Revisiting Patient-Related Barriers to Cancer Pain Management in the Context of the US Opioid Crisis

Kristine Kwekkeboom; Ronald C. Serlin; Sandra E. Ward; Thomas W. LeBlanc; Adeboye Ogunseitan; James Cleary


Pain. 2021;162(6):1840-1847. 

In This Article

Abstract and Introduction


Patient fear of addiction is a well-documented barrier to the use of analgesic medications for cancer pain control. Over the past 2 decades in the United States, an "opioid crisis" has arisen, accompanied by risk messages delivered through news outlets, public health education, and patient–provider communication. The purpose of this study was to determine if patient-related barriers to cancer pain management–specifically, fears of addiction–and related pain outcomes (pain severity, pain interference with daily life, and adequacy of pain management) have worsened over the last 20 years. A sample of 157 outpatients with active recurrent or active metastatic cancer completed the Barriers Questionnaire-II (BQ-II) and measures of pain and analgesic use. We identified 7 comparison studies published between 2002 and 2020 that reported patient-related barriers using the BQ-II. Significant linear relationships were found between later year of publication and greater fear of addiction (harmful effect subscale score, B = 0.0350, R 2 = 0.0347, F1,637 = 23.19, P < 0.0001) and between year of publication and more pain management barriers overall (total BQ-II score, B = 0.039, R 2 = 0.065, F1,923 = 73.79, P < 0.0001). Relationships between BQ-II scores (harmful effect and total) and pain outcomes did not change over time. Despite worsening in patient-related barriers, the proportion of patients with adequate vs inadequate analgesic use did not differ over time. Notably, 40% of participants reported inadequate analgesic use, a statistic that has not improved in 20 years. Additional research is necessary to clarify factors contributing to changing beliefs. Findings indicate a continuing need for clinical and possibly system/policy-level interventions to support adequate cancer pain management.


Pain is among the most feared consequences of cancer. A recent meta-analysis identified pain prevalence rates of 55% during cancer treatment and 66% in advanced, metastatic, and terminal illness.[43] Among the 17 million US residents living after cancer therapy, 31% to 35% have chronic pain.[21,37] At all stages of disease, 38% report moderate to severe pain.[43] Consequences of unrelieved pain include functional limitations,[24] diminished physical health, poor quality of life, and emergency department visits and hospitalizations for pain crises with their associated costs.[36]

Opioid analgesics are a cornerstone in cancer pain management, particularly among persons with advanced or metastatic disease.[32] Over 30 years, evidence-based guidelines, including current guidelines, have recommended opioids for moderate and severe cancer pain.[30,52] Approximately 90% of persons with moderate to severe pain can achieve mild to no pain within 2 weeks of opioid initiation and do so with few intolerable or serious adverse events.[51] However, recent publications have urged clinicians to practice risk management when prescribing opioids for cancer pain.[34]

Fear of addiction has been documented as a patient-related barrier to cancer pain management for nearly 3 decades.[7,11,13,19,22,28,35,39,45,47–49] Much of this research involved use of a questionnaire (the Barriers Questionnaire) that measures beliefs about analgesic medications with respect to harmful effects (eg, addiction), physiologic effects (eg, side effects), fatalism (eg, belief that cancer pain cannot be managed), and communication (eg, belief that "good" patients do not complain).[15,47] Studies consistently revealed that worry about addiction was the strongest barrier among patients and their caregivers and that these fears are linked to adequacy of analgesic use and quality of life.[23,27,40,41,46–49]

Misuse of opioid medications and related mortality over the past 2 decades has created an opioid "crisis" in the United States.[42] The Centers for Disease Control[6] describes 3 waves in overdose deaths. First, beginning in the 1990s, attention to the need for better cancer and postoperative pain management began shifting to the promotion of opioids as safe (with a low risk of addiction) and effective for chronic noncancer pain. That wave of the crisis often involved overdose deaths from prescription opioids, primarily in persons other than those for whom the opioids were prescribed. Second, by 2010, the falling price of illegal opioids, together with restricted access to prescription opioids led to a sharp increase in heroin use, triggering a second wave of overdose deaths.[31] In 2013, deaths associated with illicitly manufactured fentanyl accounted for a third wave. By 2018, opioid overdose deaths occurred at a rate 6 times higher than in 1999.[6] Widespread public health messages about the dangers of opioids may have exacerbated cancer patients' fears about using analgesic medications.

Our team assessed contemporary beliefs about analgesic use among patients with cancer. The objectives were to (1) determine if patient-related barriers to pain management have increased over the last 2 decades and (2) determine if relationships between barriers and outcomes (pain severity, pain interference with daily life, and adequacy of pain management) differ between contemporary and past studies.