Fear Of Addiction Research Articles

Cancer pain management in China: current status and practice implications based on the ACHEON survey.

PurposeCancer pain can seriously impact the quality of life (QoL) of patients, and optimal management practices are therefore of paramount importance. The ACHEON survey queried physicians and patients from 10 Asian countries/regions to assess current clinical practices in cancer pain management in Asia. This study presents the data obtained for cancer pain management in mainland China, with an emphasis on practices related to opioid drugs.Materials and methodsIn several tertiary hospitals across China, 250 patients experiencing cancer pain and 100 physicians were surveyed on questions designed to assess current cancer pain management practices and cancer pain impact on QoL.ResultsThe patient survey showed that 88% of patients reported moderate-to-severe cancer pain, with a median duration of 6 months. The physician survey showed that medical school/residency training with regard to cancer pain management was inadequate in ~80% of physicians. A total of 80% of physicians and 67.2% of patients reported that pain scale was used during pain assessment; 84% of physicians expressed that physician-perceived pain severity was not completely consistent with actual pain the patient experienced. Of the 147 patients who recalled the medication received, 83.7% were administered opioid prescriptions. Of the 240 patients who received treatment, 43.8% perceived the inadequacy of controlling pain. The primary barriers from physicians perceived to optimal pain management included patients’ fear of side effects (58%), patients’ fear of addiction (53%), patients’ reluctance to report pain (43%), physicians’ reluctance to prescribe (29%), physicians’ inadequacy of pain assessment (27%) and excessive regulation of opioid analgesics (47%).ConclusionKnowledge of cancer pain management should be strengthened among physicians. Quantitative pain assessment and principle-based pain management should be combined to achieve pain relief. Misconceptions about opioids in patients and physicians and poor report about pain should be overcome through training/education to improve QoL of patients impacted by pain.

A multicenter study of attitudinal barriers to cancer pain management.

The purpose of this study was to examine attitudinal barriers to cancer pain management and their relationship to pain, analgesic use, clinical, and demographic variables, as well as QOL, in a large sample of patients receiving strong opioids for pain in three European countries. Participants in the present study were 555 patients with cancer, 18years and older recruited from six centers in Germany, Iceland, and Norway. All had received strong opioids for at least 72h. Data was collected with the Barriers Questionnaire-II, the Brief Pain Inventory, and the European Organization for Research and Treatment of Cancer QLQ-C30. The mean (SD) age of patients was 61.68 (12.35)years and 53% were men. Most common diagnoses were gastrointestinal, lung, prostate, and breast cancer. The mean (SD) time from diagnosis was 32.24 (44.55) and 4.97 (9.64)months from start of opioid therapy. Mean (SD) pain severity was 3.19 (1.93) on a 0 to 10 scale, and 46.5% reported worst pain of 7 or higher. Attitudinal barriers had a mean (SD) of 1.95 (0.82) on a 0-5 scale, with fear of addiction as the strongest barrier across countries 2.85 (1.49). Barrier scores increased with age, and were higher among men than women. Higher barrier scores were associated with higher pain severity and interference, and lower performance status, but not with global health-QOL. Patients who had been on opioids for a shorter time reported higher barriers. Attitudinal barriers are frequent in cancer pain patients on opioids and are associated with less effective pain control.

INSULIN THERAPY;

Background: The increasing morbidity of diabetes mellitus in Pakistan, andinsulin refusal is one of the main challenges in managing diabetic patients who have suboptimalcontrol. Objectives: The aim of present study was to determine the trend of insulin therapyrefusal among diabetes mellitus type 2 patients in Pakistan from the healthcare provider’sperspective and to find out the reasons behind this refusal. Design: Quantitative research study.Place and duration of study: The clinics of general practitioner & consultants from differentlocations of Karachi to cover all socio-economic groups of society to avoid any biasness inselection. The duration of study is from August 2013 to February 2014. Methods: Four hundredand fifty healthcare providers were approached with convenient random sampling fromclinics and hospital located in Karachi. The pre-tested and validated questionnaire was usedto collect data. Data were authorized following double entry as given the code number of allfilled questionnaire and then data was first input in the excel sheet and then analyzed furtheron Statistical Package for Social Sciences (SPSS). Results: The 4.8% doctor observed thatpatients like to use insulin while 95.2% doctor observed that patients did not like to use insulinand insist to prescribe oral anti diabetic drug instead of insulin. 61.9% doctor believe that theirpatient avoid insulin usage due to fear of injection pain, while oral medicine are easy to use,while 9.5% doctor observed that patient avoid the insulin usage due to fear of poor quality oflife associated with insulin usage, 14.3% doctor believed that their diabetic patient avoid insulinusage due to fear of addiction or dependent on insulin injection and then oral anti diabetic drugcan never be beneficial for their diabetic management. The 4.8% doctor observed that theirpatient avoid the insulin usage due to lack of dispensing facility in their area and they himselfare not able to use insulin injection. The 9.5% doctor observed that their patient avoid insulinusage due to some other reasons like storage requirement of insulin. Conclusions: The insulinrefusal is seems to be major challenge to healthcare providers in management of diabetesmellitus type 2 in Pakistan. The proper patients counseling about benefits of insulin need onurgent basis to improve the situation.

English

Background: The increasing morbidity of diabetes mellitus in Pakistan, andinsulin refusal is one of the main challenges in managing diabetic patients who have suboptimalcontrol. Objectives: The aim of present study was to determine the trend of insulin therapyrefusal among diabetes mellitus type 2 patients in Pakistan from the healthcare provider’sperspective and to find out the reasons behind this refusal. Design: Quantitative research study.Place and duration of study: The clinics of general practitioner & consultants from differentlocations of Karachi to cover all socio-economic groups of society to avoid any biasness inselection. The duration of study is from August 2013 to February 2014. Methods: Four hundredand fifty healthcare providers were approached with convenient random sampling fromclinics and hospital located in Karachi. The pre-tested and validated questionnaire was usedto collect data. Data were authorized following double entry as given the code number of allfilled questionnaire and then data was first input in the excel sheet and then analyzed furtheron Statistical Package for Social Sciences (SPSS). Results: The 4.8% doctor observed thatpatients like to use insulin while 95.2% doctor observed that patients did not like to use insulinand insist to prescribe oral anti diabetic drug instead of insulin. 61.9% doctor believe that theirpatient avoid insulin usage due to fear of injection pain, while oral medicine are easy to use,while 9.5% doctor observed that patient avoid the insulin usage due to fear of poor quality oflife associated with insulin usage, 14.3% doctor believed that their diabetic patient avoid insulinusage due to fear of addiction or dependent on insulin injection and then oral anti diabetic drugcan never be beneficial for their diabetic management. The 4.8% doctor observed that theirpatient avoid the insulin usage due to lack of dispensing facility in their area and they himselfare not able to use insulin injection. The 9.5% doctor observed that their patient avoid insulinusage due to some other reasons like storage requirement of insulin. Conclusions: The insulinrefusal is seems to be major challenge to healthcare providers in management of diabetesmellitus type 2 in Pakistan. The proper patients counseling about benefits of insulin need onurgent basis to improve the situation.

Adherence for medication among self-reporting rural elderly with diabetes and hypertension

Background: Elderly population (age group with >60 years of age) is usually beset with multiple morbidities. Many medications (drugs) are generally prescribed for the management and care of such morbidities. For majority, consumption of such medications on a regular basis is not an easy option, therefore giving rise to nonadherence for medications. The study was conducted with the objective to assess adherence to medication for hypertension and Type 2 diabetes mellitus (T2DM) among rural elderly. Materials and Methods: A cross-sectional observational study was conducted among all rural elderly (more than 60 years of age) being managed for hypertension and type 2 diabetes, using a pretested and semi-structured questionnaire. Results: The number of female elderly was more than the male. Nearly 56% of the elderly with hypertension were not taking regular medication, whereas the comparative figure was 50% for elderly with T2DM. Compliance of treatment in geriatrics with both hypertension and diabetes in relation to the genders was found to be nonsignificant (P> 0.05). The main reasons identified for this were costs of medications, adverse events of drugs, fear of addiction, and declining memory. Conclusions: Nonadherence to medication among the elderly for hypertension and T2DM in this rural study was not uncommon.

Pain in the Bleeding Disorders Community: Patient and Caregiver Perspectives

Introduction:Pain negatively impacts individuals with bleeding disorders throughout their lives. Despite the high prevalence of pain in this population, the medical literature suggests that 40 to 60% of patients report that their pain is not well controlled. The bleeding disorders community has issued a call to confront this challenge through better prevention of bleeding and subsequent arthropathy and improved assessment and treatment of acute and chronic pain. Current efforts to address these issues lack input from patients and their caregivers (CGs) on how to prioritize specific elements of pain management for future quality improvement and research agendas. The Medical and Scientific Advisory Council of the National Hemophilia Foundation (NHF) created the Pain Initiative Task Force to address these shortcomings. This group aims to contribute to the national effort to improve pain management so that individuals with bleeding disorders can participate fully in their lives.Aims: To better understand the unmet needs of the bleeding disorders community regarding the evaluation and management of acute and chronic pain, and to identify and evaluate outcomes important to patients with bleeding disorders and their caregivers.Methods:We conducted a 1-hour session during the 2016 NHF Annual Meeting entitled "Pain in the Bleeding Disorders Community: A Call to Action." Attendance at the session was voluntary. We collected information from attendees using paper demographics forms, an electronic audience response system, and roundtable discussions. Discussion questions were presented to the group as a whole on pain types, methods of pain assessment, pain management, and perceived unmet needs. Participants were then divided into discussion groups based on whether they were a person with a bleeding disorder (PWBD) or a CG. Table discussions were moderated by a committee member who recorded field notes describing participant responses, topics of discussion, and general concerns expressed by the attendees.Results:36 PWBD and their CGs attended the session (50% patients, 50% CGs). 64% reported having chronic pain. 84% said their pain was assessed using either the 0-10 verbal response scale or the FACES scale. Only 38% reported that their pain was assessed at every clinic visit. Pain was reported as being managed by hematologists (45%), primary care providers (11%), and pain specialists (4%), while 30% reported managing their pain without any healthcare provider input. Fear of addiction to opioid medications was reported by 24% of patients and 15% of CGs. Only 52% of PWBD felt that pain was managed "fairly well" or "very well." PWBD and CG identified problems related to pain assessment, including limitations of the 0-10 pain scale for measuring pain, inadequacy of assessing only currentpain levels, and lack of assessment of sleep problems, mental health issues, and physical function. In addition, CGs noted the absence of assessment of pain's impact on CGs and other family members of patients. Participants identified many areas of pain management that were important to them, including a need for more non-pharmacologic pain treatments and non-opioid pain medications, use of physical therapy to treat/prevent pain, better understanding of the challenges of recognizing and treating pain in children, and concerns about opioids: lack of efficacy, risk of tolerance/dependence/addiction, and provider reluctance to prescribe opioid medications. Participants also felt that more research was needed to understand the role of cannabis. Areas of unmet needs identified by the groups included improvement in pain management education for providers, PWBD, and CGs, expansion of hemophilia treatment center teams to include providers with expertise in pain, improved communication between providers, and more research on prevention and treatment of pain in the bleeding disorders population.Conclusions:PWBD and caregivers identified limitations of the current healthcare delivery system and patient-valued unmet needs related to the assessment and management of pain in individuals with bleeding disorders. This information will serve to aid in prioritizing future quality improvement and research efforts to reduce the impact of pain in the bleeding disorders community. DisclosuresBuckner:Novo Nordisk: Consultancy; Genentech: Consultancy; Baxalta: Consultancy. Newman:Novo Nordisk: Consultancy. Santaella:Genentech: Consultancy; Novo Nordisk: Consultancy; CSL Behring: Consultancy. Witkop:Novo Nordisk: Consultancy, Other: Advisory Boards, Speakers Bureau; Pfizer: Consultancy, Research Funding, Speakers Bureau; BioEmergent: Consultancy, Speakers Bureau; Baxalta: Consultancy.

Physicians' Knowledge of and Attitudes Toward Use of Opioids in Long-Term Care Facilities.

Insufficient pain management in vulnerable older persons living in long-term care facilities is common, and opiophobia might contribute to this. As opiophobia and its related factors have not been investigated in long-term care, this study evaluates the degree of knowledge of opioids among elderly-care physicians (ECPs) and ECP trainees, as well as their attitudes and other factors possibly influencing the clinical use of opioids in these facilities. A questionnaire was designed and distributed among ECPs and ECP trainees by email, regional symposia, and all three university training faculties for elderly-care medicine in the Netherlands. Respondents were 324 ECPs and 111 ECP trainees. Fear of addiction did not influence the prescription of opioids. Main barriers to the clinical use of opioids were patients' reluctance to take opioids (83.3%); unknown degree of pain (79.2%); and pain of unknown origin (51.4%). ECPs' average knowledge scores were sufficient: those who felt that their knowledge of opioids was poor scored lower than those who felt that their knowledge was good. Factors identified in this study may help provide better pain management for vulnerable older persons living in a long-term care facility. Also, more patient information on the pros and cons of opioid use is needed, as well as appropriate tools for better clinical assessment of pain in a long-term care population.

Opioid prescribing habits of physicians in Kwara State, Nigeria.

Although opioid analgesics are effective in the treatment of moderate to severe acute, cancer and chronic non-malignant pains, they are under-prescribed in Nigeria. The objective of this study was to assess the prescription pattern of opioids among physicians in a north central State, Nigeria.. This was a descriptive cross sectional study. The study was conducted at the International Association for the Study of Pain (IASP)-sponsored workshops on pain and palliative care at the University of Ilorin Teaching Hospital, Ilorin, Nigeria. These were physicians at the monthly workshops organized by the Pain and Palliative Care Unit of the hospital between August 2011 and July, 2012. Pre-tested semi-structured questionnaires were used to obtain responses to questions on pain management including opioids utilization in the various hospitals of the 114 participants. The main outcome measure was opioid prescription by the participants. Out of the 114 questionnaires distributed, 113 were returned with complete information giving a response rate of 99.1%. The mean age of the respondents was 42.0±10.8 years. Although 97.3% of the respondents reported that pain was a frequent complaint in their practice, 69.5% of those who reported seeing patients with moderate to severe pain on a daily basis rarely or never prescribed opioid analgesics. The reasons given for poor opioid prescription were fear of respiratory depression (86.8%), fear of addiction (85.1%) and non-availability (28.9%). Opioid prescription rate for patients with moderate-severe pain is low possibly due to myths and misconceptions about their adverse effects. International Association for the Study of Pain (IASP) Initiative for Improving Pain Education Grant awarded to Dr. K.W. Wahab in 2011.

Comparison of Oncology Patients' and Their Family Caregivers' Attitudes and Concerns Toward Pain and Pain Management.

Both cancer patients and their family caregivers (FCs) report concerns about pain and pain management. When dyads share appraisal of the illness context, they may experience better dyadic adjustment. The aim of this study was to compare oncology outpatients' and their FCs' attitudes and concerns toward pain and pain management. In a cross-sectional study, outpatients with pain (n = 71) and their FCs completed the Barriers Questionnaire II, the Brief Pain Inventory, and information about demographic characteristics. Correlations and paired-samples t tests were calculated to evaluate agreement and differences in barrier scores between the patients and their FCs. Congruence was found in patients' and FCs' beliefs about pain and the use of analgesics on 4 of 7 subscales (ie, tolerance, immune system, side effects, distract the medical doctor) and on the Barriers Questionnaire II total score. Both patients and their FCs were most concerned about addiction. The concerns that both patients and their FCs have about pain and the use of analgesics may act as barriers to effective pain management. Fear of addiction may be an important barrier to cancer pain management. Only small differences were found in concerns between the patients and their FCs. Patients and FCs need education about perceived barriers to effective pain management. They should be coached together to maintain or increase the congruence between them.

The Opioid Pendulum and the Need for Better Pain Care.

Conflicts of interest: The author is a founding director of a small start up company researching nonpsychotropic cannabinoid formulations for treatment of pain and inflammation Panag Pharma Inc. There is a growing and disturbing trend against the use of medical opioids in the developed world. The fear of addiction continues to contribute to the under treatment of pain and further stigmatization of people living with chronic pain conditions. This fear has recently been fueled by reports of increasing opioid related deaths in a context of what came to be known as nonmedical prescription opioid use (NMPOU) [1]. A number of publications left the impression that the general medical use of opioids was the problem, leading to overly simplistic analyses and interventions that would limit the availability of and access to opioid medications [2,3]. In addition, the media have published articles that are unbalanced, using headlines that exaggerate and polarize the issue and ignore the contribution of other medications [4]. For example, a recent study has identified that the rate of overdose death among those also receiving a benzodiazepine was 10 times higher [5]. This has not been helpful in finding solutions to a complex problem and may have contributed to a fear among physicians of prescribing opioids. In fact, as presented below, the evidence from national surveys supports that since 2011 in the United States and Canada, the general use of opioids has decreased to a significant degree such that those of us on the front lines of pain management are finding that patients are experiencing difficulty accessing opioids when they are medically appropriate. In addition, the negative attention to “pain killers” has further stigmatized and harmed people suffering with pain [6]. The pendulum has swung too far …

The Evaluation of Undergraduate Nursing Students' Knowledge of Post-op Pain Management after Participation in Simulation

The purpose of this paper was to assess undergraduate nursing students' pain knowledge after participation in a simulation scenario. The Knowledge and Attitudes of Survey Regarding Pain (KASRP) was used to assess pain knowledge. In addition, reflective questions related to the simulation were examined. Student preferences for education method and reactions to the simulation (SIM) were described. Undergraduate nursing students' knowledge of pain management is reported as inadequate. An emerging pedagogy used to educate undergraduate nurses in a safe, controlled environment is simulation. Literature reports of simulation to educate students' about pain management are limited. As part of the undergraduate nursing student clinical coursework, a post-operative pain management simulation, the SIM was developed. Students were required to assess pain levels and then manage the pain for a late adolescent male whose mother's fear of addiction was a barrier to pain management. The students completed an anonymous written survey that included selected questions from the KASRP and an evaluation of the SIM experience. The students' mean KASRP percent correct was 70.4% ± 8.6%. Students scored the best on items specific to pain assessment and worst on items specific to opiate equivalents and decisions on PRN orders. The students' overall KASRP score post simulation was slightly better than previous studies of nursing students. These results suggest that educators should consider simulations to educate about pain assessment and patient/family education. Future pain simulations should include more opportunities for students to choose appropriate pain medications when provided PRN orders.

Treatment discontinuation in multiple sclerosis: The French Web-based survey ALLIANCE.

BackgroundIn multiple sclerosis (MS), treatment discontinuation leads to a higher risk of relapse, poorer quality of life and greater economic impact.ObjectiveThe objective of this work is to evaluate treatment discontinuation in MS, the reasons for this and the reasons for treatment resumption.MethodsA French national Web-based survey was carried out between May and August 2011. A total of 602 MS patients answered a questionnaire on sociodemographic data, medical follow-up, disease-modifying therapies (DMTs), symptomatic treatments, care given, factors involved in treatment discontinuation and reasons for resuming treatment.ResultsAmong 413 patients using DMTs, 54% have considered discontinuing their treatment, primarily because of anger (61%), side effects (61%) and fatigue (57%). Sixty-eight patients have actually discontinued their treatment because of side effects (43%), lack of observed outcomes (32%), exasperation (29%) or fatigue (29%). The reasons for symptomatic treatment discontinuation were fear of addiction (32%–46%) and lack of efficacy (28%–45%). Physiotherapy was discontinued because of fatigue (37%), stress (34%) or inefficiency (31%). According to patients, treatment discontinuation could have been prevented by psychological support, care team empathy and support from family.ConclusionThe major factor that could prevent treatment discontinuation is psychological support. Initiating and monitoring treatment in MS leads to emotional and personality changes, requiring adaptations that may improve compliance.

Prise de benzodiazépines au long cours chez les patients dialysés : une étude descriptive

BackgroundDialysis patients frequently have anxiety and sleeping disorders and that explains a benzodiazepine treatment. A significant proportion of dialysis patients are long-term users even though it is not recommended to take benzodiazepine for more than 3 months. Risks of such a use are well identified. Nephrologists frequently have to prescribe benzodiazepines. This prescription is complex and there are few studies regarding the factors of benzodiazepine use among this population. ObjectivesTo determine the prevalence and the factors related to a long-term benzodiazepine use by dialysis patients. To determine the prevalence and the motivation of patients to stop taking medication among the long-term users who got information about the risk of such a use. MethodThe study includes 91 dialysis chronic patients. Their characteristics were collected from medical records and interviews with the patients. ResultsThe average age of patients is 65,8 years. In all, 50.5% take benzodiazepines. Among benzodiazepine users, the prevalence of long-term use is 78.3%. Long-term benzodiazepine users (a) are older, (b) less active, (c) frequently diabetic, (d) depressive, (e) unable to walk, (f) less often registered on the kidney transplant waiting list, and (g) had less kidney transplant previously. Benzodiazepine doses of long-term users were higher than the doses of short-term users. Moreover, 60% of patients who are chronic users want to take action and stop the treatment. Observation of side effects, impression of ineffectiveness and fear of addiction are the most identified motivation to stop treatment. ConclusionThe prevalence of benzodiazepine chronic use by dialysis patients is high. Giving information to the patient about the use of these molecules seems to have a positive impact on the decision to stop.

Current practices in cancer pain management in Asia: a survey of patients and physicians across 10 countries.

In order to implement more effective policies for cancer pain management, a better understanding of current practices is needed. Physicians managing cancer pain and patients experiencing cancer pain were randomly surveyed across 10 Asian countries to assess attitudes and perceptions toward cancer pain management. A total of 463 physicians (77.3% oncologists) with a median experience of 13 years were included. Medical school training on opioid use was considered inadequate by 30.5% of physicians and 55.9% indicated ≤10 h of continuing medical education (CME). Of the 1190 patients included, 1026 reported moderate-to-severe pain (median duration, 12 months). Discordance was observed between physician and patient outcomes on pain assessment with 88.3% of physicians reporting pain quantification, while 49.5% of patients claimed that no scale was used. Inadequate assessment of pain was recognized as a barrier to therapy optimization by 49.7% of physicians. Additional barriers identified were patients’ reluctance owing to fear of addiction (67.2%) and adverse events (65.0%), patients’ reluctance to report pain (52.5%), excessive regulations (48.0%) and reluctance to prescribe opioids (42.8%). Opioid use was confirmed only in 53.2% (286/538) of patients remembering their medication. Pain affected the activities of daily living for 81.3% of patients. These findings highlight the need for better training and CME opportunities for cancer pain management in Asia. Collaborative efforts between physicians, patients, policy makers, and related parties may assist in overcoming the barriers identified. Addressing the opioid stigma and enhancing awareness is vital to improving current standards of patient care.

Oncology nurses' perception of cancer pain: A qualitative exploratory study

IntroductionPain is one of the most distressing symptoms experienced by patients with cancer undergoing active treatment (Stark, Tofthagen, Visovsky, & McMillan, 2012). Despite advances in understanding the aetiology of cancer pain, pharmacological developments, pain assessment tools and management guidelines, pain often remains poorly managed. Many patients with cancer continue to experience severe and unrelieved pain resulting in unnecessary suffering (Dulko, Hertz, Julien, Beck, & Money, 2010; Fairchild, 2010; Huntoon, 2009). Acute pain can be triggered by surgery and diagnostic procedures such as bone marrow aspirations and repeated intravenous cannulations for chemotherapy drugs (Chapman, 2011). Treatment effects such as chemotherapy-induced neuropathy may also contribute to reported pain (De Grandis, 2007; Lavoie Smith, Cohen, Pett, & Beck, 2010).Barriers to effective pain management are commonly reported throughout health care systems and may relate to the system, health professionals, and patients themselves (Bennett, Flemming, & Closs, 2011). With regard to nursing oncology practice, a lack of knowledge surrounding opioid delivery and its effects contribute to pain prevalence (Voshall, Dunn, & Shelestak, 2013). Yildirim, Cicek, and Uyar (2008) found that oncology nurses possessed inaccurate knowledge about commonly used analgesics and consequently exaggerated anxiety about the potential for psychological dependence occurring. Furthermore, patients themselves are often reluctant to report pain related to concerns about the impact of subsequent treatment decisions, personal cost, and their own fears of addiction and dependence (Simone, Vapiwala, Hampshire, & Metz, 2012).Oncology nurses are noted as being at the frontline of cancer pain management (Aycock & Boyle, 2009). Nurses perform and evaluate many interventions for pain management and have an essential role in deciding when changes in plans are required (Bernardi, Catania, Lambert, Tridello, & Luzzani, 2007; Chapman, 2011). This study explored how oncology nurses perceive, experience and assess cancer pain in their patients and, subsequently highlighted factors affecting the delivery of effective pain management strategies.MethodsA qualitative descriptive exploratory study was conducted using semi-structured interviews in order to achieve a detailed exploration of oncology nurses' perceptions of cancer pain in patients were receiving chemotherapy. A purposive sampling method was used to include experienced participants who had knowledge of the phenomenon in question (Berg, 2009; Sandelowski, 2010). The participants were five second-level chemotherapy-certified oncology nurses. The age of participants ranged from 32 to 55 years, with an average time of ten years working in the oncology field. All the available participants were female.Data were collected using one-to-one semi-structured interviews. Interviews are commonly used to gather in-depth exploration of nurse's perceptions, views, feelings, and experiences (Garton & Copland, 2010). Questions were open-ended to allow flexibility and encourage a richer narrative. Examples of the included questions were: What does pain mean to you?, How do you perceive cancer pain?, Does the pain reported by your patients have any impact on your practice?, How do you feel when your patient is in pain?, How well prepared do you feel to effectively manage a patients pain?. Further prompts, where needed, were used in order to clarify and to extend related concepts of cancer pain management.The interviews were audio-taped to ensure data accuracy. Once transcribed, inductive thematic analysis was conducted to identify codes, categories and themes relevant to the research question (Fereday & Muir-Cochrane, 2006). A Framework Analysis approach was applied (Richie & Spencer, 1994). Immersion in the raw data was achieved by listening to the interview tapes and then repeated reading of the transcripts to ensure familiarity with the data. …

Inside preview of procuring narcotic license.

Sir, In India, around 555,000 people died of cancer in 2010, representing 8% of estimated cancer deaths globally and 6% of deaths in India.[1] Physical and psychological effects of chronic pain affect the progression of the disease.[2] Opioids are considered as a key component for treatment of moderate to severe pain in cancer patients. Despite the abundant opium availability in India, opioid consumption, as estimated by World Health Organisation Collaborating Centre in 2012, is only 0.24 mg/person [Table 1].[3]Table 1: Opioid consumption 2010 (Pain and Policy Studies Group, UWCCC/WHO Collaborating Center, 2012)In India, only 0.4% of the total population have access to the opioids. Complicated rules and regulations along with problems related to attitude and knowledge regarding pain relief and opioids among the medical professionals and the public are major hindrances for poor access to opioids.[4] According to Narcotic Drugs and Psychotropic Substances (NDPS) Act (1985), to procure opioids, all the medical institutes should possess a license; they should specify the drug, the required quantity and also the formulation of the drug. The procedure to procure the license includes filing an application to the Drug Controller in the capital city; the drug inspector then institutes an inspection. Inspector inspects for adequate storage facilities, security setup, facilities to discard drugs, etc. Approval by the Drug Inspector is transmitted to the Drug Controller. Then the health authority confirms the approval to Drug Controller and License is issued. Frequently, the validity of one licence expires by the time another licence is obtained. Thus, it becomes a tedious job for doctors and hospitals to get all the licences to procure morphine.[5] Narcotic Drugs and Psychotropic Substances Amendment Bill, 2014 has been passed in 2014 with path-breaking changes for access to narcotics by medical specialty, breaking the various barriers which were included in the 1985 act. Parliament has adopted a new category of essential narcotic drugs in which central government can notify on the basis of expediency in medical practice. Drugs considered as essential will be subjected to central rules and will apply uniformly throughout the country. With the relaxation of rules, chances of misuse may be more and also due to the possibility of pilferage, chances of addiction increase. Physicians are scared to prescribe narcotic drugs due to unfounded fear of addiction and respiratory depression in patients. Patients who want pain relief are seen as drug addicts and doctors fear prosecution under NDPS Act.[6] Many laws and government policies so far were restrictive, and availability was difficult, without realising their rational medical use in pain management.[78] Next is fear of dependence; for a patient in pain, dependence rarely results and this is not the reason for not prescribing opioids to ailing patients.[9] Studies in palliative care showed that increased use of morphine did not lead to misuse.[10] Our aim is to update the readers on improved access and awareness of opioids to patients and identify regulatory barriers in the availability of opioids. Physicians and nurses should be educated about the principles of palliative care. Sustained and persistent efforts should be made by the palliative care leaders so that regulatory barriers can be overcome. Awareness can be created by conducting more and more workshops on the proper use of narcotics. Administration also plays a great role as it monitors the administration of narcotics and ensures the accountability of these drugs. It also guides and helps in maintaining the records. License should be issued to the institution or to the panel of physicians rather than on the individual basis and punishment should be harsher. New ampoules are expected to be exchanged for the discarded ones. According to the the Drug Inspector, the provisions of the NDPS Act, 2014 will allow medical institutes to have uninterrupted supply of narcotics for the patient care and process of getting the different licences is expected to be less tedious. It is better to remember that by simplifying the narcotic regulation, opioid availability cannot be improved to the cancer patients as it needs education of health care professionals in pain management and palliative care along with the integration of the palliative care programmes into the health care system.[4]

Thrombotic Thrombocytopenic Purpura (TTP) Patient Attitudes Regarding Depression Management: a Qualitative Study

▪Introduction: Recovery from an acute episode of TTP was previously thought to be complete except for a risk for relapse. However, the Oklahoma TTP-HUS Registry has documented that patients have multiple health problems that persist following recovery, including an increased prevalence of major depression (Blood122:2023;2013). Untreated major depression impacts daily functioning, quality of life and is a risk factor for suicide. Recognizing depression and establishing effective treatment should be a critical part of TTP follow-up care. The objective of our study was to identify TTP patient attitudes regarding treatments for depression.Methods: The study was based on the theoretical framework of the Theory of Planned Behavior (TPB). The theory suggests that intention is the immediate predictor of behavior. Intention is determined by 3 factors: attitude toward a behavior, subjective norms, and perceived behavioral control. This study focused on attitude; therefore, patients were primarily asked if there were any advantages or disadvantages of treating depression with either pharmacotherapy or counseling.One-on-one semi-structured interviews were conducted by the first author. Interviews were transcribed verbatim and content analysis was conducted by 3 qualitative researchers and facilitated by using the NVivo 10 software. A codebook was developed to guide the data analysis. Similar beliefs were grouped into themes and key ideas.Patients: Registry patients whose initial episode was associated with severe ADAMTS13 deficiency (<10%), 1995-2012, and who had major depression on at least 1 screening evaluation from 2004-2012. Qualitative purposeful sampling was used instead of random sampling. Patients were stratified by previous/current or no pharmacotherapy treatment regardless of counseling history.Results: Fifty-six ADAMTS13-deficient patients in clinical remission had been screened for depression; 50 patients were alive in 2013; 24 had a score of major depression at least once. Of the 24 patients, 12 (50%) had taken pharmacotherapy for their depression and 12 (50%) patients had never taken pharmacotherapy.Data saturation was achieved after interviewing 16 patients (9 pharmacotherapy; 7 no pharmacotherapy). Fourteen patients (88%) were women, 9 (56%) were black, and the median age was 49 years (range 28-69). Patients were a median of 8.5 years from their most recent TTP episode (range 2-17 years), 5 (31%) had relapsed, and 7 (44%) had been treated with rituximab.Interviews among all patients revealed that a TTP diagnosis was 'life-altering’ and 'traumatic’. Many patients felt the residual effects of TTP (a fear of relapsing, fatigue, and mild cognitive impairment) were related to their depression. A major theme across groups was that patients had a positive attitude toward counseling and believed counseling could be an effective way to treat depression. However, a history of a negative counseling experience seemed to discourage many patients from continuing counseling. Additionally, regardless of previous counseling experience, a key idea across groups was mistrust toward the mental healthcare provider’s ability. However, this mistrust was only a perception among those who had never tried counseling. Within the pharmacotherapy group, patients believed that medication was an effective way to treat depression; however, many patients reported side effects (feeling 'sluggish’ and 'not caring about anything’) as the reasons for stopping the medication. On the contrary, among the non-pharmacotherapy group patients were unsure if pharmacotherapy actually worked-'Uh, I guess it kind of would keep you steady-minded I guess’. The fear of side effects and the fear of addiction were the biggest barriers among the non-pharmacotherapy group for using pharmacotherapy.Conclusion:Hematologists need to recognize that TTP is a long-term life-altering diagnosis following recovery. Identifying and managing depression is a critical issue that can save lives. TTP patients seem to have a positive attitude toward counseling and a mixed attitude toward pharmacotherapy. Whether these fears are valid is beyond the scope of this study; however, it is imperative that hematologists discuss the issue of depression in depth with their patients and address the barriers to acceptance of treatment. This study is a first step in identifying barriers to depression treatment in TTP survivors. DisclosuresNo relevant conflicts of interest to declare.

Abstract A79: Empowering Latino cancer patients on the reality of cancer pain and debunking cultural myths via an interactive pain education program

Abstract Introduction: Limited educational programs on pain management are available for Spanish speaking cancer patients. One way of addressing Latinos cancer pain needs and barriers was to conduct a needs assessment. Thus taking a patient centered approach by involving Latino patients/families to enhance their care, expand their voice and address needs. The purpose of the Spanish interactive pain education program was to provide patients and families with tools and resources to assist them in communicating their pain to the healthcare team and debunking the cultural myths of cancer pain during and after treatment. Methods: Needs assessments (n=132) were mailed to all new Spanish speaking patients over a 90 day period, 57 were completed. Data identified the need to educate patients/families on cancer pain management and greater need for Spanish educational programs versus support. Thus, an interactive pain management education program was developed. Cultural factors were considered in designing and delivering the education intervention such as the significance of family or “familismo” which is considered one of the most culturally specific values for Latinos. Three Spanish pain classes were conducted by an Advanced Practice Nurse and a Health Educator. Five interactive components were embedded into the program to ensure patients understanding and learning. Education was provided on how to interpret and use two pain scales (Faces versus ten point scale), creating a pain diary, medication list, and how to read medication bottles and warnings, including complementary and alternative options for pain management. A Bingo game was used as a way for patients to demonstrate the skills and knowledge gained during the class, and for educators to re-address objectives or provide clarification. Data was collected at the end of each class to evaluate effectiveness and knowledge gained. Patients received a one week follow-up phone call to see if they applied any of the skills gained during the class. Findings: The pilot program further identified a distorted perception of pain when undergoing cancer treatment: (1) pain was not manageable (2) part of the treatment process (3) a way that the body is getting rid of cancer. Others refused medication for fear of addiction. When asked how they dealt with pain, the majority mentioned that they preferred to receive support or comfort in their families or talk with other cancer patients in similar situations. Some patients shared that they did not communicate their pain issues to their healthcare team, for fear of treatment delay. Patients stated that the class provided them with tools and resources to take more of an active role in their care and managing their pain. Conclusion: After attending class patients are able to take more of an active role in their care. Attendees are able to communicate their pain to their health care team by using descriptive words and/or using the pain scale to rate their pain or describe it. Patients have incorporated non-drug intervention strategies to help them cope with pain (music, meditation, attending educational classes). Citation Format: Gloria Juarez, Lina Mayorga. Empowering Latino cancer patients on the reality of cancer pain and debunking cultural myths via an interactive pain education program. [abstract]. In: Proceedings of the Sixth AACR Conference: The Science of Cancer Health Disparities; Dec 6–9, 2013; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2014;23(11 Suppl):Abstract nr A79. doi:10.1158/1538-7755.DISP13-A79

Morphine: Patient Knowledge and Attitudes in the Central Anatolia Part of Turkey

In Muslim majority countries (MMC) opioid use for pain management is extremely low. The underlying factors contributing to this are not well defined. The aim of this study was to survey the attitudes of cancer patients towards morphine use for pain management in a MMC and identify the factors that influence patient decisions to accept or refuse morphine as treatment for cancer pain. Patients were questioned whether they had pain or not, the severity and the medications for pain management. Questions included what type of medication they thought morphine was, whether or not they would be willing to take morphine if recommended for pain management and the basis for their decision if they were against morphine use. Four hundred and eighty-eight patients participated in the study. Some 50% of the patients who refused morphine use and 36.8% of the patients who would prefer another drug, if possible, identified fear of addiction as the basis for their decision. Reservation of morphine for later in their disease was the case for 22.4% of the patients who refused morphine use. Only 13.7 % of the patients refusing morphine and 9.7% of the patients who preferred another drug, if possible, cited religious reasons as the basis for this decision. Identifying the underlying factors contributing to low opioid use for pain management in MMC is important. Once the underlying factors are identified, all efforts should be taken to overcome them as they are barriers to improving patient pain management.

Hospice and palliation in the English-speaking Caribbean.

This article presents empirical data on the limited availability of hospice and palliative care to the 6 million people of the English-speaking Caribbean. Ten of the 13 nations therein responded to a survey and reported employing a total of 6 hospice or palliative specialists, and having a total of 15 related facilities. The evolving socioeconomic and cultural context in these nations bears on the availability of such care, and on the willingness to report, assess, and prioritize pain, and to prescribe opiates for pain. Socioeconomics and culture also impinge on what medications and modalities of care are routinely available for pain or other conditions and can challenge professionalism, empathy, and responsiveness to patients' unrelieved pain. Although all respondents report having a protocol for pain management, hospice, or end-of-life care, their annual medical use of opiates is well below the global mean. The International Narcotics Control Board (INCB), which monitors such use, encourages Caribbean and other low- and middle-income countries to increase their use of opiates to treat pain, and to overcome both unfounded fears of addiction and overly restrictive interpretation of related laws and regulations. Contextual considerations like those described here are important to the success of policies and capacity-building programs aiming to increase access to hospice and palliation, and perhaps to improving other aspects of health and healthcare. Exploring and responding to the realities of socioeconomic and cultural conditions will enhance public and policy dialogue and improve the design of interventions to increase access to palliative and hospice care. Improving access to palliative and hospice care in the Caribbean demonstrates beneficence and helps to fulfill human rights conventions.