Background:

The prevalence of undertreated cancer pain remains high. Suboptimal pain control affects quality of life and results in psychological and emotional distress. Barriers to adequate pain control include fear of opioid dependence and its side effects.

Aim:

To investigate the attitudes and perceptions of morphine use in cancer pain in advanced cancer patients and their caregivers and to examine the influence of caregivers’ attitudes and perceptions on patients’ acceptance of morphine.

Design:

Qualitative study involving semi-structured individual interviews transcribed verbatim and analyzed thematically. Setting/Participants: A total of 18 adult opioid-naïve patients with advanced cancer and 13 caregivers (n=31) were recruited at a private tertiary hospital via convenience sampling.

Results:

Attitudes and perceptions of morphine were influenced by previous experiences. Prevalent themes were similar in both groups, including perceptions that morphine was a strong analgesic that reduced suffering, but associated with end-stage illness and dependence. Most participants were open to future morphine use for comfort and effective pain control. Trust in doctors’ recommendations was also an important factor. However, many preferred morphine as a last resort because of concerns about side effects and dependence, and the perception that morphine was only used at the terminal stage. Caregivers’ attitudes toward morphine did not affect patients’ acceptance of morphine use.

Conclusion:

Most participants were open to future morphine use despite negative perceptions as they prioritized optimal pain control and reduction of suffering. Focused education programs addressing morphine misperceptions might increase patient and caregiver acceptance of opioid analgesics and improve cancer pain control.

1. 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.
2. Breivik H, Cherny N, Collett B, et al. Cancer-related pain: a pan-European survey of prevalence, treatment, and patient attitudes. Ann Oncol 2009; 20(8): 1420–1433.
3. van den Beuken-van Everdingen MH, Hochstenbach LM, Joosten EA, et al. Update on prevalence of pain in patients with cancer: systematic review and meta-analysis. J Pain Symptom Manage 2016; 51(6): 1070–1090.
4. Saifan A, Bashayreh I, Batiha AM, et al. Patient- and family caregiver-related barriers to effective cancer pain control. Pain Manag Nurs 2015; 16(3): 400–410.
5. Deandrea S, Montanari M, Moja L, et al. Prevalence of undertreatment in cancer pain. Ann Oncol 2008; 19(12): 1985–1991.
6. Chen CH, Tang ST and Chen CH. Meta-analysis of cultural differences in Western and Asian patient-perceived barriers to managing cancer pain. Palliat Med 2012; 26(3): 206–221.
7. McPherson CJ, Hadjistavropoulos T, Lobchuk MM, et al. Cancer-related pain in older adults receiving palliative care: patient and family caregiver perspectives on the experience of pain. Pain Res Manag 2013; 18(6): 293–300.
8. Schaller A, Liedberg GM and Larsson B. How relatives of patients with head and neck cancer experience pain, disease progression and treatment: a qualitative interview study. Eur J Oncol Nurs 2014; 18(4): 405–410.
9. Wiffen PJ, Wee B and Moore RA. Oral morphine for cancer pain. Cochrane Database Syst Rev 2016; 4: CD003868.
10. Caraceni A, Hanks G, Kaasa S, et al. Use of opioid analgesics in the treatment of cancer pain: evidence-based recommendations from the EAPC. Lancet Oncol 2012; 13(2): e58–e68.
11. National Comprehensive Cancer Network. Adult cancer pain, NCCN clinical guidelines in oncology, 2019, https://www.nccn.org/professionals/physician_gls/default.aspx#pain (accessed 19 July 2019).
12. International Narcotics Control Board. Availability of narcotic drugs for medical use, 2019, https://www.incb.org/incb/en/narcotic-drugs/Availability/availability.html (accessed November 2019).
13. International Narcotics Control Board. Narcotic drugs, Report 2018, Estimated World Requirements for 2019, 2018, https://www.incb.org/documents/Narcotic-Drugs/Technical-Publications/2018/INCB-Narcotics_Drugs_Technical_Publication_2018.pdf (accessed 24 November 2019).
14. International Narcotics Control Board. Progress in ensuring adequate access to internationally controlled substances for medical and scientific purposes, 2019, https://www.incb.org/documents/Publications/AnnualReports/AR2018/Supplement/Supplement_E_ebook.pdf (accessed 24 November 2019).
15. Cleary J, Radbruch L, Torode J, et al. Formulary availability and regulatory barriers to accessibility of opioids for cancer pain in Asia: a report from the Global Opioid Policy Initiative (GOPI). Ann Oncol 2013; 24(Suppl. 11): xi24–xi32.
16. Linge-Dahl L, Vranken M, Juenger S, et al. Identification of challenges to the availability and accessibility of opioids in twelve European countries: conclusions from two ATOME six-country workshops. J Palliat Med 2015; 18(12): 1033–1039.
17. Larjow E, Papavasiliou E, Payne S, et al. A systematic content analysis of policy barriers impeding access to opioid medication in central and eastern Europe: results of ATOME. J Pain Symptom Manage 2016; 51(1): 99–107.
18. Vranken MJ, Lisman JA, Mantel-Teeuwisse AK, et al. Barriers to access to opioid medicines: a review of national legislation and regulation of 11 central and eastern European countries. Lancet Oncol 2016; 17(1): e13–e22.
19. Kim YC, Ahn JS, Calimag MM, et al. Current practices in cancer pain management in Asia: a survey of patients and physicians across 10 countries. Cancer Med 2015; 4(8): 1196–1204.
20. Ward SE, Goldberg N, Miller-McCauley V, et al. Patient-related barriers to management of cancer pain. Pain 1993; 52: 319–324.
21. Wills BS and Wootton YS. Concerns and misconceptions about pain among Hong Kong Chinese patients with cancer. Cancer Nurs 1999; 22(6): 408–413.
22. Potter VT, Wiseman CE, Dunn SM, et al. Patient barriers to optimal cancer pain control. Psychooncology 2003; 12(2): 153–160.
23. Edrington J, Sun A, Wong C, et al. Barriers to pain management in a community sample of Chinese American patients with cancer. J Pain Symptom Manage 2008; 37(4): 665–675.
24. Colak D, Oguz A, Yazilitas D, et al. Morphine: patient knowledge and attitudes in the central anatolia part of Turkey. Asian Pac J Cancer Prev 2014; 15(12): 4983–4988.
25. Lin CC. Barriers to the analgesic management of cancer pain: a comparison of attitudes of Taiwanese patients and their family caregivers. Pain 2000; 88(1): 7–14.
26. Ferrell BR, Cohen M, Rhiner M, et al. Pain as a metaphor for illness. Part II: family caregivers' management of pain. Oncol Nurs Forum 1991; 18(8): 1315–1321.
27. Ward SE, Berry PE and Misiewicz H. Concerns about analgesics among patients and family caregivers in a hospice setting. Res Nurs Health 1996; 19(3): 205–211.
28. Flemming K. The use of morphine to treat cancer-related pain: a synthesis of quantitative and qualitative research. J Pain Symptom Manage 2010; 39(1): 139–154.
29. Strang P. Qualitative research methods in palliative medicine and palliative oncology—an introduction. Acta Oncol 2000; 39(8): 911–917.
30. Flemming K, Adamson J and Atkin K. Improving the effectiveness of interventions in palliative care: the potential role of qualitative research in enhancing evidence from randomized controlled trials. Palliat Med 2008; 22(2): 123–131.
31. Braun V and Clarke V. Using thematic analysis in psychology. Qualit Res Psychol 2006; 3(2): 77–101.
32. Tong A, Sainsbury P and Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care 2007; 19(6): 349–357.
33. Magnusson E and Marecek J. Doing interview-based qualitative research: a learner's guide. Cambridge: Cambridge University Press, 2015.
34. Miles MB and Huberman AM. Qualitative data analysis: an expanded sourcebook, 2nd ed. Thousand Oaks, CA: SAGE, 1994.
35. QSR International. What is NVivo? 2018, https://www.qsrinternational.com/nvivo/nvivo-products/nvivo-12-pro (accessed 11 June 2019).
36. Grant M, Ugalde A, Vafiadis P, et al. Exploring the myths of morphine in cancer: views of the general practice population. Support Care Cancer 2015; 23(2): 483–489.
37. Suwanwela C and Poshyachinda V. Drug abuse in Asia. Bull Narc 1986; 38(1–2): 41–53.
38. Scholten W, Simon O, Maremmani I, et al. Access to treatment with controlled medicines rationale and recommendations for neutral, precise, and respectful language. Public Health 2017; 153: 147–153.
39. Reid CM, Gooberman-Hill R and Hanks GW. Opioid analgesics for cancer pain: symptom control for the living or comfort for the dying? A qualitative study to investigate the factors influencing the decision to accept morphine for pain caused by cancer. Ann Oncol 2008; 19(1): 44–48.
40. Devi BC, Tang TS and Corbex M. What doctors know about cancer pain management: an exploratory study in Sarawak, Malaysia. J Pain Palliat Care Pharmacother 2006; 20(2): 15–22.
41. Liao Z, Hao J, Guo Y, et al. Assessment of cancer pain management knowledge in southwest China: a survey of 259 physicians from small city and county hospitals. J Palliat Med 2012; 16(6): 692–695.
42. Stiefel F, Morant R, Radziwill A, et al. Attitudes of Swiss physicians in prescribing opiates for cancer pain. Support Care Cancer 1993; 1(5): 259–262.
43. Yanjun S, Changli W, Ling W, et al. A survey on physician knowledge and attitudes towards clinical use of morphine for cancer pain treatment in China. Support Care Cancer 2010; 18(11): 1455–1460.
44. Ger LP, Ho ST and Wang JJ. Physicians' knowledge and attitudes toward the use of analgesics for cancer pain management: a survey of two medical centers in Taiwan. J Pain Symptom Manage 2000; 20(5): 335–344.
45. Manchikanti L, Helm S II, Fellows B, et al. Opioid epidemic in the United States. Pain Phys 2012; 15(Suppl. 3): ES9–E38.
46. Ciccarone D. The triple wave epidemic: supply and demand drivers of the U.S. opioid overdose crisis. Int J Drug Policy 71: 183–188.
47. Soelberg CD, Brown RE Jr, Du Vivier D, et al. The U.S. opioid crisis: current federal and state legal issues. Anesth Analg 2017; 125(5): 1675–1681.
48. Dowell D, Haegerich TM and Chou R. CDC guideline for prescribing opioids for chronic pain—United States. JAMA 2016; 315(15): 1624–1645.
49. Paice JA. Managing pain in patients and survivors: challenges within the United States opioid crisis. J Natl Compr Canc Netw 2019; 17(55): 595–598.
50. Edwards H and Bennett M. Access to opioids for patients with advanced disease. Curr Pharm Des 2019; 25(30): 3203–3208.
51. Malterud K. Qualitative research: standards, challenges, and guidelines. Lancet 2001; 358(9280): 483–488.