are included in the discussion. This review documents that, at this time, very little information is available regarding the public's attitude to pharmacogenetic testing and the use of pharmacogenomics in therapy. Thus, studies of lay attitudes to and expectations of pharmacogenomics are highly relevant. Research is increasingly being conducted in the area, and studies have shown that education, income, age, ethnicity and nationality seems to influence lay attitudes. Based on this, it is concluded that knowledge of the relation between national /cross-national cultural and subcultural settings, and attitudes toward pharmacogenomics seem to be important to a successful pharmacogenomics implementation in healthcare.