1 3 The impact of communication on adherence in pain management 4 5 6 Phyllis Butow a,⇑ Q1 , Louise Sharpe b 7 a Centre for Medical Psychology and Evidence based Decision-Making (CeMPED) and the Psycho-Oncology Co-operative Research Group (PoCoG), School of Psychology, 8 University of Sydney, NSW, Australia 9 b School of Psychology, University of Sydney, Sydney, NSW, Australia 10 12 article info 13 Article history: 14 Received 12 April 2013 15 Received in revised form 19 July 2013 16 Accepted 25 July 2013 17 Available online xxxx 18 Keywords: 19 Adherence 20 Pain management 21 Provider–patient communication 22 23 abstract 24 Despite Q2 a high prevalence of acute and chronic pain and ongoing effort to understand and reduce pain, 25 studies show that there remains a considerable unmet need for pain relief and management. Some unmet 26 need arises from the lack of effective interventions. However, even where the evidence indicates that 27 interventions, such as medication, exercise, and cognitive-behavioral therapy are effective, patients do 28 not always adhere to these treatment recommendations. How can we, as health professionals, improve 29 adherence? There are numerous models in health psychology that aim to explain why people engage 30 in health behaviors (or opt not to), such as the health belief model, self-regulation theory, and the theory 31 of planned behavior. These all suggest that patients’ beliefs about their health condition and the recom- 32 mended behavior are important predictors of adherence. Reviews of interventions to increase adherence 33 identify 2 key factors in promoting adherence: (1) good health care provider–patient communication and 34 (2) interventions that are tailored to individuals’ reasons for nonadherence. Hence, communication skills 35 that express a nonjudgmental approach, allow open exploration of patient beliefs and concerns, and use a 36 negotiating approach that fosters shared decision making are crucial. Randomized, controlled trials of 37 brief communication skills training have shown improved outcomes in primary care settings for patients 38 with fibromyalgia and acute pain. Although treatment of chronic pain is challenging, good communica- 39 tion between the health provider and patient can promote adherence to lifestyle changes and appropriate 40 medical interventions that appear to result in important, clinically significant benefits for a range of pain Q3 41 conditions. 42 Ó 2013 Published by Elsevier B.V. on behalf of International Association for the Study of Pain. 43 44 45 1. Introduction 46 1.1. Definition, prevalence, and impact of pain 47 Chronic pain and acute pain are common and distressing. In 48 Australia (with a population of 23 million), the point prevalence 49 of chronic pain is estimated to be 3.2 million people, and this num- 50 ber is projected to increase to 5 million by 2050 [1]. Pain in those 51 with serious illnesses is also common. A recent meta-analysis [57] 52 reported that 44%–73% of patients receiving anticancer treatment 53 and 58%–69% of patients with advanced cancer reported pain. Of 54 these, more than one-third graded their pain as moderate or 55 severe. 56 Pain is one of the strongest predictors of poor quality of life [52]. 57 The economic burden to Western countries from days lost to work, 58 sickness and disability benefits, and health care use is enormous 59 [36]. Importantly, patients with persistent pain who wait >6 60 months from referral to access to treatment have been shown to 61 deteriorate in terms of health-related quality of life and psycholog- 62 ical status [32]. As such, it is particularly important that effective 63 treatments are recommended to patients and that they adhere to 64 those recommendations. 65 1.2. Challenges in managing pain 66 There are challenges in managing patients with both acute and 67 chronic pain. The subjective experience of pain, which is difficult to 68 objectively measure, means that acute pain patients may be pre- 69 scribed insufficient medication, whereas widespread misconcep- 70 tions about pain medication may prevent patients from accepting 71 prescribed medication. Furthermore, advice to immobilize early 72 on and rest can lead to a failure to resume normal activity in a 73 gradual way as the injury heals. However, the challenges of acute 74 pain are generally far fewer than those inherent of managing 75 chronic pain. 76 The general experience of patients in health care systems is that 77 doctors assess them, make a formal diagnosis, and, on the basis of 78 that diagnosis, prescribe an intervention that is effective. The first 79 problem with this framework in guiding patients through the 0304-3959/$36.00 Ó 2013 Published by Elsevier B.V. on behalf of International Association for the Study of Pain. http://dx.doi.org/10.1016/j.pain.2013.07.048 ⇑ Corresponding author. Address: School of Psychology, Transient Building (F12), University of Sydney, Sydney, NSW 2006, Australia. Tel.: +61 2 93512859; fax: +61 2 90365292. E-mail address: [email protected](P. Butow). PAIN Ò xxx (2013) xxx–xxx www.elsevier.com/locate/pain PAIN 8938 No. of Pages 7, Model 5G 21 August 2013 Please cite this article in press as: Butow P, Sharpe L. The impact of communication on adherence in pain management. PAIN Ò (2013), http://dx.doi.org/ 10.1016/j.pain.2013.07.048
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PAIN 8938 No. of Pages 7, Model 5G
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w w w . e l s e v i e r . c o m / l o c a t e / p a i n
The impact of communication on adherence in pain management
0304-3959/$36.00 � 2013 Published by Elsevier B.V. on behalf of International Association for the Study of Pain.http://dx.doi.org/10.1016/j.pain.2013.07.048
⇑ Corresponding author. Address: School of Psychology, Transient Building (F12),University of Sydney, Sydney, NSW 2006, Australia. Tel.: +61 2 93512859; fax: +61 290365292.
Please cite this article in press as: Butow P, Sharpe L. The impact of communication on adherence in pain management. PAIN�
(2013), http://dx.d10.1016/j.pain.2013.07.048
Phyllis Butow a,⇑, Louise Sharpe b
a Centre for Medical Psychology and Evidence based Decision-Making (CeMPED) and the Psycho-Oncology Co-operative Research Group (PoCoG), School of Psychology,University of Sydney, NSW, Australiab School of Psychology, University of Sydney, Sydney, NSW, Australia
24252627282930313233
a r t i c l e i n f o
Article history:Received 12 April 2013Received in revised form 19 July 2013Accepted 25 July 2013Available online xxxx
Keywords:AdherencePain managementProvider–patient communication
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a b s t r a c t
Despite a high prevalence of acute and chronic pain and ongoing effort to understand and reduce pain,studies show that there remains a considerable unmet need for pain relief and management. Some unmetneed arises from the lack of effective interventions. However, even where the evidence indicates thatinterventions, such as medication, exercise, and cognitive-behavioral therapy are effective, patients donot always adhere to these treatment recommendations. How can we, as health professionals, improveadherence? There are numerous models in health psychology that aim to explain why people engagein health behaviors (or opt not to), such as the health belief model, self-regulation theory, and the theoryof planned behavior. These all suggest that patients’ beliefs about their health condition and the recom-mended behavior are important predictors of adherence. Reviews of interventions to increase adherenceidentify 2 key factors in promoting adherence: (1) good health care provider–patient communication and(2) interventions that are tailored to individuals’ reasons for nonadherence. Hence, communication skillsthat express a nonjudgmental approach, allow open exploration of patient beliefs and concerns, and use anegotiating approach that fosters shared decision making are crucial. Randomized, controlled trials ofbrief communication skills training have shown improved outcomes in primary care settings for patientswith fibromyalgia and acute pain. Although treatment of chronic pain is challenging, good communica-tion between the health provider and patient can promote adherence to lifestyle changes and appropriatemedical interventions that appear to result in important, clinically significant benefits for a range of painconditions.
� 2013 Published by Elsevier B.V. on behalf of International Association for the Study of Pain.
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1. Introduction
1.1. Definition, prevalence, and impact of pain
Chronic pain and acute pain are common and distressing. InAustralia (with a population of 23 million), the point prevalenceof chronic pain is estimated to be 3.2 million people, and this num-ber is projected to increase to 5 million by 2050 [1]. Pain in thosewith serious illnesses is also common. A recent meta-analysis [57]reported that 44%–73% of patients receiving anticancer treatmentand 58%–69% of patients with advanced cancer reported pain. Ofthese, more than one-third graded their pain as moderate orsevere.
Pain is one of the strongest predictors of poor quality of life [52].The economic burden to Western countries from days lost to work,sickness and disability benefits, and health care use is enormous[36]. Importantly, patients with persistent pain who wait >6
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months from referral to access to treatment have been shown todeteriorate in terms of health-related quality of life and psycholog-ical status [32]. As such, it is particularly important that effectivetreatments are recommended to patients and that they adhere tothose recommendations.
1.2. Challenges in managing pain
There are challenges in managing patients with both acute andchronic pain. The subjective experience of pain, which is difficult toobjectively measure, means that acute pain patients may be pre-scribed insufficient medication, whereas widespread misconcep-tions about pain medication may prevent patients from acceptingprescribed medication. Furthermore, advice to immobilize earlyon and rest can lead to a failure to resume normal activity in agradual way as the injury heals. However, the challenges of acutepain are generally far fewer than those inherent of managingchronic pain.
The general experience of patients in health care systems is thatdoctors assess them, make a formal diagnosis, and, on the basis ofthat diagnosis, prescribe an intervention that is effective. The firstproblem with this framework in guiding patients through the
health care system is that in chronic pain, there is rarely a ‘‘diagno-sis’’ as such that clearly explains the cause of the pathology. Fur-thermore, historically, where patients were given diagnoses,these were ultimately unhelpful or purely descriptive (eg, chronicpain syndrome, degenerative disc disease) and rarely indicated alikely effective treatment.
Second, to date, despite the best research efforts, there is nocurative treatment for chronic pain. Instead, pain interventionsaim to reduce disability associated with the pain and hence facili-tate functioning. Intervention options include surgery, medication(opioids and/or antidepressants), graduated exercise, and cognitivebehavior therapy. There is evidence that all these interventions areat least moderately effective in certain contexts. Although none ofthem provide a panacea for chronic pain and most have only mod-erate effect [55], there is evidence that these interventions are notbeing used, even in situations in which the evidence base wouldsupport their use [31].
Although there are many practical reasons why optimal inter-ventions for both acute and chronic pain are not always used, suchas lack of availability or accessibility of treatments, 2 other factorscontribute to underuse of effective treatments. First, in some in-stances, effective treatments are not prescribed due to inadequatehealth provider knowledge, assessment, or practice. Second, evenwhen practitioners prescribe or recommend an evidence-basedtreatment, there is evidence that many patients are nonadherentto the recommended treatments [37,40].
1.3. Health professionals’ attitudes and pain
Research suggests that general practitioners (GPs) and otherhealth care professionals are only moderately adherent themselvesto prescription of interventions consistent with guidelines for themanagement of pain, which necessarily results in the underuseof potentially helpful interventions for pain patients. In a cross-sectional postal survey, 442 GPs and 580 physiotherapists whohad recently treated a patient with back pain completed the PainAttitudes and Beliefs Scale and a vignette of a patient with nonspe-cific lower back pain [4]. Although the majority of health care pro-viders (HCPs) reported providing advice for the vignette patientthat was broadly in line with guideline recommendations; 28% re-ported they would advise this patient to remain off work. Theywere more likely to do so if they endorsed biomedical (rather thanbehavioral) approaches to managing pain. These results are consis-tent with findings that those with a biomedical treatment orienta-tion [42]; HCPs who endorse higher fear avoidance beliefs or astrong belief that pain and impairment are invariably linked [30]are more likely to endorse some form of rest. Thus, it may beimportant to modify health professionals’ beliefs to ensure thatthey provide the correct advice, even before attempting to changea patient’s behavior. Indeed, in one of the few studies to implementa population-wide campaign to change unhelpful beliefs aboutpain, Buchbinder et al. [7] found that the attitudes of physiciansbecame more positive, which influenced medical managementand resulted in reduced health care costs associated with pain.
1.4. What is nonadherence?
However, even when health care professionals follow best prac-tice guidelines, the treatment may still be ineffective if the patientdoes not adhere to the recommendations. Adherence to treatmenthas received a great deal of attention across disease groups. Theissue was formerly conceptualized as compliance in the late1970s, when it was defined as ‘‘the extent to which the patient’sbehavior coincides with medical or health advice’’ [17]. A concernthat compliance may carry overly authoritarian overtones has ledsome authors to seek alternative terms such as cooperation [22],
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adherence [16], therapeutic alliance [33], collaboration [18], mutu-ality [19], and concordance [48], with adherence now emerging asthe preferred term [8].
In their review of definitions of adherence, Kyngas et al. [28]identified 3 common elements relating to (1) patients’ self-careresponsibilities, (2) their role in the treatment process, and (3)their collaboration with HCPs. Some authors have tended to viewadherence as more or less synonymous with shared decision mak-ing, with responsibility therefore shared by the parties involved[19,33,48]. Typical of this approach are the definitions of the WorldHealth Organization: ‘‘The extent to which a person’s behavior cor-responds with the agreed recommendations from a health careprovider’’ [49], and the National Institute for Health and ClinicalExcellence (NICE) guidelines comment that ‘‘[a]dherence presumesan agreement between prescriber and patient about the pre-scriber’s recommendations’’ [37].
Other definitions have focused on patients’ cognitive-motiva-tional processes, including that of Kyngas et al. [28], which definesadherence as ‘‘the patient’s active, intentional, and responsibleprocess of care, in which the individual works to maintain his orher health in close collaboration with health care personnel.’’
All definitions assume adherence to be a dynamic process ratherthan an outcome. This focus means that it is important to under-stand the factors that contribute to nonadherence over time. Fur-thermore, adherence is viewed as relative rather than absoluteand should be appraised according to its impact on therapeutic ben-efit rather than as divergence from prescribed treatment [15,41].Partial adherence is much more common than total adherence,may not have an impact on outcomes, and therefore may not be aconcern. Essentially, both approaches are also nonjudgmental andassume that nonadherence is always understandable within the pa-tient’s world view. Thus, it is the task of the health practitioner tounderstand this world view. As noted by NICE, ‘‘[n]on-adherenceshould not be seen as the patient’s problem. It represents a funda-mental limitation in the delivery of healthcare, often because of afailure to fully agree the prescription in the first place or to identifyand provide the support that patients need later on’’ [37].
1.5. Is nonadherence common or important?
1.5.1. Adherence to medicationAdherence is an underresearched issue in both disease-related
pain and chronic pain. A recent systematic exploratory review[21] identified only 7 papers exploring adherence in malignantpain. Many of these studies had methodological weaknesses. Theirsynthesis of results showed that 50%–91% of cancer patientsreported adhering to scheduled regimens of opioid medicationand 22%–27% reported adhering to medication on an as-needed ba-sis. These figures are similar to those reported in a study of adher-ence to medication for pain in rheumatoid arthritis, in which 37%of patients were nonadherent to medication [26]. In general,adherence rates are higher among patients with acute conditions[49] compared with patients with chronic diseases [23]. These re-sults were borne out in a recent meta-analysis [6] that investigatedmedication nonadherence in patients with chronic, nonmalignantpain that found that nonadherence to medication was commonwith �30% of patients reporting that they were nonadherent.Although the most common form of nonadherence to medicationwas underuse, a notable and concerning statistic indicated that be-tween 4% and 21% of participants overused their medication.
In the Broekman et al. [6] meta-analysis, only 2 studies hadinvestigated the impact of nonadherence on patient outcome, andalthough both showed differences in the direction of worse painamong nonadherent patients, the outcomes were not significantlypoorer. Nonetheless, data from the United States indicate thatdeaths from opioid overdose increased fourfold between 1999
and 2007 [53]. Indeed, in 2007, there were more deaths from opioidoveruse and abuse than there were from cocaine and heroin over-doses together [53]. Furthermore, studies of deaths associated withopioid use have highlighted patient nonadherence as a major con-tribution [62]. Hence, there is good evidence for suboptimal adher-ence to medication in chronic pain patients. Although there is lessdirect evidence of an impact of nonadherence (underuse) on patientoutcome, statistics indicate a worrying trend toward an increase inpoor outcomes after overuse, particularly of opioid medication.
1.5.2. Adherence to nonmedication-based interventionsAdherence to nonmedical interventions is even more infre-
quently studied; however, adherence to exercise recommenda-tions appears to be even lower than adherence to medication,with 1 study reporting adherence rates to exercise <30% in patientswith lower back pain [14]. Kolt and McEvoy [27] found higher ratesof adherence in low back pain patients attending private physio-therapy practices, with �70% of patients completing their home-based practice. Importantly, they were able to demonstrate thatadherence predicted good rehabilitation outcomes. The fact thatadherence predicts functional outcomes has been shown in a rangeof conditions including osteoarthritis of the knee or hip [44] andback pain among older adults [20].
Similar results have also been found in those few studies thatinvestigated adherence to self-management strategies in the con-text of multidisciplinary chronic pain management programs. Forexample, Nicholas et al. [38] assessed adherence in a large studyof >500 consecutive chronic pain patients who completed a 3-weekpain management program. Only 30% of patients were found to beregularly using all the skills offered in the program. Further, adher-ence was a strong predictor of treatment outcome, even after con-trolling for other relevant variables that would be expected topredict outcome (eg, catastrophizing, fear of pain). These data wererecently replicated in an independent sample, and the results againclearly indicated that the benefit that patients experience from theprogram is directly linked to their adherence and that these bene-fits can still be observed 12 months later [39].
Despite the fact that the literature on adherence in pain is sur-prisingly sparse, there is good evidence that nonadherence is com-mon, both to medication and pain management interventions.Furthermore, at least for self-management and exercise, adherenceappears to be directly associated with greater benefit from theintervention. Hence, there is good reason to be concerned aboutthe low rates of adherence among chronic pain patients.
1.6. Models of nonadherence
Why do people fail to adhere to pain medication or other treat-ments? A number of models have been applied to better under-stand nonadherence, including the health belief model (HBM),the theory of planned behavior (TPB), and self-regulation theory.
The HBM was designed to predict a range of health behaviorsand suggests that adherence will be predicted by individuals’demographic factors (such as social class, sex, and age) and a rangeof beliefs about a health issue, including their perceived suscepti-bility to the problem (‘‘I have or will get pain’’), perceived severity(‘‘the pain is bad’’), perceived treatment benefits (‘‘I believe exer-cise will help my pain’’), perceived treatment barriers (‘‘I have notime to exercise’’), cues to action (pain), and health motivation(‘‘I really want to control my pain and am prepared to work hardto do so’’). Recently, the concept of self-efficacy was incorporatedinto the HBM [28]. Self-efficacy refers to ‘‘beliefs in one’s capabili-ties to organize and execute the courses of action required to pro-duce given attainments’’ [29] (‘‘I believe I can motivate myself andstick to my exercise regimen’’).
Please cite this article in press as: Butow P, Sharpe L. The impact of communic10.1016/j.pain.2013.07.048
Although individual variables from the HBM have been ex-plored in relation to pain adherence (such as perceived barriers),very few studies have comprehensively explored the model. Oneexception to this is a study by Valeberg et al. [56] in the contextof cancer. In this study of 174 oncology outpatients, only 41% ofthe patients were adherent to their analgesic regimen. HBM vari-ables explained 29.9% of the variance in adherence. Higher adher-ence scores were associated with lower self-efficacy for physicalfunction scores (against the hypothesis), higher average pain inten-sity scores, higher pain relief scores, and the use of strong opioidanalgesics. The authors suggested that perhaps patients with lowself-efficacy for being able to manage their physical problems feltthat pain medication offered a good option requiring little fromthem, that great high pain may act as a cue for action, and thatstronger analgesics and greater pain relief may promote belief inthe efficacy of the medication.
The TPB proposes that behavior is often determined by a per-son’s social context and his or her social expectations. In particular,this model emphasizes the concept of social norms (‘‘I believe peo-ple I love and respect want me to exercise and better manage mypain’’). Few studies have used the TPB in exploring adherence topain medication. One study explored patient views of a posturetraining intervention versus exercise, using TPB variables.Although many obstacles to exercising were reported, few barriersto learning the postural training were described because it madesense, could be easily incorporated into daily life, and the teachersprovided personal advice and support. The authors concluded thata more convincing rationale, better social support, and a better per-ceived fit with the patient’s particular symptoms and lifestylemade postural training more attractive.
In another study of 100 women in the third trimester of preg-nancy, pharmacological beliefs and subjective norms indepen-dently predicted intentions to use analgesia during delivery.Beliefs about self-efficacy to use nonpharmacological pain man-agement strategies did not significantly enhance the predictionof intention to use analgesics.
The self-regulation theory posits that mental representationsprovide a framework for coping with illness and that these repre-sentations include both cognitive and emotional responses [29].Both types of responses prompt a coping strategy that is then ap-praised and, depending on its perceived success, is continued oramended. Thus, the degree of emotion associated with pain as wellas its objective severity may hinder or encourage people to adhereto treatment. It is thought that if the emotion associated with thehealth threat is high, then patients will be motivated to act in away to reduce the distress rather than to necessarily improve theirhealth, per se [51]. For example, patients who catastrophize abouttheir pain and are highly fearful of pain and distressed by it may bequite adherent to analgesia or other interventions aimed at directlyreducing pain. Indeed, highly distressed patients may persist intrying to solve the problem of their pain by becoming overadherentin taking medication or visiting a range of health professionals.However, these same patients might be less adherent to a gradedactivity treatment that includes movements and activities thattemporarily increase pain, even if these are the precise activitiesthat would reduce the health threat. Very little research has explic-itly evaluated the self-regulation theory as a model for understand-ing adherence to pain medication, but 1 small study that piloted anintervention based on an adapted self-regulation theory by John-son [23] failed to have an effect [60].
Nevertheless, despite the paucity of evidence supporting thesemodels in the context of adherence to pain management, theycan be useful in directing conversations about pain managementadherence with patients. Discussing patients’ beliefs, attitudes,self-efficacy, social norms, and feelings about pain management
may lead to significantly greater understanding between doctorsand patients.
1.7. Empirically derived reasons for nonadherence in pain
Empirical studies have revealed a large number of cognitive,attitudinal, and affective concepts that contribute to nonadherence(Table 1). One study found that in acute pain rehabilitation, ageneral tendency to forget physician instructions was related topredicted nonadherence to psychopharmacological treatmentrecommendations for pain [13]. Three key cognitive barriers toadherence to pain in cancer have been widely identified [21]:concerns about analgesic use (fear of addiction, tolerance, and sideeffects and fear that analgesics will mask new pain that could beimportant diagnostically), concerns about pain communication(not wanting to distract the clinician from curing their disease,wanting to be a ‘‘good patient,’’ wanting to present to others asstrong and in control), and a belief that pain is inevitable andcannot be controlled. A further issue is that some patients fear thatpain heralds disease progression and deny it with the aim ofsuppressing such fears.
Such beliefs are common. For example, a recent Australianstudy of 93 cancer patients in active treatment [45] found that>50% of patients reported a range of cognitive barriers to pain med-ication, closely approximating the findings of a similar Americanstudy [61] (Fig. 1). However, there may be some cultural differ-ences in the degree to which barriers to pain medication adherenceare evidenced. For example, a recent meta-analysis found thatAsian cancer patients’ perceived barriers to managing cancer painwere significantly greater than those for Western patients [9], sug-gesting that particular care may need to be taken to assess andcarefully manage perceived barriers to optimize cancer pain man-agement in some patients.
Available literature supports similar determinants to nonadher-ence in chronic pain. A qualitative study of older adults with oste-oporosis found 2 major themes. The first was a general aversion totaking pain management for fear of addiction or for perceived inef-fectiveness. The other major reason cited for nonadherence was abelief that pain medication should be used only for ‘‘extreme’’ painand that pain tolerance would increase if lower levels of pain weresimply endured [50]. Importantly, according to the Broekman et al.[6] meta-analysis, pain, pain duration, and pain intensity were notpredictors of nonadherence. Rather, patients who were highly dis-tressed or concerned about medication side effects or who re-ported a poor relationship with their doctor or mistrust of thedoctors were more likely to be nonadherent. Similarly, Rosseret al. [47] found that pain medication concerns were more predic-tive of adherence to pain medication than level of pain or reportedseverity of side effects.
In addition to these individual predictors of adherence, affectiveand communication issues are also significant predictors of adher-ence. One study [11] reported that adherence to recommendations
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Table 1Documented patient attitudinal barriers to complying with pain medication.
Analgesia concernsAddiction, toleranceSide effectsDislike of pills, disbelief in their efficacyWorry that pain medicine could mask new painsMeaning of painThat pain signifies disease progression and is to be deniedPain communication concernsDesire to be a ‘‘good patient’’ for physician and carerShould be grateful for care and not complain about painWillingness to tolerate painDo not want to distract physician from focusing on treating disease
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for patients with fibromyalgia included lower patient–physiciandiscordance on patient well-being and lower patient psychologicaldistress. The authors concluded that adherence is influenced byboth clinical (patient–physician communication) and psychological(distress) factors in women with fibromyalgia and that improve-ments in these domains may improve adherence in fibromyalgia.
1.8. The importance of health professional–patient communication
As evidenced by the results of Sale et al. [50] and Dobkin et al.[11], 1 of the critical barriers to pain management is inadequatecommunication between patients and health professionals aboutpain. The Jacobson et al. (2009) review [21] revealed bothhesitancy on patients’ part to communicate their pain andpatient-perceived inadequacy of health professional communica-tion about pain. Specifically, patients wanted to be more activein their care and for their doctors to be open and honest and to ad-dress their fears regarding cancer pain management.
Communication factors have been found to have a significantimpact on patient adherence to pain medication. A meta-analysisof existing studies [64] revealed a 19% higher risk of nonadherenceamong patients whose physician communicated poorly, whereasthe odds of patient adherence were 1.62 times higher if the physi-cian had received communication training. For example, in a studyof 89 breast cancer patients, those who rated their physicians asmore receptive and facilitative reported fewer pain barriers, betterpain management, and higher satisfaction with care.
1.9. The communication cycle in chronic pain
Little is known about the specific reasons for nonadherence inchronic pain samples because it has been so infrequently studied;however, communication clearly plays a role. Chronic pain patientsand primary HCPs typically start the treatment cycle early in thecourse of the pain symptom (often after an acute injury) with theshared goal of ameliorating the pain. In the case of treating anacute injury, 75% of patients will improve with the initially pre-scribed treatment, regardless of the prescription [43]. That is,75% of cases of acute pain improve in the ensuing 3–6 months,although many will have recurrent problems. Nonetheless, chronicpain patients typically begin their ‘‘chronic pain career’’ as ‘‘treat-ment failures.’’ That is, some health care professionals considerthese patients to have failed the usual course of treatment, which,in their experience, has been effective in the majority of cases. Pa-tients, however, do not typically view themselves as having failedthe treatment, but rather view the treatment previously recom-mended as having failed them. Kenny [25] documented the viciouscycle of frustration that often results in the breakdown in commu-nication in which patients feel that they are not being listened toand are being stigmatized, and the doctor feels powerless andhelpless to intervene. Once established, this breakdown in commu-nication is likely to lead to both a lower chance of the HCP recom-mending the most appropriate treatment, but also the greatestlikelihood of the patient not adhering to future recommendationswhen made.
1.10. What communication styles increase adherence to painmedication?
Although research into specific communication strategies thatfacilitate adherence in pain management is rare, such communica-tion strategies are likely not very different from those that facilitateeffective doctor–patient relationships in general. Patient-centeredcare in which the patient’s experience, priorities, and views areelicited and respected to foster a collaborative relationship andempower and validate the patient and achieve shared decision
PROXIMAL: Increased sa�sfac�on Be�er Informed Be�er doctor -pa�ent communica�on
INTERMEDIATE: Increased inten�on towards health behavior Adherence with recommenda�ons
DISTAL: Improved pa�ent outcomes
Fig. 1. Proposed model of the role of the health care professional (HCP) and the patient (PT) in enhancing communication during consultations with a view to enhancingpatient outcomes. AdaptedQ14 from de Haes and Bensing (2008).
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making is critical [12]. The NICE guidelines for optimal communica-tion to increase adherence generally [37] emphasize a frank,nonjudgmental, and open approach to asking about adherence;acknowledging how common nonadherence is; exploring barriersand facilitators to adherence; providing verbal and written evi-dence-based information couched without jargon; tailoring com-munication to suit the individual’s preferences for the amount andstyle of information; and a patient-centered approach that includesshared decision making, recognizing that the patient’s decision mayultimately not be in accord with medical recommendations.
Physician responses to emotion may also influence adherenceto pain recommendations. For example, in a recent study of wo-men with severe menstrual pain [59], GPs communicated eitherin a warm and empathic or a cold and formal way and either raisedpositive or uncertain expectations of pain relief. Results showedthat only warm and empathic communication combined with po-sitive expectations led to a significant decrease in state anxiety andan expectation of better pain relief. The authors concluded thatcommunicating in warm and empathic way combined with raising
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positive expectations seems to lead to the most favorable effects onpatients’ state anxiety and outcome expectancies (and thereforelikely adherence).
De Haes and Bensing [10] recently proposed a model to guidedoctor–patient communication. They argued that medical commu-nication consists of 6 functions: (1) fostering the doctor–patientrelationship, (2) eliciting information from the patient, (3) provid-ing information relevant to their presenting symptom, (4) facilitat-ing shared decision making, (5) enabling health behaviors, and (6)responding to affect. They argue that these functions are importantoutcomes in themselves and link the behavior of the HCP with pa-tient adherence (see Fig. 1 for a diagrammatic representation).
1.11. Are current communication practices adequate?
Evidence suggests that communication practices related to paincould be improved. For example, a recent survey of Spanish oncol-ogists [54] reported that the majority believed that oncologistscommonly failed to comprehensively and systematically evaluate
pain, provide written information, and confirm that patients under-stand what they are told. In another study of pharmacist–patientcommunication, 100 randomly selected Swedish pharmacies weresent 3 simulated patients each with various prescriptions. Simu-lated patients recorded details of the exchange on forms after eachvisit. No questioning occurred for 37% of visits, no information wasgiven for 26%, and negative comments from the simulated patientabout previous use of the medication were commonly ignored.Thus, an important opportunity to increase adherence to medica-tion was not maximized. In a rare study of provider views on thistopic, Matthias et al. [34] found that HCPs reported feeling pres-sured into prescribing opioids to chronic pain patients, despite wor-ries that they had about secondary gain and/or the believability ofthe patient’s pain. These feelings led doctors to feel frustrated,and the doctors believed that this emotional toll compromised theirability to adopt helpful communication styles with their patients.
1.12. Interventions to increase adherence
There is a large literature on interventions to increase adher-ence across health disorders. However, the results of trials aremixed. In their 2002 meta-analysis, McDonald et al. [35] found thatonly 49% (19 of 39) of treatment comparisons in the literature hadresulted in improvement in adherence, although the majority ofthese had translated into associated clinical benefits (17 of 19). Al-most all the effective treatments included a range of strategies,including more accessible care, education, supportive counseling,reminders, self-monitoring, reinforcement, and other forms of psy-chotherapy. In the chronic pain literature, however, there has beenonly 1 study assessing the efficacy of increasing levels of contact asan intervention for patient adherence [63]. Unfortunately, therewas little evidence from this trial to support any of the interven-tions, although the absence of a no-intervention control groupmakes the interpretation of results difficult. Although there is noparticular reason to think that interventions that promote adher-ence in other illnesses would not be relevant to chronic pain, inmost settings, the complex interventions that have so far beenshown to have demonstrated efficacy are expensive and unlikelyto be affordable under public health systems.
There have been a number of studies that have aimed to inves-tigate changes in the nature of exercise regimens and evaluate theirimpact on adherence to exercise in patients with a range of painproblems. As with general interventions to promote adherence,Jordan et al. [24], in their Cochrane review, were unable to identifyparticular interventions that were associated with increasedadherence, although there was some suggestion that individualizedexercise therapy may result in better adherence.
Despite the absence of interventions focused specifically onimproving adherence in chronic pain or clear recommendationsfor particular forms of self-management or exercise programs,there is strong evidence from a recent meta-analysis that briefphysician training in communication can improve patient adher-ence. Indeed, as noted previously, the patients of physicians whohad attended communication training were 1.62 times more likelyto be adherent [64]. Training physicians in communication skillshas only been examined in the chronic pain literature within thepast decade. Alamo et al. [2] trained physicians in shared decisionmaking. In their study, patients with chronic pain were lessdistressed 1 year later and had fewer tender joints with a trendtoward less pain 12 months later if they saw a physician whohad been randomized to the communication training intervention.Beiber et al. [3] were more recently able to effectively train physi-cians treating patients with fibromyalgia to communicate better,as rated by the patients. However, these benefits did not translateinto clinical benefits. However, the study was likely to be under-powered as there were only 84 participants in the trial. Unfortu-
Please cite this article in press as: Butow P, Sharpe L. The impact of communi10.1016/j.pain.2013.07.048
nately, neither of these studies assessed adherence; however,adherence would be a plausible mechanism for these findings.
2. Summary
Adherence is a much neglected topic in the area of pain. Despitea plethora of trials on the efficacy of various intervention strate-gies, there are relatively few studies that have tried to documentrates of nonadherence, reasons for nonadherence, or interventionsto improve adherence. However, adherence is a problem in that asizable minority of patients are not adherent to interventions.There is, at least preliminary evidence, that nonadherence cancompromise the gains seen from effective interventions [40]. Todate, interventions that specifically target adherence have not beenapplied to pain. However, in the general literature, 2 issues areimportant: (1) communication between the doctor and patientand (2) the doctor understanding the reasons for nonadherenceand addressing them. Research confirms that communicationtraining is 1 way in which to enhance patient outcomes. Althoughwe need more research to make firmer recommendations aboutimproving adherence, consultations that consider the patient’sview and encourage them to share in the decision making regard-ing treatment are likely to be associated with better adherence.
Conflict of interest
None.
Uncited references
[5,46,58].
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