The Opinions of the Cancer Patients About Pain Management: a Questionnaire Study

114 Turkish Journal of Cancer Volume 34, No.3, 2004

The opinions of the cancer patients about pain management: A questionnaire study

BÜLENT YALÇIN, F‹L‹Z ÇAY ﬁENLER, ABDULLAH BÜYÜKÇEL‹K, GÜNGÖR UTKAN, ‹BRAH‹M TEK, HAT‹CE DORUK, HAKAN AKBULUT, F‹KR‹ ‹ÇL‹

Ankara University School of Medicine, Department of Medical Oncology, Ankara-Turkey

ABSTRACT INTRODUCTION

The aim of this study is to evaluate the opinions of patients It is now known that the pain especially, cancer-pain is with cancer related pain about analgesics, by using a a multifactorial phenomenon that results in complexity questionnaire. All patients with chronic cancer pain were interactions between physiological, psychological, cognitive, given questionnaires by the primary physicians who have social and other factors. Up to 50% of patients with any been treating them. One hundred eleven cancer patients stage of the cancer experience significant pain. The under- with median age of 52 years (range: 21-75) were entered lying causes of cancer pain should be treated whenever the study. The pain was relieved completely by analgesics possible (1). Despite advances in cancer-pain management, in only 50 patients (45%). Thirty-one (27,9%) patients took there is evidence that cancer pain remains inadequately the prescribed analgesics regularly. Forty (36%) patients treated (2-5). Several factors, including inadequate commu- believed frequent uses will lead to addiction to analgesics. nication between patients and doctors have been blamed Significant positive correlation was observed between using for this inadequacy. narcotic analgesics and regular use of them (p=0.024) plus patients belief of improvement and good communication The aim of this study is to learn the judgment of patients with physician (p=0.03) [Turk J Cancer 2004;34(3):114-117] with cancer related pain about using analgesics by using a questionnaire.

KEY WORDS: PATIENTS AND METHODS

Advanced cancer, pain, questionnaire study Patients with chronic cancer pain who were treated at outpatient clinic of Ankara University School of Medicine, Department of Medical Oncology from October 2002 to June 2003, were given questionnaires about pain management (Figure 1). The questions were asked to the patient by the physician if the patient was illiterate. Yalçın et al. 115

Statistical analysis Table 1 All answers in questionnaire were tested with univariate- The characteristics of patients Spearman rho and multivariate-logistic regression tests for comparison of the pain control and other answers. N (%) Total 111 (100 %) Do you think you informed your doctor about your pain appropriately? Gender If not, why? Male 66 (59,4 %) Do you think your doctor understood you clearly? Female 45 (40,6 %) If not, why? Median age, years 52 years Do you know what the cause of your pain is? (range, years) 21, 75 years Do you have pain controlled with analgesics? Education level If not, do you think your pain will improve? Illiterate 15 (13,5 %) When do you take analgesics? And how do you use? Elementary school 62 (55,8 %) Have you ever seen any side effects of analgesics? High school 20 (18,1 %) If yes, what are they? University 14 (12,6 %) Do you believe in analgesic addiction? Do you take narcotic analgesics called Contramal®, M-Eslon® or sticking tapes on skin called Durogesic® ? What do you think about narcotic analgesics in your pain management? interview or their shyness. Twenty-three patients (19,8%) thought the doctor might not understand them adequately. Fig 1. The questionnaire They thought that the main causes of physician’s misunderstanding about pain were short interview and less communication with physician (Table 3). Although 48 patients RESULTS (43,3%) didn’t know the cause of the pain, others (56,7%) The characteristics of 111 patients included in the study were aware that it was related to cancer. are shown on table 1. Also, further interviews were done Eighty patients (72.1%) have been taking analgesics with 15 patients in this group who were illiterate. The irregularly. Twenty (32,7%) of 61 patients who didn’t have results of these questionnaire are depicted on table 2. improvement of the pain completely, have lost their hope Thirteen patients (11,8%) indicated that they could not on relief of pain. Only 13 (21,3%) of these patients have inform the doctor about pain clearly because of either short been taking analgesics regularly.

Table 2 Results of questionnaire

Yes No

Believe that he/she informed the physician about the pain 98 (88,2%) 13 (11,8%) Believe that physician understood him/her clearly 88 (79,2%) 23 (19,8%) Know the cause of the pain 63 (56,7%) 48 (43,3%) Pain is relieved completely 50 (45%) 61 (55%) Take analgesics regularly 31 (27,9%) 80 (72,1%) Have analgesic side effect 31 (27,9%) 80 (72,1%) Afraid that analgesics addiction will develop 40 (36 %) 40 (36 %) Take narcotic analgesic 29 (26,1%) 68 (61,2%) Refuse narcotic analgesic use in future 12 (10,8%) 99 (89,2%) 116 Questionnaire Study in Patients with Cancer Pain

relation between regularly taking analgesic and control of Table 3 pain (p=0.026). The causes of physician’s During individual interviews with 15 patients who were misunderstanding of pain according to illiterate, we observed wrong perceptions about pain in patients patients with advanced cancer such as, pain is fatalistic and the analgesic addiction will occur in future which will Total, N (%) 23 (100%) Lack of interest of physician to pain 3 (13%) lead to more suffering. Most of the patients were not taking Unable to describe the pain to physician 5 (21.7%) analgesics, because of such fears and wrong beliefs. Short interview with physician 9 (39.1%) Others 1 (4.3%) No answer 5 (21.9%) DISCUSSION

It was found that approximately 70% of the patients in Thirty-one (27,9%) of the patients said analgesics had this study have not taken analgesics regularly. Interestingly, some side effects on gastrointestinal system and sleeping. we also observed that most of the patients who had analgesic Interestingly, 28 of 31 patients (90,3%) who had side effects side effects have been taking them regularly. Although we of analgesic have been taking them regularly. could not exactly explain why most of the patients did not While 40 patients (36%) believed that the analgesic take analgesics regularly, possible causes may be side addiction would occur, other 40 patients (36%) didn’t effects and psychosocial distresses including wrong percep- believe it would and the rest of them (28%) had no any tions, such as ‘pain is fatalistic’ and ‘the analgesic tolerance idea about it. will occur at the end’. In our study, the rate of taking analgesics regularly was approximately 30%, which was Twenty-nine patients (26.1%) used narcotic analgesics similar to the results in the literature (6). and pain was not controlled completely in 13 of them (44,8%). Fourteen of these 29 patients (48,2%) didn’t know Spiegel et al. (7), found a significant association between whether their medicine was narcotic or not. Also pain was pain intensity and psychological distress. Chronic unrelieved not controlled completely in 37 of 68 patients (54,4%) who pain has caused psychological variations in cancer patients. didn’t take narcotic analgesics. But in the same study, they did not find significant association between pain intensity and depression. In our study, There was a significant positive correlation between most of the patients indicated that they had informed the using narcotic analgesics and regular use of them (p=0.024). physician about their suffering from pain. The patients who Also, we observed a significant positive correlation between could not inform the doctor about their suffering from pain the patients confidence of improvement and communication clearly related it to short interview with the doctor or their with the physician (p=0.03). shyness which may be secondary to psychological depres- Although 12 patients (10,8%) refused taking narcotic sion. Interestingly, approximately 10% of all the patients analgesics in future, others accepted it, after they were refused to use narcotic analgesics forever, in this study. convinced by their doctor that it was necessary (Table 2). Some studies have shown that unrelieved pain have The rejection rate of narcotic analgesics in future was negative effects on quality of life and survival in cancer significantly higher in patients who had completely relieved patients (8-11). Although the pain management in cancer pain at the present time than unrelieved group (49% vs. patients is improved, some studies related to this subject 91.6%, respectively) (p=0.001). Also, another significant still report that the treatment of cancer pain remains inad- finding was that rate of narcotic consent was higher in equate. It has been indicated that causes of undertreating unrelieved pain group (p=0,001). The rate of belief on cancer pain were usually the low rate of using narcotics developing analgesic addiction was higher in patients taking and the inadequate communication between the patient and narcotics than others (51.7% vs. 30.8%, p=0.04). Multivari- physician (2-5). We found there was a significant correlation ate regression analyses showed that there was a significant Yalçın et al. 117

between the improvement in patients’ belief and the com- In conclusion, despite the small number of study popu- munication of patients with their physician, compatible lation, present study showed that the majority of cancer with the knowledge of literature. patients have inadequate information about analgesic use in the control of cancer pain. They also have fears and There are some clinical recommendations about the wrong beliefs in this area. We suggest that physicians management of cancer pain to address the problem of should spend time to understand the suffering of cancer inadequate cancer pain management. It was recommended patients from pain and analgesics, and especially narcotics that physicians must inquire about pain and measure pain should be given adequately to control pain in patient with intensity, and should also evaluate and monitor factors advanced cancer. The effective management of pain is best associated with pain (1,6,11). accomplished by multidisciplinary approach in patients with advanced cancer.

References

1. Lesage P, Portenoy RK. Trends in cancer pain management. 7. Spiegel D, Sands S, Koopman C. Pain and depression in Cancer Control 1999;6:126-45. patients with cancer. Cancer 1994;74:2570-8. 2. Kelsen DP, Portenoy RK, Thaler HT, et al. Pain and depression 8. Ferrell BR, Grant MM, Funk BM, et al. Quality of life in in patients with newly diagnosed pancreas cancer. J Clin breast cancer survivors: implications for developing support Oncol 1995;13:748-55. services. Oncol Nurs Forum 1998;25:887-95. 3. Portenoy RK. Cancer pain: epidemiology and syndromes. 9. Herndon JE, Fleishman S, Kornblith AB, et al. Is quality of Cancer 1989;63:2298-307. life predictive of the survival of patients with advanced 4. Warncke T, Breivik H, Vainio A. Treatment of cancer pain nonsmall cell lung carcinoma? Cancer 1999;85:333-40. in Norway: a questionnaire study. Pain 1994;57:109-16. 10. Page GG, Ben-Eliyahu S. The immune-suppressive nature 5. Sapir R, Catane R, Strauss-Liviatan N, et al. Cancer pain: of pain. Semin Oncol Nurs 1997;13:10-5. knowledge and attitudes of physicians in Israel. J Pain 11. Zaza C, Baine N. Cancer Pain and Psychosocial Factors: A Symptom Manage 1999;17: 266-76. Critical Review of the Literature. J Pain Symptom Manage 6. Peteet J, Tay V, Cohen G et al. Characteristics and treatment 2002;24:526-42. in outpatient cancer population. Cancer 1986;57:1259-65.