Chronic pain: treatment barriers and strategies for clinical practice.

BACKGROUND: Chronic pain is a clinical challenge for the practicing physician. Lack of knowledge about opioids, negative attitudes toward prescribing opioids, and inadequate pain-assessment skills combine to create major barriers to pain relief. Patient-related barriers, such as lack of communication and unwarranted fears of addiction, further complicate pain assessment and treatment. The health care system itself can hinder pain relief through practical constraints in the community and fear of regulatory scrutiny by the physician. METHODS: Information was gathered by doing a literature search, collating clinical information from practice and additional research findings from national meetings, and reviewing the Bulletin of the American Pain Society. Key search terms included "pain," "chronic pain," "pain management," "pain assessment," "pain treatment," and "barriers to pain management." RESULTS AND CONCLUSIONS: Concrete steps for the clinician engaged in the treatment of chronic pain include selection and administration of an effective opioid, dose titration, short- vs long-acting opioids, opioid rotation, ongoing assessment, and consideration of patient preferences. In addition, communication, coping behaviors, and pain education play important roles in the pain equation.

Knowledge and perceived competence of home care nurses in pain management: a national survey.

This national mail survey assessed pain-related knowledge and subjective competence of a random sample of home care nurses across the United States. Other study objectives were to examine the relationship between nurse characteristics, knowledge and perceived competence, and assess continuing education practices. On average, the 1236 nurses scored only 56% of the items correctly, demonstrating stronger knowledge in pain assessment than treatment. Respondents reported most confidence in patient and family communication, discussion of advance directives and pain assessment. The lowest competence was reported in sophisticated pain treatment techniques. The relationship between knowledge and subjective competence was found to be highly significant. Sixty-three percent of the sample displayed a realistic assessment of their pain management knowledge, while 37% under- or overestimated what they knew. It is challenging to engage the latter group who overestimate their competence but score low on pain management knowledge. Educational strategies need to differentiate these two groups and target the audience appropriately.

Cancer pain management and the role of social work: barriers and interventions.

Quality of life has become increasingly important in the management of cancer, because patients with the disease are surviving longer. Although effective therapies exist, more than half of all cancer patients suffer unrelieved pain during illness and treatment. Undertreated and unnecessary pain represents a failure of the multidisciplinary team, including the social worker, to respond appropriately to the needs of cancer patients. This article increases social workers' awareness of the prevalence of cancer-related pain, identifies the barriers that undermine effective pain relief, and develops a model for social work intervention. Skills such as communication, assessment, problem solving, and psychological support are explored in detail.

Psychosocial barriers to cancer pain relief.

The goal of this study was to investigate the relationship between unrelieved cancer pain and three psychosocial factors: mood state, interference with life, and physician-patient communication. One hundred ninety-one outpatients were interviewed using a structured personal interview schedule. Results show that pain disrupted mood state, life activity, and enjoyment. In addition, pain intensity, education level, and family communication about pain were related. This study confirms earlier research suggesting that cancer pain is multidimensional. Psychological factors (mood, communication), demographics (education), and medical factors (functional impairment, pain intensity) can complicate the assessment and treatment of cancer pain. Patients' reluctance or inability to report pain to physicians or family assures the continuation of untreated and unnecessary pain. In light of these findings, strategies for interdisciplinary clinical intervention are offered, with the ultimate goals of identifying and resolving these psychosocial barriers.

Psychosocial consequences of inadequate health insurance for patients with cancer.

The psychosocial aspects of health insurance in general, and inadequate coverage in particular, have received scant attention from psycho-oncology professionals. However, with the dehospitalization of cancer treatment, and the longer survival time for patients with cancer, the economic and social burden of cancer has shifted to the patient and family. This article explores several domains of the life of the patient with cancer that can be affected by insufficient health insurance. These include the physical, emotional, financial, social, and employment consequences of inadequate insurance coverage, which can be far-reaching. Health insurance can influence the patient's decision making regarding treatment, choice of physician, and hospital. The unmet needs that arise from deficient insurance coverage can cause strain and distress for the family and the patient. These areas of concern are discussed, and recommendations are made for clinical, educational, and research activities.