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Journal of Pain and Symptom Management

Original Article

Mediating Effect of Family Caregivers Hesitancy to Use Analgesics

on Homecare Cancer Patients Analgesic Adherence
Bih-O. Lee, PhD, RN, Yi Liu, PhD, RN, Yi-Hsien Wang, PhD, Hsin-Tien Hsu, PhD, RN, Chien-Liang Chen, PhD,
Pi-Ling Chou, PhD, RN, and Wen-Chung Hsu, PhD candidate
Department of Nursing (B.-O.L.), Chang Gung University of Science and Technology, Chia-Yi Campus; School of Nursing (Y.L., H.-T.H., P.L.C.), College of Nursing; Research Center for Nonlinear Analysis & Optimization (Y.-H.W.), Kaohsiung Medical University, Kaohsiung;
Department of Physical Therapy (C.-L.C.), I-Shou University, Kaohsiung; Institute of Human Resource Management (W.-C.H.), National
Sun Yat-sen University, Kaohsiung, Taiwan

Context. Family caregivers play an increasingly critical role in cancer patients symptom management as the number of
cancer patients receiving home care grows. However, there is a lack of research measuring the impact of the family caregivers
hesitancy to use analgesics on analgesic adherence and the resulting influence on patient pain intensity.
Objectives. To examine whether family caregivers hesitancy to use analgesics is a mediator that influences patient
adherence and investigate how analgesic regimen adherence affects pain intensity.
Methods. This study used a cross-sectional and descriptive design. One hundred seventy-six patient-family caregiver dyads
(N 352) were recruited from one local hospital in southern Taiwan. Instruments included the Short Version of the Barriers
Questionnaire-Taiwan, the Morisky Medication Adherence Measure-Taiwan, the Brief Pain Inventory-Chinese, and
demographic and illness questionnaires. A one-way analysis of variance and post hoc comparisons were performed to assess
the influence of analgesic regimen adherence on pain intensity. Sobel tests were used to examine mediating effects.
Results. Family caregivers hesitancy to use analgesics was a significant mediator between patient barriers to use analgesics
and patient analgesic regimen adherence (P < 0.0001). Patients with low and moderate adherence levels reported
significantly higher levels of pain severity (F 3.83, P < 0.05).
Conclusion. This study showed that family caregivers hesitancy to use analgesics was a significant mediator associated with
their hesitancy to use analgesics and the patients analgesic adherence. It is important for health care providers to consider
family caregivers hesitancy to use analgesics when attempting to improve adherence to pain management regimens in clinical
practice. J Pain Symptom Manage 2015;-:-e-. 2015 American Academy of Hospice and Palliative Medicine. Published by Elsevier
Inc. All rights reserved.
Key Words
Cancer pain, family caregivers, hesitancy to use analgesics, analgesics adherence, pain management

Insufficient pain control in cancer patients remains
a significant challenge.1e3 The effective management
of cancer pain relies mainly on adequate adherence
to analgesic regimens.4,5 The number of cancer patients receiving care at home in Taiwan and Western
countries is increasing rapidly because of limitations

Address correspondence to: Pi-Ling Chou, PhD, RN, School of

Nursing, College of Nursing, Kaohsiung Medical University,
100, Shih-Chuan 1st Road, Kaohsiung 80708, Taiwan, Republic of China. E-mail: piling.chou@gmail.com
2015 American Academy of Hospice and Palliative Medicine.
Published by Elsevier Inc. All rights reserved.

in health insurance benefits.6,7 Therefore, family caregivers are now playing a more critical role in cancer
outpatients symptom management.7,8 Recent studies
have shown that family caregivers rising concerns
and hesitancy regarding the use of analgesics is significantly correlated with the effectiveness of pain management in cancer patients.9 Indeed, in clinical

Accepted for publication: July 6, 2015.

0885-3924/$ - see front matter


Lee et al.

settings, patients and family caregivers hesitancy to

use analgesics is the main obstacle to optimal pain
control. Therefore, it is important to understand
why patients and family caregivers are reluctant to
use analgesics in cancer pain management. As well,
it is important for clinical practice to understand the
mechanisms behind family caregivers hesitancy to
use analgesics for patients and how caregivers
encourage patients to continue analgesic use.
A previous study regarding analgesic adherence has
shown that primary family caregivers play an important role in the promotion of analgesic regimen
adherence in patients suffering from chronic diseases.10 Family caregivers often have very intimate
and closely bonded relationships with patients.11 In
addition, they monitor patient pain severity, report
to medical professionals, and help with the administration of analgesics.12e14 Lin et al.15 investigated the
opinions of hospice patients family caregivers
regarding analgesic use. Approximately 15% of caregivers were reluctant to report patients pain, and
30% had been hesitant to give analgesics to patients
within the preceding month. In comparison with family caregivers who were not hesitant to use analgesics,
patients of those family caregivers who expressed hesitancy reported relatively less adequate pain control.15
Inadequate adherence to analgesic regimens is
often the result of myths regarding analgesics.16e18 Patients pain intensity and the pain management index
have been shown to be significantly correlated to analgesic dose.19e21 Therefore, inadequate analgesic doses
have been suggested to lead to an increase in average
pain intensity.4 In a study wherein patients were
divided into two groups according to whether they
adhered to medication regimens adequately, results
showed that patients in the adequate-adherence group
experienced significantly lower levels of sustained
pain relative to that reported by the inadequateadherence group.22 Based on the aforementioned
research, adherence to analgesic regimens has a significant impact on pain intensity.
Studies on the relationship between family caregivers
hesitancy to use analgesics and cancer patients analgesic regimen adherence, the impact this relationship
has on pain intensity, and how the mechanism underlying family caregivers hesitancy to use analgesics influences patients adherence to the analgesics regimen
are scarce. Most previous studies have focused on family
caregivers perceptions regarding cancer patients pain,
barriers to the use of analgesics, and the relationship between these barriers and pain intensity.23e25 To date,
few studies have focused on patients hesitancy as an indicator of adherence to analgesics. In addition, there is
a lack of large-scale studies exploring correlations between barriers to analgesic use by home care patients



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family caregivers and patient adherence to an analgesic

regimen. To improve adherence to pain management
regimens, health providers should be aware of both cancer patients and primary caregivers concerns surrounding analgesics and provide individualized
education regarding pain medication.
Two hypotheses were proposed in this study: 1) family caregivers hesitancy to use analgesics could be a
significant mediator between barriers to use analgesics
and patient analgesic regimen adherence and 2) family caregivers who were more hesitant to use analgesics
would weaken patients analgesic regimen adherence,
which would increase pain intensity. The objectives
were to investigate whether family caregivers hesitancy to use analgesics is a mediator that influences
patients adherence and to examine how analgesic
regimen adherence affects pain intensity.

A cross-sectional and descriptive design was used. A
convenience sample was recruited from an outpatient oncology clinic at a teaching hospital in Taiwan.
Inclusion criteria were as follows: 1) a pathological
diagnosis of cancer, 2) at least 20 years old, 3) could
communicate in Mandarin or Taiwanese, 4) experienced average pain >0 on the Brief Pain InventoryChinese version (BPI-C), 5) had been taking oral
analgesics for more than one week, and 6) lived
with the family. Patients were excluded if they were
cognitively impaired or only used fentanyl patches
as we could not calculate adherence.
Inclusion criteria for family caregivers were as follows: 1) at least 20 years old, 2) could communicate
in Mandarin or Taiwanese, 3) lived with the patient,
and 4) not foreign workers or certified care workers.

A survey questionnaire including three instruments
and demographic and disease information sheets was
used in this study.
Short Version of the Barriers Questionnaire-Taiwan. The
original Barriers Questionnaire-Taiwan (BQT) was
translated and adapted from the Barriers Questionnaire by Lin and Ward26,27 and specifically modified
for Taiwanese cancer patients; it was used to measure
patients and families hesitancy toward analgesic use
in previous studies.11,28,29 The original BQT includes
nine subscales: 1) addiction, 2) disease progression,
3) pain tolerance, 4) fatalism, 5) religious fatalism,
6) p.r.n. (pro re nata or as needed), 7) concern
regarding side effects, 8) fear of distracting physicians,
and 9) a desire to be good.



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Family Caregivers Hesitancy to Use Analgesics

Chou et al.30 adapted the Short Version of the BQT

(S-BQT) from the original BQT by extracting one item
from each original BQT subscale; this nine-item S-BQT
has demonstrated good reliability and validity. Patients
with higher S-BQT scores were more hesitant to report
their pain and take analgesics relative to patients with
lower scores. Total scores range from 0 to 5, with higher
scores indicating a greater degree of hesitancy to use analgesics. The test-retest reliability for this study was 0.85
and was evaluated between pre- and post-tests over a
two-week interval within a sample of 30 family caregivers.
Cronbachs a was 0.87 as tested by the same 30 caregivers.
Taiwanese Version of the Morisky Medication Adherence
Measure. The original version of the Morisky Medication Adherence Measure (MMAM)31 is a structured
four-item instrument to measure compliance with prescribed analgesic regimens. The rationale underlying
this measure is that errors of omission can occur for
any or all the following reasons: forgetfulness, carelessness, ceasing to take the drug when symptoms improve,
and initiation of the drug regimen when symptoms
worsen. The sum of the yes responses provides a composite measure of nonadherence. Total scores range
from 0 to 4, with higher scores indicating higher levels
of adherence. High, moderate, and low adherence
levels were defined via total scores of 4, 2e3, and
0e1, respectively. The validity was supported by good
known groups, construct, and criterion-related validities.17 The internal consistency for the Taiwanese
version of MMAM (MMAM-T) was 0.76 in this study.
Chinese Version of the Brief Pain Inventory. The BPI-C
was used to measure pain intensity and the degree to
which pain interfered with daily activities. The BPI-C
comprises four single-item measures of pain intensity
over the past 24 hours: worst pain, least pain, average
pain, and current pain. Participants circle the number
that best describes each type of pain on a scale of 0 (no
pain) to 10 (the worst pain I can imagine). Cronbachs
a for pain severity was 0.89.32 The reliability and validity
of this measure have been established in a number of
research samples with cancer pain.11,33,34
Demographic and Disease Information Questionnaires. A
demographic information sheet was used to record
basic patient information, such as age, sex, education
level, marital status, religious belief, performance status,
and occupation. A disease information sheet was used
to record the patients diagnosis, the presence/absence
of metastases, types of analgesics, and treatment status.

Ethical Considerations
Ethical approval for the study was granted by the
Human Subject Committee of a local hospital in

southern Taiwan. All participants provided written

informed consent.

Participants who met the inclusion criteria were
referred to the primary investigator (PI) by their physicians. The PI approached patient-family dyads to
explain the study and obtain informed consent. Data
collection was conducted in the outpatient department. Patients and caregivers completed questionnaires either before or after outpatient department
consultations in a separate room to avoid crosscontamination of responses. Patients filled out the
S-BQT, MMAM-T, and BPI-C questionnaires. Family
caregivers completed the S-BQT only. Demographic
and illness data were collected by the PI. If the patient
appeared distressed or verbalized any distress, the
interviewer ceased the interview until the patients
symptoms were relieved.

Statistical Analysis
Descriptive statistics were used to assess the distribution of patients and family caregivers demographic
data and family caregivers S-BQT scores. Associations
between patients and family caregivers S-BQT scores
and patients pain intensity and family caregivers
S-BQT scores were determined using Pearsons
product-moment correlation coefficient. One-way analyses of variance (ANOVAs) and post hoc comparisons
were performed to assess the effect of analgesic
regimen adherence on pain intensity. A regression
model, the Sobel test, was used to examine the mediating effects of family caregivers hesitancy to use analgesics. The Sobel test of mediating effects is an
extension of the four regression equations proposed
by Baron and Kenny35 and Preacher and Hayes.36
The mediation equation also controlled for covariates
in the equation.37 In this study, the Sobel tests were
performed using SAS, version 9.1 (SAS Institute,
Inc., Cary, NC) to assess the mediating role of caregivers hesitancy to use analgesics. Other statistical
procedures were performed using SPSS, version 18.0
(SPSS, Inc., Chicago, IL). The significance level was
set at 0.05; all P-values were two-tailed.

Patients and family caregivers demographic and
disease information are presented in Table 1.

Patients and Family Caregivers S-BQT Scores

Family caregivers mean S-BQT score was 1.97
(SD .94). The three subscales with the highest
mean scores were disease progression, p.r.n., and
tolerance. The highest subscale score was for disease

Lee et al.

Table 1
Demographic and Disease Information on Patients and
Their Family Caregivers (N 352)

(n 176)


progression, with a mean score of 2.90 (SD 1.52).

The lowest subscale score was for fatalism, with a
mean score of 1.05 (SD .92). The patients mean
S-BQT score was significantly lower than that of the
family caregivers. Details are presented in Table 2.

Relationships Between Patients S-BQT Scores, Family

Caregivers S-BQT Scores, and Pain Intensity
Family caregivers S-BQT scores were significantly
correlated with patients S-BQT scores (r 0.53,
P < 0.001). In addition, family caregivers S-BQT


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Table 2
S-BQT Scores of Patients and Their Family Caregivers
(N 352)

(n 176)

Age, yrs
59.21 (SD 15.58) 44.98 (13.11)
Education, yrs
8.08 (SD 4.54) 10.93 (3.94)
Karnofsky Performance Status 82.65 (SD 12.63)
Gender, n (%)
70 (40)
86 (49)
106 (60)
90 (51)
Marital status, n (%)
144 (82)
130 (74)
32 (18)
46 (26)
Relationship to patient, n (%)
85 (48)
67 (38)
12 (7)
5 (3)
7 (4)
Diagnosis, n (%)
Nasopharyngeal cancer
37 (21)
Liver cancer
35 (20)
Breast cancer
33 (19)
Oral/buccal cancer
30 (17)
Lung cancer
9 (5)
Cervical cancer
9 (5)
Colorectal cancer
7 (4)
Various others
16 (9)
Metastasis, n (%)
132 (75)
44 (25)
Medication used, n (%)
Nonsteroidal anti123 (70)
inflammatory drug
74 (42)
46 (26)
40 (23)
Adjuvant medication (e.g.,
55 (31)
Treatment status, n (%)
Only chemotherapy
30 (17)
Only radiotherapy
67 (39)
Chemotherapy with
23 (13)
(chemoradiation therapy)
57 (32)
Pain scores
5.26 (SD 2.22)
3.02 (SD 1.67)
1.81 (SD 1.91)
2.49 (SD 1.97)


Distract physicians
Religious fatalism
Side effects
Desire to be good












S-BQT Short Version of the Barriers Questionnaire-Taiwan; p.r.n. pro re

nata or as needed.

scores were significantly correlated with the patients

average and worst pain intensity (r 0.27, P < 0.001
and r 0.29, P < 0.001, respectively). The results indicated that family caregivers who reported higher
S-BQT scores also reported greater pain intensity.
Details are shown in Table 3.

Determining the Mediating Role of Family Caregivers

Hesitancy to Use Analgesics in Patients Analgesic
Regimen Adherence and Barriers to the Use of
We performed Pearsons product-moment correlation analyses to determine correlations between age,
education level, Karnofsky Performance Status, pain
intensity, and patients analgesic regimen adherence.
In addition, we used independent t-tests and ANOVAs
to determine differences in patients analgesic
regimen adherence according to gender, treatment
status, metastasis status, and morphine and fentanyl
use. Adherence had a normal distribution, and the results showed that patients analgesic regimen adherence differed significantly according to gender
(t 2.40, P 0.02) and the amount of morphine
used (t 2.06, P 0.04). Thus, in the four-step mediation regression analysis, the variables of gender and
morphine use were controlled.
Table 3
Relationship Between Patient S-BQT Score, Family
Caregiver S-BQT Score, and Pain (N 352)

Patient S-BQT
Family caregiver S-BQT
Mean pain
Worst pain










S-BQT Short Version of the Barriers Questionnaire-Taiwan.

All P < 0.01 (two-tailed test).
Mean pain intensity (worst pain average pain least pain pain now/4).



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Family Caregivers Hesitancy to Use Analgesics

The Sobel tests showed that family caregivers hesitancy to use analgesics was a significant mediator
between patients analgesic regimen adherence and
barriers to analgesics use (P < 0.0001) (Table 4). An
explanation for this may be that family caregivers hesitancy to use analgesics is an underlying and important
factor that influences patients hesitancy to use analgesics, especially to predict poorer patient analgesic
regimen adherence.

Relationship Between Analgesic Regimen Adherence

and Pain Intensity
Levenes tests indicated that the ANOVA assumption was not violated, F(2, 86) 0.161, P 0.92. Patients with lower adherence scores (0e1) reported
pain of a significantly greater severity than did patients
with moderate2,3 and higher4 adherence scores. The
details are shown in Table 5.

To our knowledge, this is the first study that examined the mechanism underlying family caregivers hesitancy to use analgesics with regard to patients
analgesics adherence. Our study has revealed that
family caregivers hesitancy to use analgesics was
moderately correlated with patients hesitancy to use
analgesics. Family caregivers hesitancy to use analgesics was a significant mediator between patients analgesic regimen adherence and reluctance to use
analgesics. In addition, patients with lower levels of
analgesic regimen adherence experienced more
intense pain.
Family caregivers and patients mean S-BQT scores
were correlated. Family caregivers mean S-BQT score
was 1.97 (SD .94), indicating that it may be quite
common for Taiwanese cancer patients family caregivers to experience a certain degree of hesitation
with respect to taking analgesics. In this study, the first
three barriers to analgesic use, according to score,

were disease progression (score 2.90), p.r.n

(score 2.66), and tolerance (score 2.62). This
finding is consistent with results from previous
studies.15,28 However, the family caregivers mean
S-BQT score in this study was higher than those
observed in studies conducted by Letizia et al.9 and
Oliver et al.38 in Western countries.27 A meta-analysis
was conducted recently to determine the differences
between Western and Asian patients perceptions of
analgesics; results showed that in 22 studies that
used Wards Barriers Questionnaire, Asian patients
mean barrier scores were significantly higher than
were those of Western patients, particularly with
respect to disease progression, tolerance, distracting
the physician, and fatalism.39 Two other Western
studies suggested that cancer patients greatest concerns were opioid-related side effects, fears of addiction, and the belief that pain represented disease
There are several possible explanations for the higher mean hesitancy found in Asian family caregivers
relative to those of Western countries. First, Asian cancer patients family caregivers are more concerned
with pain being a representation of disease progression. They did not understand that pain could be
caused by tumor compression or the side effects of
chemotherapy or radiation therapy, or that such
discomfort could be relieved or disappear with the
conclusion of treatment. Second, their concern
regarding disease progression may result from the
Asian cultural characteristic of concealing cancer patients prognoses and survival rates.39 Another situation unique to Taiwan is that of a tendency to ignore
prescribed dosages and instructions provided by doctors and to restrict analgesic use to occasions in which
pain is actually present. Moreover, caregivers also
worried that analgesics would lose effectiveness if
taken too early and felt that they should not be taken
for mild pain.30 Asian cancer patients and their families did not understand different kinds of analgesics,
uses, or tolerance; they further did not understand

Table 4
Determining the Mediating Role of Family Caregiver Hesitancy to Use Analgesics on Patients Hesitancy to Use Analgesics
and Analgesic Adherence (N 352)
Standard b
1. PS barriers (independent)
2. FC barriers (mediator) /
3. PS barriers (independent)
4. PS barriers (independent)

/ FC barriers (mediator)
adherence (dependent)
/ adherence (dependent)
/ adherence (dependent) with mediator




Test Statistic
Mediation results



Standard b standardized beta coefficient; PS barriers patient S-BQT score; FC barriers family caregiver S-BQT Score; Adherence analgesics adherence.
P-value at 0.05 level.
Steps 1e4 controls: patient gender (men vs. women) and morphine used (yes vs. no).

Lee et al.

Table 5
Relationship of Analgesics Adherence, Pain Intensity
(N 352)
Mean (SD)
Adherence Level

Low adherence
Moderate adherenceb
High adherencec

n (%)

Mean Pain

78 (43)
91 (50)
13 (7)

2.92 (1.50)
2.73 (1.62)
1.60 (1.42)





Worst Pain

Low adherence
Moderate adherenceb
High adherencec
Scheffe post hoc:

a b

78 (43)
91 (50)
13 (7)

5.13 (2.26)
4.70 (2.39)
3.08 (2.39)

> c.

that tolerance could be overcome with dose adjustment. The notion of restricting analgesic use to an
as-needed basis to avoid a lack of available drugs in
the future often led family caregivers to encourage patients to endue the pain; this prevented patients from
using the analgesics as prescribed. These concerns
affected Taiwanese patients compliance behaviors
with respect to analgesics and caused them to experience more prolonged pain of greater intensity. The
concept of pain endurance and a lack of appreciation
of the possibility of dose adjustment have created significant obstacles to the use of analgesics for the people of Taiwan.
In this study, family caregivers hesitancy to use analgesics significantly predicted patients analgesic
regimen adherence (b 0.70, P < 0.0001) and was
a significant mediating factor affecting the concerns
and compliance behaviors of patients with respect to
analgesic use. One study showed that pain intensity
and interference were increased in patients with lower
levels of analgesic regimen adherence.41 Cancer patients analgesic regimen adherence is often inadequate, which has been shown to result in poor pain
management.4 A study of 92 cancer outpatients in
Taiwan found that 84.6% and 30.6% of patients
adhered to opioid regimens on an around-the-clock
and p.r.n. basis, respectively.18 Another large study in
the U.S. investigated oncology outpatients analgesic
regimen adherence and found that only 53% of
patients had complete compliance with physicians
prescriptions.42 In our study, 43%, 50%, and 7% of patients reported low (MMAM-T score: 0e1), moderate
(MMAM-T score: 2e3), and high (MMAM-T score: 4)
levels of analgesic regimen adherence, respectively.
This finding is very similar to that of a previous study
conducted in Taiwan.17
The promotion of cancer patients analgesic
regimen adherence is an important issue with respect
to improving their pain management. Family caregivers cannot be ignored in the promotion of patient
analgesic regimen compliance involving pain



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management in clinical settings.43 The education of

patients and their family caregivers with respect to
compliance with physicians analgesic prescriptions
for increased pain control could proceed in several
ways: 1) pain assessment should be comprehensive
and tailored to each individual and family, 2) patients
and families should be empowered to assess and
manage pain themselves, 3) patients and families
should be supported and advised about analgesic
self-management and their concerns surrounding
analgesic use,44 and 4) regardless, the self-efficacy of
patients and their families with respect to analgesic
use should be improved.14
The results of this study should be interpreted with
caution because of a number of limitations. Middleaged cancer outpatients were recruited to participate
in the study; therefore, the inferences made in the
study may not apply to elderly patient groups or
weak hospitalized patients. In addition, we did not
consider whether family caregivers administered the
analgesics to patients. To our knowledge, this study
was the first to apply the S-BQT in family caregivers;
the sensitivity and validity of the S-BQT can be verified in future studies. A longitudinal design and
longer follow-up period are required to allow understanding of the way in which patients analgesics
regimen adherence changes with pain intensity over

Implications for Clinical Practice

Family caregivers often assist patients in communicating their symptoms and needs to medical professionals during outpatient visits, and it is common for
family caregivers to take on the role of administering
analgesics and making medical decisions if patients
are physically weak.45 Family caregivers also help patients overcome obstacles to using analgesics and identifying the adverse effects of the medications.46 This
can result in highly complicated situations when patients are in a homecare setting. Some qualitative
studies have shown that caregivers are often unable
to assess pain, are overly concerned with side effects,
are inexperienced in administering analgesics, and
found communicating with medical professionals
difficult.47 Because the family caregivers role in cancer pain management at home is crucial, helping
them develop sufficient self-confidence and the capability to effectively assist professionals in cancer pain
management should include establishing trusting relationships between all parties involved (patients, family
caregivers, and medical professionals).48 Educating
family caregivers with respect to communicating with
health professionals, improving analgesic regimen
adherence, and the importance of maintaining the
prescribed dosage may provide patients with more



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Family Caregivers Hesitancy to Use Analgesics

confidence in coping with pain management at

home.6 To achieve optimum pain control, medical
professionals should endeavor to understand and
address the needs of families during the course of
the illness.

not a doctor, and I dont know if I helped her go faster or

slower. J Pain Symptom Manage 2013;46:846e858.
9. Letizia M, Creech S, Norton E, Shanahan M, Hedges L.
Barriers to caregiver administration of pain medication in
hospice care. J Pain Symptom Manage 2004;27:114e124.
10. Osterberg L, Blaschke T. Adherence to medication.
N Engl J Med 2005;353:487e497.

This study revealed that family caregivers hesitancy
to use analgesics is a mediator between patients hesitancy to using analgesics and their analgesics adherence. This study also demonstrated that patients with
lower levels of analgesic regimen adherence experienced more intense pain. Family caregivers are an
important part of cancer pain management and
should be part of all patient education. Therefore,
the impact of the family on the patients analgesic
regimen adherence and the quality of pain management should not be ignored.

Disclosures and Acknowledgments

This research received no specific funding/grant
from any funding agency in the public, commercial,
or not-for-profit sectors. The authors declare no conflicts of interests.

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