PITTSBURGH, Pennsylvania — – A new interventional model for self-management of cancer pain focusing on reinforcement of the perception of pain control shows efficacy in the treatment of African Americans with cancer pain in a longitudinal, randomized study and may have benefits in other populations.
“Interventions to increase perceived control over pain have the potential to improve functional status by decreasing pain and pain-related distress,” said first author, April Hazard Vallerand, PhD, from the College of Nursing at Wayne State University, Detroit, Michigan, in presenting the findings here at the American Pain Society (APS) 2017 Annual Scientific Meeting.
Dubbed Power Over Pain – Coaching (POP-C), the intervention was designed with the goal of giving patients the perception of having control over pain, hence reducing pain-related distress, which has a strong link to functional status.
The program focuses on three main components: medication management, pain advocacy, and aspects of living with pain. The intervention is delivered by nurses trained in its components in home and phone visits to patients.
Previous research has shown that African Americans experience higher levels of pain and pain-related distress and consequently have lower functional status with cancer-related pain. Dr Vallerand and her colleagues therefore focused on African American patients with cancer for this initial investigation of the POP-C intervention.
For the study, they randomly assigned 236 African American patients (63% female), with a mean age of 56.2 years, from an urban comprehensive cancer center to receive the POP-C intervention, including home and phone visits (n = 180) or home and phone visits by nurses for data collection only and with no delivery of the intervention (n = 130). Home visits were made at weeks 2, 4, and 6 and phone calls for reinforcement were made at weeks 3 and 5.
At baseline, the patients had an average level of pain in the past 24 hours of 5.81 on the Brief Pain Inventory scale, which rates pain on a scale from 0 to 10.
At week 7 of the 12-week study, patients receiving the intervention reported significant improvement in all measures compared with baseline. The greatest improvement was in the living with pain component (6.4%), followed by medication management (5.9%) and pain advocacy (2.7%). There were no additional changes at week 12, which demonstrated the intervention’s durability, Dr Vallerand noted.
Patients receiving the intervention also showed a significant increase in the measure of perceived control over pain (P = .003), and the change was associated with improvements in outcomes of pain, pain-related distress, and functional status (all P < .01).
As expected, changes in the control group were much smaller and not significant.
The three components of the POP-C intervention are each specifically designed with a focus on educating patients on the various facets that affect their pain and ultimately play a role in the perception of control over the pain.
Instruments used to measure the components included the Pain Self-Management Questionnaire, the Patient Pain Questionnaire, the Brief Pain Inventory, and the Chronic Pain Acceptance Questionnaire.
The Medication Management component, for instance, teaches the importance of pain management, misconceptions of pain, types of analgesics, side effect management, and effective use of analgesics.
Examples of instrument items used in Medication Management include “taking acetaminophen or ibuprofen with my other pain medicine may improve my pain” or “pain medicines should be given only when pain is severe.”
The Pain Advocacy component teaches such elements as communication skills, role playing, communication with healthcare providers, and overcoming fear and mistrust Examples for assessment include “talking about my pain and how it affects me will help my family understand my mood and actions” and “doctors might find it annoying to be told about pain.”
And the Living with Pain component focuses on such factors as modifying patients’ as well as caregivers’ responses to pain, decreasing pain-related distress, having positive reactions to increased self-efficacy, remaining functional with pain under control, acceptance of pain, and building confidence to manage pain.
The component also focuses on spiritual and religious resources, use of nonpharmacologic modalities, and use of complementary and/or alternative therapies.
Items of assessment include “Keeping busy when I have pain is a good way to keep my mind off of pain” and “I lead a full life even though I have chronic pain.”
An important feature of the intervention is the tailoring to individual needs, Dr Vallerand told Medscape Medical News.
“The tailoring and individualization of POP-C are strengths of our approach,” she said.
“Most hospitals and outpatient centers do not have staffing for home visits, [but] the home visits were invaluable to understand what is truly experienced by the patient and to develop trust of the patient and caregiver for the nurse.”
Dr Vallerand added that the individualized approach allows for the identification of meaningful goals — and motivation.
“We’ve all seen patients who say ‘As long as I don’t move from this recliner, I’m fine,’ but the goal of our work is to get them moving and being able to do the things that are meaningful to them.
“My question of patients is always, ‘What does this pain keep you from doing?’ If I can find out what that is, we can target that specific thing and work to get them back to functioning and doing those things that are important.”
Dr Vallerand noted that the intervention, though tailored to African Americans for the study, shows promise of offering benefits to broader populations.
“This study was targeted toward the African American population because our prior work showed they needed it the most, but it is generalizable in that we can tweak it a little to each population.”
Among future studies planned for the intervention is one looking at patients with chronic back pain who repeatedly use the emergency department system to handle their pain, Dr Vallerand said.
In commenting on the research, David J. Tauben, MD, clinical professor and chief of the University of Washington’s Division of Pain Medicine, in Seattle, Washington, said the findings underscore the importance of better understanding in addressing the known racial and ethnic distinctions in pain management.
“This is a complex story, requiring vastly improved cultural competency of clinicians and improved communication strategies across socioeconomic boundaries, rather than the stereotyping and prejudgments that lead to disparity of care so common in racial and ethnic populations,” he told Medscape Medical News.
“All patients are people, and the need to understand ‘who they are’ requires a deeper understanding of their personal backgrounds, stories, and cultural perspective before we can effectively help them to manage their pain.”
The study received funding from the National Cancer Institute. The authors and Dr Tauben have disclosed no relevant financial relationships.
American Pain Society (APS) 2017 Annual Scientific Meeting. Abstract 444. Presented May 20, 2017.
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