Factors related to pain management adequacy in patients receiving palliative care: data from a tertiary hospital in Indonesia

Hamzah Shatri, Ratih Arianita Agung, Vera Abdullah, Dina Elita, Rudi Putranto, Mizanul Adli, Cosphiadi Irawan

Background

Adequate pain management must be applied to improve the quality of life, particularly in patients receiving palliative care. Thus, this study aimed to determine the factors related to pain management adequacy in patients receiving palliative care.

 

Methods

This cross-sectional study included all patients sent for consultation to the palliative care team complaining of pain in Cipto Mangunkusumo Hospital, Jakarta, Indonesia from 2016 to 2018. All data such as gender, age, employment status, disease type, primary cancer location, pain intensity, analgesic drug treatment duration, and the presence of anxiety and depression were retrieved from medical records. Pain management adequacy was evaluated using the pain management index. Logistic regression included all variables with p<0.25 related to pain management adequacy in bivariate analysis.

 

Results

Out of 175 patients with pain, 85.7% reported having adequate pain management. Pain was more adequately treated in patients with employment (p = 0.001), milder pain intensity (p<0.001), those using opioids (p<0.001), and those who did not experience anxiety (p = 0.05). Factors related to pain management adequacy were opioid use (OR = 3.23, 95% CI = 1.71–6.13) and milder pain (OR = 11.15, 95% CI = 3.89–31.99).

 

Conclusions

Most of the patients received adequate pain management which related to opioid use and milder pain.

 

Keywords

adequacy factors, pain management, palliative care

Pain is a common symptom in palliative patients and a complaint of more than 50% of patients with advanced cancer, as well as non-cancer diseases.1,2 Pain is an uncomfortable sensation that may occur because of the disease itself or as a side effect of the treatment.3 Pain should be managed adequately because otherwise, it will reduce the quality of life.4 Until now, pain management used the World Health Organization (WHO) analgesic ladder, which is based on pain intensity.5,6

Pain intensity may vary among patients with a similar disease entity or severity since pain is a subjective feeling. This feeling is affected by previous experiences of pain, family support, and self-resistance. Therefore, pain medication must be administered in a unique way for every patient.4,7 Sometimes patients with mild-to-moderate pain may need opioids,8 but the physician should be cautious about side effects such as gastrointestinal and neurological problems.9,10

There have been numerous studies evaluating the adequacy of pain management in cancer cases; meanwhile, there are limited studies assessing in both cancer and non-cancer patients. Moreover, enhancing quality of life is the main purpose for patients receiving palliative care by eliminating their pain as soon as possible. Thus, it is important to explore the proportion of patients receiving adequate pain management, especially in a tertiary referral hospital in which chronic diseases with complex problems are treated, and assess the factors related to the adequacy of pain management.

 

 

This cross-sectional study used secondary data from medical records. The subjects were adult patients (>18 years old) experiencing pain and receiving palliative care from the Psychosomatic Palliative Team, Cipto Mangunkusumo Hospital, Jakarta, Indonesia, a tertiary referral hospital, from 2016 to 2018. There were 285 patients referred for consultation to the Psychosomatic Palliative Team, and 175 of them experienced pain. All patients with pain was included in this study as a sample. This study was approved by the Ethics Committee of the Faculty of Medicine Universitas Indonesia (No: 0406/UN2.F1/ETIK/2018).

In Cipto Mangunkusomo Hospital, we used the visual analogue scale to assess pain intensity. All data including gender, age, employment status, disease type (cancer or non-cancer), primary cancer location, pain intensity, analgesic type, and the presence of anxiety and depression were retrieved from medical records. The pain management index (PMI) was used to evaluate pain management adequacy in the range −3 to +3 by evaluating the pain intensity and drugs used based on the WHO analgesic ladder. PMI ≥0 indicates adequate pain management, while a negative value indicates inadequate pain management.10

Factors related to pain management adequacy in patients with pain in palliative care were observed using logistic regression. All variables that met p<0.25 in bivariate analysis of pain management adequacy using either chi-square analysis or Fisher’s exact test were included in the multivariate analysis. SPSS software version 25 (IBM Corp., USA) was used in all statistical analyses.

 

 

There were 285 patients consult to Psychosomatic and Palliative Team. Out of 175 patients experiencing pain. All patients with pain was included in this study, with 85.7% reported having adequate pain management. The demographic and clinical characteristics of palliative patients with pain can be seen in Table 1. Most of the subjects had cancer, of which the digestive system was the most frequent location. Among both cancer and non-cancer patients, most had adequate pain management. Employment, mild pain intensity, opioid use, and the absence of anxiety were associated with adequate pain management, but only mild pain intensity and opioid use were factors related to adequacy (Table 1).

 

 

 

 

In this study, 85.7% of palliative care patients reported having adequate pain management. This may be because most of them had mild and moderate pain intensity (65.9%). Hence, non-steroidal anti-inflammatory drugs (NSAIDs) were common drugs of choice for pain in this study, as recommended by the WHO.9,11,12 The patient’s medical condition and pain intensity should be the primary concerns in pain management. However, the combination of opioids and NSAID are often needed for palliative patients in mild and moderate pain. A meta-analysis showed that monotherapy with paracetamol or NSAIDs could not reduce pain symptoms, but a combination of paracetamol and weak opioids produced a better outcome.13 Opioid use also produced better pain relief than NSAID, but long-term opioid use may result in several side effects.14,15 Hence, patients must be educated on the possible side effects and should seek for help if needed, and physicians should weigh the risks and benefits of using these drugs. This also makes it challenging for patients and physicians to decide whether to take and prescribe opioids, respectively.16 Opioid may be administered directly for severe pain according to the WHO pain ladder.17–19 A combination of opioid and NSAIDs may be the best alternative treatment to improve pain management and lower dose-related side effects. These findings support our results showing that milder pain intensity and opioid use were factors related to pain management adequacy. Patients with mild pain would be treated adequately with NSAIDs without any hesitancy, and when opioids were used, patients would surely obtain adequate treatment, since opioids are the top analgesics for pain management.

In this study, inadequate pain management was similarly found in adults and the elderly,20 without any difference based on primary cancer location. Singh et al21 reported that inadequate treatment was mostly found in patients aged 40–50 years and with genitourinary cancer. Eighty-eight percent of patients with mild and moderate pain received adequate treatment; meanwhile, only 40% of patients with severe pain had adequate pain management. Appropriate pain management could improve patients’ quality of life.22 Moreover, unresolved pain may affect psychological aspects such as anxiety and depression. When they occurred, psychological treatment is needed to improve pain perception.23

The limitation of this study was that we used medical records in retrieving the data. We did not assess dosage, treatment duration, and changes in pain before and after treatment. Moreover, we did not provide any data about patients conditions. Some of the patients may have been treated in an intensive care unit or high care unit. This may also contribute to fewer patients having anxiety and depression. Further prospective studies should consider the dosage and side effect of pain treatment related to pain improvement. In conclusion, most palliative care patients had adequate pain management. Milder pain intensity and opioid use were the factors related to pain management adequacy.

 

 

 

 

 

 

 

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