Katherine Yeager, PhD, RNResearch Assistant Professor
Nell Hodgson Woodruff School of Nursing at Emory University.
Effective pain treatments exist. Proper application of the World Health Organization Pain Relief Ladder allows 80% to 90% of patients to find relief from pain, regardless of care setting or social and/or cultural environment.4 This three-step "ladder" includes the prompt oral administration of drugs in order (non-opioids; then, as needed, mild opioids; then strong opioids (eg, morphine), until the patient is pain free. To maintain freedom from pain, drugs should be given around the clock at a specific time interval depending on the drug, rather than on demand or PRN. For many with severe cancer pain, around-the-clock with long-acting opiates is the preferred treatment.
Unfortunately African Americans experience a disproportionate burden of cancer pain and suffer worse treatment outcomes.5 Although fundamentally important, the explanations for these disparities in cancer pain are not fully known; most likely an interplay between individual, social, and system-level factors contribute to African Americans with cancer pain not getting adequate relief.
Numerous individual factors may affect a person’s ability to get relief from pain. African Americans with cancer pain have expressed reluctance to verbalize pain or to seek help due to beliefs of stoicism, concerns about possible addiction and drug tolerance, fears of side effects, and a desire only to take medications when pain is severe.6 Counterproductive beliefs about pain include such notions as, pain is an expected part of life; grin and bear it; pain is God’s will; people that succumb to pain are weak.
The role of social support as it relates to pain relief can both positively and negatively influence a person to take pain medication when in pain. Attitudes about pain and pain treatment may influence both the individual experiencing pain and their social network, especially in the the context of the current national dialogue about drug abuse and the over-prescription of opioids.
Nearly 15,000 people die each year of overdoses involving prescription painkillers, the CDC reports.7 Opiate abuse widely discussed in the medical community and lay media, and this likely influences not only individuals who have been prescribed medications for cancer pain, but also the individuals who support them. Despite—or perhaps because of—these influences, cancer patients often underuse prescribed opiates rather than overuse these medicines.8
Systemic barriers to pain relief for minorities have been identified.9 Regardless of age or socioeconomic status, African Americans are less likely than Whites to receive analgesic medication for pain. Primary providers are more likely to underestimate pain intensity in African Americans than in other ethic groups. Pharmacies located in minority neighborhoods are less likely to carry sufficient prescription analgesics than those located in white neighborhoods. Compared with white patients, black patients were more likely to have more referrals for substance abuse assessment, fewer referrals to a pain specialist and increased drug urine tests.
These alarming examples of bias in our healthcare system impact cancer patients daily. Care of pain does not occur in a vacuum but in a context that includes social and system- level influences (family, friends, neighbors, church community, and healthcare systems). Many avenues exist to improve cancer pain relief for minorities, and the role of nurses is a great place to start.
The Nurse’s Role
Nurses must use their assessment skills to assess cancer pain in all individuals and partner with patients to help them achieve pain relief. The first step in building this partnership is to ask individuals to describe how they have managed their pain through self-management strategies.
In a recently published qualitative study of advanced cancer patients,10 individuals reported the use of many nonpharmacologic strategies to manage pain. Study participants adjusted the speed of their activities or type of activities in search of pain relief. Despite not feeling well, participants needed to continue to care for themselves and their family and plan out their day. Many changed the activities they participated in, sometimes eliminating activities or trying new activities. Most participants spoke of adjusting their diet in order to manage pain.
As well as self-management strategies individuals use to treat pain, patients with cancer pain are often expected to manage complex pain medication regimens. Nurses need to examine the complexity of these medicine regimens frequently. With prescription medications, healthcare providers write the order, but the patient has the responsibility of taking the medications and often adjusts the medications to suit their needs. Pain medication adjustments included differentiating the type, dose, and timing of the medication. In the study of advanced cancer patients, participants took medications for pain, but also for cough, sleep, anorexia, wheezing, insomnia, constipation, nausea, high blood pressure, neuropathy, blood clots, depression, and anxiety and as part of their cancer treatment. All of these medications required education which most often is provided by nurses. The decisions that patients make as they manage complex medication regimens need to be examined further.
Understanding the barriers to symptom relief for all individuals is important. Additional barriers may exist for African Americans and other minorities at the individual, social, and system level. Nurses have a great opportunity to assist patients in working through these barriers with the end result of improved pain relief for all.
1. American Cancer Society. Cancer Facts & Figures 2015. Atlanta: American Cancer Society; 2015.
2. van den Beuken-van Everdingen MH, de Rijke JM, Kessels AG, et al. Prevalence of pain in patients with cancer: a systematic review of the past 40 years. Ann Oncol. 2007;18(9):1437-1449.
3. Deandrea S, Montanari M, Moja L, Apolone G. Prevalence of undertreatment in cancer pain. A review of published literature. Ann Oncol. 2008;19(12):1985-1991.
4. World Health Organization. WHO's Pain Ladder. http://www.who.int/cancer/palliative/painladder/. Accessed August 18, 2015.
5. Institute of Medicine. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington DC: The National Academic Press; 2011.
6. Anderson KO, Richman SP, Hurley J, Palos G, et al. Cancer pain management among underserved minority outpatients: perceived needs and barriers to optimal control. Cancer. 2002;94(8):2295-2304.
7. Centers of Disease Control and Prevention. Vital Signs: Prescription Painkiller Overdoses in the US. http://www.cdc.gov/vitalsigns/PainkillerOverdoses/index.html. Accessed August 18, 2015.
8. Meghani SH, Thompson AM, Chittams J, et al. Adherence to analgesics for cancer pain: a comparative study of African Americans and whites using an electronic monitoring device. J Pain. 2015;16(9):825-835.
9. National Institute of Neurological Disorders and Stroke. Disparities in Pain Care. http://painconsortium.nih.gov/News_Other_Resources/dpc.pdf. Accessed on August 17, 2015.
10. Yeager KA, Sterk CE, Quest TE, DiIorio C, Vena C, Bauer-Wu S. Managing one's symptoms: a qualitative study of low-income African Americans with advanced cancer [published online ahead of print June 20, 2015]. Cancer Nurs.