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


Sample Characteristics

Sample characteristics are summarized in Table 1. Participants were largely Anglo-American (n = 145, 92%) and well educated, with 73% (n = 115) having more than a high-school education. Their mean age was 61.89 years (SD = 11.49, range 24–89). The majority had metastatic disease (n = 151, 96%) but still largely maintained good performance status, (median AKPS = 80, range 50–100). The total BQ-II score (N = 157) was M (mean) = 1.83 (SD = 0.77). Subscale scores, from highest to lowest, were harmful effects M = 2.50 (0.98), physiologic effects M = 2.17 (SD = 0.97), fatalism M = 1.11 (0.83), and communication M = 0.89 (0.98).

Forty-six participants (29%) reported never having pain because of their present disease. Among those participants who reported experiencing pain and/or using pain medications in the past week (n = 97, Table 2), the mean worst pain severity was 5.75 (SD = 2.55). Forty-one percent reported worst pain in the "severe" range and 39% reported using strong analgesics. More than half (n = 56, 58%) demonstrated adequate use of analgesics for the level of pain severity experienced. On average, participants reported mild-to-moderate pain interference with daily life (M = 3.87, SD = 2.54).

Change in Patient-related Barriers to Pain Management

We identified a total of 7 study reports that met criteria and provided data for one or more of the planned analyses (Table 3). The samples from these studies were similar to the current sample with respect to the inclusion criteria (adults, with cancer diagnosis, experiencing pain) and observed demographic and clinical characteristics. All samples included persons of both sexes, with reported mean ages of 55 to 61 years old, and a majority of the sample being Anglo-American race and having some education beyond high school. The samples were commonly comprised of a mix of persons with breast, lung, gastrointestinal, genitourinary, and gynecologic cancers.

Findings were analyzed by the publication year because most did not report the dates of recruitment and data collection. A total of 5 previous studies reported scores on the harmful effects BQ-II subscale for comparison with the current study.[4,15,23,29,40] A significant linear relationship was found between year of publication and harmful effects subscale score (B = 0.0350, R2 = 0.0347, F1,637 = 23.19, P < 0.0001). Belief that analgesics have harmful (addictive) effects increased by approximately 0.035 points per year, and a total of 0.63 points on the 0 to 5 scale since 2002. A total of 6 previous studies reported total BQ-II scores.[4,15,23,27,41,44] A significant linear relationship was found between year of publication and the BQ-II total score (B = 0.039, R 2 = 0.065, F1,923 = 73.79, P < 0.0001). Total BQ-II mean scores increased by approximately 0.039 points per year; over the 18-year span of publications, mean scores increased by 0.70 points on the 0 to 5 scale.

Relationship Between Barriers and Adequacy of Pain Management

Two of the identified studies reported the association between barriers and pain severity, one reporting correlations with the harmful effects subscale score,[29] and another reporting correlations with the total BQ-II score[15] (Table 4). Correlations between harmful effects and pain severity observed in the current sample (r = 0.13–0.22) did not differ from scores reported in 2009 (consistent pain r = 0.03–0.28; breakthrough pain r = −0.02 = 0.16).[29] Correlations between total BQ-II and pain severity (r = 0.10–0.19) and between total BQ-II and pain interference with daily life (r = 0.13) observed in the current sample did not differ from those reported in 2002 (pain severity r = 0.10–0.16; pain interference r = 0.16).[15]

One previous study described harmful effects and total BQ-II scores by the PMI category (adequate vs inadequate analgesic use).[15] In comparison with the current findings, there were no significant differences in mean score differences on the harmful effects subscale or the total BQ-II score by the PMI category (Table 5).

Two previous studies reported PMI scores for their participants.[15,44] Logistic regression analysis did not identify any change in the proportions of people in the adequate vs inadequate analgesic use categories by the year of publication (Table 6).