Patient-Related Barriers To Cancer Pain Management

THEORETI CAL STUDI ES doi: 10.1111/j.1471-6712.2008.00601.
x
Patient-related barriers to cancer pain management: a
systematic exploratory review
Ramune Jacobsen MSc, MPH (PhD Student)
1
, Claus Mldrup PhD (Associate Professor)
1
, Lona Christrup
PhD (Associate Professor)
1
and Per Sjgren MD, DMSc (Anaesthesiologist)
2
1
Department of Pharmacology and Pharmacotherapy, Section for Social Pharmacy, The Faculty of Pharmaceutical Sciences, University of
Copenhagen, Copenhagen, Denmark and
2
The Multidisciplinary Pain Centre, Danish National Hospital, Copenhagen, Denmark
Scand J Caring Sci; 2009; 23; 190208
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 nd new areas that might be
important for better understanding of patient barriers
phenomenon. The method used in this study was a com-
puterised literature search, carried out in Cochrane Li-
brary, Medline (through PubMed), Web of Science and
EMBASE databases for the period 19942005. Thirty-se-
ven studies, dealing with cognitive, sensory and affective
patient-related barriers, as well as studies, describing pa-
tients pain communication and their adherence to anal-
gesic 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
ndings from different studies regarding relationships be-
tween cognitive barriers and pain intensity were not con-
sistent. On the contrary, the quality of pain communica-
tion was consistently found to be not satisfactory in some
key areas. The associations between more expressed atti-
tudinal 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 re-
search 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.
Keywords: literature review, cancer pain, opioids, patients,
barriers, attitudes, side effects, pain communication,
adherence.
Submitted 2 April 2007, Accepted 2 January 2008
Introduction
The prevalence of acute and chronic pain in cancer pa-
tients is high: approximately 30% in patients with newly
diagnosed cancer, 5070% in patients receiving active
anti-cancer therapy and 6080% in patients with far ad-
vanced disease (1). For most patients (up to 90%), suf-
cient pain relief can be obtained if adequate treatment, as
suggested by various guidelines, is provided (25). Under-
treatment of cancer pain can be caused by the barriers to
the use of opioid analgesics. In this respect, institutional,
health-care professional and patient-related barriers have
been identied (6). In many countries institutional barriers
cover health-care system-related barriers, such as compli-
cated bureaucratic regulations governing the supply, pre-
scription and administration of opioids. There are also
problems related with continuity of care, when the patient
is seen by different physicians across a number of different
health-care settings, with no one capable or willing to take
full responsibility for the overall pain management (7).
Health-care professional-related barriers include physi-
cians, nurses and other medical staffs lack of knowledge in
key areas of pain management, including misconceptions
about the pharmacological effects of available drugs and
insufcient practice in pain assessment (8). Patients
reluctance to report pain and adhere to treatment recom-
mendations were reported among the most signicant
patient-related barriers to cancer pain management (8
10). Barriers to opioid therapy of cancer pain may not only
be derived from the patients but their families may also
Correspondence to:
Ramune Jacobsen, Department of Pharmacology and Pharmaco-
therapy, Section for Social Pharmacy, The Faculty of Pharmaceutical
Sciences, University of Copenhagen, Universitetsparken 2,
Copenhagen, Denmark.
E-mail: raj@farma.ku.dk
190 2008 The Authors. Journal compilation 2008 Nordic College of Caring Science
contribute substantially to the under-treatment of cancer
pain (1113).
To enhance the quality of cancer pain management, it is
very important to better understand the phenomenon of
patient-related barriers to cancer pain management. For
this reason, it is essential to systematically explore the
current knowledge about these barriers. However, there
have been no attempts to systematise this knowledge from
the literature to date. Instead, it has been stated that a
theoretical framework, related to pain experience and
pain-related behaviours, could be helpful in understanding
the patients barriers phenomenon (14). Furthermore, the
biomedical theories and models of disease-related pain
have been recognised as limited, while theories taking into
account the importance of social or psychological patient-
related factors seem to be more promising (15, 16). Thus, a
systematic exploratory review of the current evidence on
patient-related barriers to cancer pain management, based
on the integrative theory of pain experience and behav-
iour, will help to identify the gaps in our knowledge re-
lated to patients barriers and consequently will enhance
the quality of cancer pain management.
Aims and objectives
The aim of this paper is to systemically explore the current
evidence regarding patient-related barriers to cancer pain
management to discover new areas that are important for
better understanding of the barriers phenomenon. For this
reason, the model of patient-related barriers, based on
the theories taking into account biological, cognitive,
psychological and behavioural aspects in relation to pain
experience, was elaborated. The relationships between the
different parts of the model were explored; attempts to
compare the ndings, reported in the literature, were
made. The results of such an exploratory analysis are dis-
cussed, partly in the light of the theories used. In the
conclusions, new directions for research on patient-related
barriers to cancer pain management are suggested.
Methods
Analytical approach
Portenoy (17) and Melzack (18) proposed a theoretical
framework, explaining how pain is perceived and conse-
quently reported. Their ideas can be summarised with the
statement that three dimensions constitute the intensity of
pain that patients perceive and report. These dimensions
are: cognitive factors (e.g. patients attitudes, beliefs,
knowledge about pain and pain medication), sensory fac-
tors, or physical input of pain and its treatment (e.g. side
effects of pain medication), and affective factors, or emo-
tional experience of cancer patients (e.g. anxiety and
depression). Only one study, where the multidimensional
theory of pain was used as a theoretical basis to study
patient-related cognitive barriers to cancer pain manage-
ment, has been undertaken to date (19).
The theories of reasoned action and planned behaviour
assert that the person-specic attitudes toward the
behaviour in question can be expected to predict that
behaviour (20). According to health-care personnel, pa-
tients reluctance to communicate about pain and adhere
to treatment recommendations are the most signicant
behaviours that hinder good cancer pain management (8
10). The theories of reasoned action and planned behav-
iour have been widely used to explore adherence to
medication in different acute and chronic illnesses (21).
The model used in this paper combines both the above
mentioned theoretical assumptions. According to the
model, three dimensions of pain experience cognitive,
sensory and affective factors impact on the intensity of
pain experienced and reported by the patients. Besides
that, cognitive, as well as affective or sensory factors, may
impact on patients behaviours, such as pain communica-
tion and medication use, which consequently has an effect
on pain intensity. For example, patients who do not
communicate their pain are not prescribed with adequate
medication and therefore end-up with a higher intensity of
pain, while patients who do not comply with the pre-
scribed regimen, suffer from more intensive pain as well.
Despite the possibility to use both pain relief and pain
intensity as outcomes of patients pain experiences and
pain-related behaviours or barriers to pain management
only the latter was chosen because of methodological
reasons: the measurement of pain intensity, in particular
cancer-related pain, is well validated (22, 23). The model
of patient-related barriers used for the literature review in
this paper is graphically presented in Fig. 1.
Literature search
The literature search was conducted in Cochrane Library,
Medline (through PubMed), Web of Science and EMBASE
databases using the words barriers and cancer and pain
Pain
communication
Medication
adherence
Cognitive f.
Affective f. Sensory f.
Figure 1 The model of patient-related barriers used for the literature
review is graphically represented.
2008 The Authors. Journal compilation 2008 Nordic College of Caring Science
Patient-related barriers to cancer pain management 191
management with and without MeSH or Thesaurus. In
line with the above presented model, the terms, for which
MeSH and Thesaurus were explored, included attitudes,
knowledge, affective, symptoms, communication,
and adherence (for barriers), pain, cancer and anal-
gesia (for pain management). The last search was carried
out in May 2006. Descriptive quantitative and qualitative
studies in English language on adult patients barriers to
drug therapy for cancer pain were included. Intervention
studies on cancer pain management were excluded be-
cause they largely focused on the results of interventions
rather than on the barriers themselves. Studies on chronic
nonmalignant pain were only included when they had
relevance for patient-related barriers in cancer pain
management.
Results
Thirty-seven relevant papers were identied. All the
literature is classied into three main groups: group 1
consists of papers describing cognitive, sensory, affective
barriers and their mutual relationships, as well as rela-
tionships with pain intensity (Table 1). Group 2 consists of
papers describing pain communication and its relationship
with other barriers as well as pain intensity (Table 2); and
group 3 consists of papers describing medication adherence
together with its relationship with other barriers and pain
intensity (Table 3).
Cognitive, sensory and affective patient-related barriers to
cancer pain management
Table 1 summarises the main ndings from studies found
on cognitive, affective and sensory barriers.
1. Cognitive barriers. Investigation of the beliefs and atti-
tudes of patients with chronic pain is a comprehensive and
complicated research area (24). In this paper we focus on
the knowledge, beliefs, attitudes and concerns which are
related to pain treatment or pain medication. Thus, by
cognitive barriers we understand less knowledge about
pain treatment possibilities as well as beliefs and attitudes
having a negative inuence on the outcome of pain
management.
Systematic investigation of patients cognitions as bar-
riers to cancer pain management started with the con-
struction of the Barriers Questionnaire (BQ), which was
initially validated in a study including 270 cancer patients
(25). The questionnaire consisted of 27 items and included
eight beliefs: (a) fear of addiction; this belief often origi-
nates from a misunderstanding about the distinction
between psychological addiction, physical dependence and
tolerance, (b) fear of becoming tolerant to the effects of
analgesics; many patients are not aware that there is no
upper limit for opioid dosing, (c) concern that the side
effects of analgesics (drowsiness, nausea, constipation or
mental confusion) are inevitable and unmanageable, (d)
belief and fear that increased pain indicates a progression
of the disease, (e) fear of injections, (f) fatalistic belief
about cancer pain, or belief that it is impossible to control,
(g) belief that good patients do not complain about pain,
(h) belief that health-care professionals nd it annoying to
talk about pain, and that this talk distracts them from
treating the cancer; this latter belief is based on the idea
that there is a trade-off between treating the pain and
curing the disease (26). In the survey both reliability and
validity of the questionnaire were assessed, and preva-
lence of patients barriers was demonstrated. BQ was
found to have good psychometrical characteristics: inter-
nal consistency alpha was 0.89, testretest reliability cor-
relation coefcient r was 0.90. Around 3785% of the
respondents expressed some concerns; highest scores had
concerns about addiction. Later, BQ, in the original,
shortened or modied forms (BQ-II), as well as transla-
tions into different languages, were used in the research of
patients barriers in many other studies, where similar
validity and reliability gures were shown (2638). A
number of researchers have used other validated (19,
3845) or not validated questionnaires (4649), as well as
qualitative research methods (5053) to assess patients
attitudes to cancer pain management. In one of the
studies, patient-related cognitive barriers were presented
to the respondents as a multiple choice check list (54).
Reported internal consistency alpha of used question-
naires to assess cognitive barriers ranged from 0.47 (39,
40) to 0.94 (42).
The ndings of all these studies revealed that there were
three types of patients cognitive barriers to cancer pain
management: concerns about analgesic use (fear of
addiction, tolerance and side effects, fear that pain
medicine will mask new pains), concerns about pain
communication (willingness to tolerate pain, to be a good
patient, and a belief that physicians will prioritise curing
cancer instead of relieving pain), and maladaptive beliefs
about the possibility of controlling pain in general (belief,
that pain related to cancer is inevitable, or that pain
medication in general is not efcient enough). Different
cognitive barriers were identied in qualitative studies on
patient-related barriers to cancer pain management.
Among these barriers were concerns regarding family
reaction to pain reports, concerns about the careers atti-
tudes towards the credibility of the need for opioid anal-
gesia (52), perceived lack of planned treatment and lack of
trust in the health-care system (50) and general dislike of
taking pills (53).
Many researchers have investigated the relationship
between cognitive barriers and pain severity. Pain
intensity was measured with validated one-dimensional
[e.g. visual analogy (49), verbal rating (44, 47) and
numerical rating (32, 36, 42)] or multidimensional [e.g.
192 R. Jacobsen et al.
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Brief Pain Inventory (19, 25, 26, 2831, 33, 3740, 45,
46)] Scales. All mentioned measures of pain intensity are
previously shown to be valid in various settings of pain
patients (22, 23). This review revealed that the ndings
from the different studies regarding relationships be-
tween cognitive barriers and pain intensity were not
consistent. Some researchers claimed the existence of an
association between better knowledge and less-pain
intensity, or between more negative beliefs and more
intensive pain (19, 25, 30, 33, 43, 44); others could not
(34, 3840, 47) or could only partially (26, 45) conrm
an association.
According to the model used in this study, cognitive
factors might inuence reported pain intensity directly
and indirectly. The direct inuence means that negative
beliefs about opioids cause high-pain intensity despite
good compliance with the prescribed regimen. Such
interpretation is also in line with the previously reported
ndings from the research in chronic nonmalignant pain
patients, where it has been concluded that maladaptive
beliefs adversely affect the pain experience and is a risk
factor for poor response to pain management (24). The
indirect inuence means that patients negative beliefs
negatively affect their pain communication and adher-
ence to the analgesics regimen, and therefore results in
high-pain intensity as well. Thus, to specify the role of
cognitive factors on cancer pain treatment outcome, the
level of pain communication and adherence to prescribed
regimen should be controlled. If so, the results of different
studies measuring association between cognitive barriers
and pain intensity probably would not vary much.
Unfortunately, none of the studies found tried to differ-
entiate the direct and indirect impact of cognitive factors
on pain intensity.
2. Affective barriers. By affective patient-related barriers to
cancer pain management in this study, we mean any kind
of emotional changes studied among cancer patients under
pain treatment. There are a few things that we nd
interesting with respect to affective barriers to cancer pain
management. Firstly, despite the fact that cancer pain pa-
tients have been earlier shown to have high prevalence of
mood disorders (55), the emotional changes were not
studied in the context of barriers to pain treatment to the
same extent as cognitive factors. There were only six sur-
veys, where affective factors were taken into account (26,
33, 37, 38, 54, 56). Secondly, contrary to cognitive barri-
ers, groups of categories, which could be covered by the
term affective barriers, were not revealed. In different
studies, different psychological, or affective, factors were
the focus of interest, e.g. anxiety (37), depression (33, 54),
mood uctuations (26, 56) and stress (37, 38). In all cases,
different measures, mostly with good psychometrical
characteristics, were used (see Table 1). Thirdly and most
interestingly, despite the absence of conceptual consensus T
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regarding affective barriers, the association between
affective and cognitive factors has consistently been dem-
onstrated in cancer patients settings. Depression, negative
mood and stress were associated with maladaptive beliefs
about pain control and concerns about the use of pain
medication (26, 37, 38, 54). Such a conclusion suggests
interdependency of attitudinal and emotional factors.
Unfortunately, a causality regarding the order of these
factors cannot be identied because of the cross-sectional
nature of the studies. To nd causality, longitudinal
or experimental studies should be performed. Earlier
conducted analyses of longitudinal studies on chronic
nonmalignant pain experience have shown that the asso-
ciation between pain intensity and depression was caused
by cognitive mediators, or, in other words, affective factors
were determined by cognitive ones (57). The previously
reported results of psychophysical, or experimental, ap-
proaches to measure the dimensions and stages of pain also
support the notion that cognitive elements are of major
importance (58). Thus, one could infer that the inuence
of cognitive factors in cancer pain management is probably
more important than the inuence of affective ones.
Nevertheless, none of the studies on patient-related bar-
riers to cancer pain management attempted to test such a
hypothesis.
The ndings regarding association between affective
factors and pain intensity in studies on barriers to cancer
pain management were in agreement with the earlier
reported results of analogical analysis in chronic nonma-
lignant pain research, where the possibility of association
between depression and pain intensity has caused con-
siderable dispute (57). In a couple of studies found, a
positive association between pain intensity and negative-
mood state and depression was demonstrated (33, 37,
56). Other researchers did not see any signicant differ-
ence in pain between those who were emotionally
stressed and those who were not (37). The inconsistency
of the results on associations between pain and emotional
distress in studies on patient-related barriers to cancer
pain management could be explained in line with the
other conclusions made in this review. Firstly, we stated
that cognitive barriers might impact pain intensity both
directly and indirectly. Secondly, we argued about the
major importance of cognitive factors if compared with
the affective ones. Thus, affective barriers determined by
the cognitive ones could probably inuence the intensity
of perceived pain directly and also through pain com-
munication or pain medication adherence. Therefore, to
have a more stable picture regarding associations between
pain intensity and affective status of cancer patients,
researchers should consider patients pain communication
and medication adherence patterns as well. However,
such a research perspective was not discussed in any of
the studies on patient-related barriers to cancer pain
management.
3. Sensory barriers. One of the major challenges in treating
pain with opioids is to achieve the best obtainable balance
between analgesia and side effects. Side effects of opioids in
this review are presented as sensory patient-related barri-
ers to cancer pain management. A few studies on barriers
to cancer pain therapy showed that approximately 20
75% of the respondents reported that they were bothered
by side effects of pain treatment (46, 49). The only study
on relationships between side effects and cognitive, as well
as affective barriers, revealed that there was no correlation
between severity of side effects and attitudinal barriers; but
there was a positive correlation between severity of side
effects and depression (33). Severity of side effects in this
study was assessed with a validated side effects check list.
Relationship between severity of pain and severity of side
effects in the studies on patient-related barriers to cancer
pain management was not investigated.
Insufcient patient-physician communication as the barrier to
cancer pain management
One of the most important barriers to cancer pain man-
agement is the lack of patients communication of their
pain experience to health-care providers (9). By pain
communication in this paper we mean actual behaviour,
or patients and health-care professionals interactions,
concerning pain and pain treatment. Patients hesitation or
unwillingness to communicate pain was classied as a
cognitive barrier, and was covered by the category of
concerns about pain communication. The studies in which
the associations between patients cognitive barriers and
their hesitation to communicate pain were found (19, 27,
29, 30, 43) are mentioned in the rst section of this paper.
Table 2 summarises the main ndings of the studies,
regarding actual cancer patients pain communication.
More than half of the studies have focused on the
quality of pain communication between cancer patients
and physicians (50, 52, 53, 5962). In most of these
studies, it was shown that the quality of communication
was not satisfactory in some key areas. Patients wanted to
be more active in the process of information exchange by
expressing their own needs; they also wanted their phy-
sicians to have better communication skills, to be open and
honest, and to address patients fears regarding cancer pain
management. In only one study patients describe their
interaction with physicians in positive terms: trust, respect,
open and honest communication, support, education and
condence in the pain treatment plan (53).
The studies where the quantitative approach (e.g.
questionnaires surveys and structured interviews) was
used focused on the extent of pain communication (45, 46,
46, 48, 49, 63). The results differed, depending on the
questions asked or the questionnaires used. For example,
93100% of patients talked with their providers about pain
(46, 49); 63% discussed the symptoms, including pain
(48); 47% did not talk to anyone about pain-relieving
medication within the past 24 hours (45) or waited for
spontaneous decrease of pain intensity before asking for
medications (63). In one of the studies a positive associa-
tion between more extensive communication and more
adequate attitudes toward symptom management was
found (48).
Unfortunately, none of the studies attempted to look at
the relationship between pain communication and severity
of side effects, emotional status or pain intensity as re-
ported by cancer patients. Such a shortage of research
might be partially explained by the lack of validated
instruments to assess pain communication. In none of the
above mentioned quantitative studies was validity of used
measures discussed. Hopefully, the recent validation report
of an instrument to assess the quality of the patients
perceived communication with their physicians in the
presence of chronic pain (64) will be used as an opportu-
nity to study the area in more detail.
Inadequate medication adherence as the barrier to cancer pain
management
Adherence is dened as the self-administration of medi-
cations in prescribed amounts and at prescribed intervals.
It is monitored by using patients self-reports, tablets
counts or laboratory methods (65). Thus, in this paper, by
inadequate adherence we mean overuse, partial use or
nonuse of prescribed opioid analgesics, as well as use of
these medications at random intervals. More specically,
we talk about self-reported adherence, as in all the studies
on patients barriers to pain management found only pa-
tients reports were used to assess the compliance with
analgesic regimen.
It is debatable what measures assess self-reported
medication adherence adequately. In the earlier reported
literature reviews on medication adherence, medication
diaries and adherence questionnaires were suggested as the
preferable measures for self-reported medication use (66,
67). Thus, in our analysis we included: (i) surveys where
adherence questionnaires were applied (41, 46), (ii) studies
where adherence was assessed with medication diaries (62,
70, 71) and (iii) qualitative studies where semi-structured
interviews with cancer patients were performed (53, 60).
Studies on reported hesitation to use medication, which
might have been interpreted by some authors as a measure
of adherence, were not included in the section about
adherence in our paper. Additionally, in the section about
adherence, we did not analyse studies where adequacy of
analgesic use was calculated (25, 26, 28, 29, 3133, 39)
(see Table 1). Adequacy of analgesic treatment in these
studies was measured with the Pain Management Index
(PMI) (68). PMI is calculated by subtracting the value of
pain intensity (higher values represent more intensive
pain) from the value of used analgesics (higher values
represent stronger analgesics). Negative scores of PMI
indicate inadequate analgesic treatment and scores of 0
and greater indicate acceptable analgesia. Therefore, PMI
does not specically identify whether the inadequacy of
analgesic use reects the patients willingness to report
pain, their physicians prescriptions or the patients
adherence and cannot be interpreted as a pure measure
of adherence (69). Other aspects of the above mentioned
studies were analysed in rst section of this paper.
Table 3 summarises the main ndings regarding pain
medication adherence from the included studies. The
magnitude of adherence in different studies was found to
vary. From 50% to 91% of respondents adhered to
scheduled regimens of opioid medication (41, 60, 70).
From 22% to 27% of respondents were adherent for
medication on an as needed basis (70), and not <58% of
respondents adhered to all opioid prescriptions (46). The
results of the studies looking for an association between
adherence and cognitive barriers were consistent. In all
these studies, the association between more greatly ex-
pressed attitudinal barriers and less optimal adherence was
shown (21, 41, 62, 71). The results of the studies exam-
ining the relationship between adherence and sensory
barriers to cancer pain management were also consistent:
prior experience of side effects or severe current side effects
prevented cancer patients from analgesic use, despite
moderate to severe pain (46, 53, 62). In addition, a positive
association between the quality of adherence and quality
of patientphysician communication was demonstrated
consistently (62, 71). This consistency supports the notion
that patients prioritise symptoms (72) and that the out-
come of the treatment is better if patients priorities are
considered (73). Unfortunately, no studies reported the
magnitude of association between analgesic adherence and
reported pain intensity.
One may notice that the number of studies on adher-
ence included in our analysis was not very large (seven
from 37). Additionally, not all surveys that were included
met the highest quality criteria. For example, different
researchers used different adherence questionnaires and
none of them was validated (see Table 3). Thus, in line
with the results of this review in pain communication re-
search, we believe that the existence of validated instru-
ments to measure pain medication adherence would also
result in more fruitful research activities. On the other
hand, we understand that the task to construct a measure
for analgesic adherence in case of cancer (especially
breakthrough) pain is a challenging one.
Limitations
This review has few limitations.
(1) Not all the studies included in the analysis had com-
mon categories for analysed factors (this especially applies
to the studies about affective barriers). Some of the studies
used quite different measures to assess the same factors
(this especially applies to the studies about pain commu-
nication and medication adherence). Besides that, the
quality of several quantitative studies could not be care-
fully assessed because the psychometrical characteristics of
the used instruments were not reported. Thus, our attempt
to compare the results, at least in some of the cases, might
be questionable. However, there are several arguments for
the approach used in this exploratory review. Regarding
the comparisons of ndings from the studies on affective
factors, which were categorised differently, we argue that
our approach was supported by post hoc analysis. Results
from all the studies looking for the relationship between
cognitive and affective factors were similar. Regarding the
different measures, we could argue that at least with re-
spect to adherence we made an attempt to unify the out-
come measure. Only results on adherence, assessed with
questionnaires, medication diaries, and semi-structured
interviews were included in the analysis. Finally, with this
exploratory review, we aimed to indicate what might be
relevant to study in more depth (74, p. 47), and the lack of
conceptual consensus or shortage of validated instruments
were revealed to be those elements that we have to pay
more attention.
(2) In some of the quantitative studies, where the same
instruments assessing patients barriers to cancer pain
management were used, the differences between the bar-
riers of western and nonwestern patients were obvious,
e.g. the percentage of respondents reporting cognitive
barriers was considerably smaller in Puerto Rico than in
the USA (25, 32). Thus, social and/or cultural differences
might be important when trying to understand patient-
related barriers to cancer pain management. However, we
did not analyse the above mentioned differences in more
detail. The argument for this was the fact that the most of
the studies in this review were from the western culture,
including Scandinavian countries, where individuals val-
ues are prioritised and where the results are going to be
used.
Conclusions
The analysis of the current knowledge about patient-re-
lated barriers to cancer pain management, involving the
ideas of the theory of multidimensional or total pain, have
given rise to some suggestions for further research in this
area. Firstly, cognitive barriers might negatively affect pa-
tients pain communication and adherence to analgesic
regimen; even in the case of good adherence to analgesics,
these barriers might inuence pain treatment by causing
poor outcomes. However, further research is needed to
specify the role of the impact of cognitive barriers on pain
relief, pain communication and medication adherence. The
same might be stated about the research on affective bar-
riers. Furthermore, the importance of cognitive factors vs.
affective ones could also be investigated in more detail.
Secondly, it was shown that sensory barriers or side effects
of analgesics consistently prevented cancer patients from
optimal adherence to a prescribed medication regimen.
However, there were no studies assessing the effects of
sensory factors to patients pain communication, emotional
status or their reports on pain intensity. Thus, a deeper look
at the impact of side effects for the quality of cancer pain
management is recommended for the research agenda.
Finally, well-dened denitions of patients pain commu-
nication and their adherence to analgesic regimen, as well
as validated instruments to assess these latter factors would
be helpful in all the above mentioned research directions.
Author contributions
Ramune Jacobsen was responsible for the study concep-
tion, methods, data collection and analysis and drafting of
manuscript. Claus Mldrup, Lona Christrup and Per Sjg-
ren participated in the development of the design, methods
and in critical revisions of the manuscript for important
intellectual content.
Funding
The study is a part of a PhD project at The Faculty of
Pharmaceutical Sciences, University of Copenhagen, partly
supported by Nycomed A/S, Denmark.
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Patient-Related Barriers To Cancer Pain Management

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THEORETI CAL STUDI ES doi: 10.1111/j.1471-6712.2008.00601.

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