Trajectories of Pain and Analgesics in Oncology Outpatients With Metastatic Bone Pain

Published:February 11, 2011DOI:


      A large proportion of oncology outpatients with bone metastasis report unrelieved pain that significantly interferes with daily functioning and quality of life. However, little is known about the longitudinal pattern of pain intensity and analgesic prescriptions or use. Moreover, despite considerable advantages, the use of sophisticated statistical techniques, such as hierarchical linear modeling (HLM) has not been applied to the study of pain and analgesic outcomes. In a prospective longitudinal study, HLM was used to explore predictors of pain intensity and analgesic prescription and intake at the time of enrollment into the study (intercept) and over the course of 6 weeks (trajectory) in a sample of oncology outpatients with bone metastasis who received standard care for pain. In addition to corroborating known predictors of pain intensity, previously unrecognized variables were found that appear to affect both pain and analgesic outcomes. Importantly, some of the predictors of the trajectories of pain intensity and analgesic use (ie, pain-related distress and Pain Management Index (PMI) scores) are particularly amenable to interventions. Findings from this study suggest that sophisticated statistical modeling can be used in pain research to identify individual risk factors and propose novel targets that can be used to improve pain management in oncology outpatients with bone metastasis.


      Findings from this study suggest that a large amount of inter-individual variability exists in patients' experiences with cancer pain and analgesic use. Future studies need to elucidate the mechanisms that underlie these differences.

      Key words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The Journal of Pain
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Benedetti C.
        • Brock C.
        • Cleeland C.
        • Coyle N.
        • Dube J.E.
        • Ferrell B.
        • Hassenbusch 3rd, S.
        • Janjan N.A.
        • Lema M.J.
        • Levy M.H.
        • Loscalzo M.J.
        • Lynch M.
        • Muir C.
        • Oakes L.
        • O’Neill A.
        • Payne R.
        • Syrjala K.L.
        • Urba S.
        • Weinstein S.M.
        NCCN Practice Guidelines for Cancer Pain.
        Oncology (Williston Park). 2000; 14: 135-150
        • Body J.J.
        • Bartl R.
        • Burckhardt P.
        • Delmas P.D.
        • Diel I.J.
        • Fleisch H.
        • Kanis J.A.
        • Kyle R.A.
        • Mundy G.R.
        • Paterson A.H.
        • Rubens R.D.
        Current use of bisphosphonates in oncology. International Bone and Cancer Study Group.
        J Clin Oncol. 1998; 16: 3890-3899
        • Bryk A.S.
        • Raudenbush S.W.
        Hierarchical Linear Models: Applications and Data Analysis Methods. Advanced Qualitative Techniques in the Social Sciences, 1.
        Sage Publications, Inc., Thousand Oaks, CA1992
        • Cleeland C.
        Research in cancer pain. What we know and what we need to know.
        Cancer. 1991; 67: 823-827
        • Cleeland C.S.
        • Gonin R.
        • Hatfield A.K.
        • Edmonson J.H.
        • Blum R.H.
        • Stewart J.A.
        • Pandya K.J.
        Pain and its treatment in outpatients with metastatic cancer.
        N Engl J Med. 1994; 330: 592-596
        • Corizzo C.C.
        • Baker M.C.
        • Henkelmann G.C.
        Assessment of patient satisfaction with pain management in small community inpatient and outpatient settings.
        Oncol Nurs Forum. 2000; 27: 1279-1286
        • Dawson R.
        • Spross J.A.
        • Jablonski E.S.
        • Hoyer D.R.
        • Sellers D.E.
        • Solomon M.Z.
        Probing the paradox of patients’ satisfaction with inadequate pain management.
        J Pain Symptom Manage. 2002; 23: 211-220
        • Dudley W.N.
        • McGuire D.B.
        • Peterson D.E.
        • Wong B.
        Application of multilevel growth-curve analysis in cancer treatment toxicities: The exemplar of oral mucositis and pain.
        Oncol Nurs Forum. 2009; 36: E11-E19
        • Ferrell B.R.
        • Rhiner M.
        • Rivera L.M.
        Development and evaluation of the family pain questionnaire.
        J Psychosoc Oncol. 1993; 10: 21-35
        • Foley K.M.
        The treatment of pain in the patient with cancer.
        CA Cancer J Clin. 1986; 36: 194-215
        • Gear R.W.
        • Miaskowski C.
        • Gordon N.C.
        • Paul S.M.
        • Heller P.H.
        • Levine J.D.
        Kappa-opioids produce significantly greater analgesia in women than in men.
        Nat Med. 1996; 2: 1248-1250
        • Ger L.P.
        • Ho S.T.
        • Wang J.J.
        • Cherng C.H.
        The prevalence and severity of cancer pain: A study of newly-diagnosed cancer patients in Taiwan.
        J Pain Symptom Manage. 1998; 15: 285-293
        • Gordon D.B.
        • Dahl J.L.
        • Miaskowski C.
        • McCarberg B.
        • Todd K.H.
        • Paice J.A.
        • Lipman A.G.
        • Bookbinder M.
        • Sanders S.H.
        • Turk D.C.
        • Carr D.B.
        American pain society recommendations for improving the quality of acute and cancer pain management: American Pain Society Quality of Care Task Force.
        Arch Intern Med. 2005; 165: 1574-1580
        • Gralow J.
        • Tripathy D.
        Managing metastatic bone pain: The role of bisphosphonates.
        J Pain Symptom Manage. 2007; 33: 462-472
        • Harris K.
        • Li K.
        • Flynn C.
        • Chow E.
        Worst, average or current pain in the Brief Pain Inventory: Which should be used to calculate the response to palliative radiotherapy in patients with bone metastases?.
        Clin Oncol (R Coll Radiol). 2007; 19: 523-527
        • Hedecker D.
        • Gibbons R.D.
        Longitudinal Data Analysis.
        1st ed. John Wiley & Sons, Hoboken, NJ2006
        • Jacox A.
        • Carr D.B.
        • Payne R.
        New clinical-practice guidelines for the management of pain in patients with cancer.
        N Engl J Med. 1994; 330: 651-655
        • Jenkinson C.
        • Coulter A.
        • Bruster S.
        • Richards N.
        • Chandola T.
        Patients’ experiences and satisfaction with health care: Results of a questionnaire study of specific aspects of care.
        Qual Saf Health Care. 2002; 11: 335-339
        • Karnofsky D.A.
        • Burchenal J.H.
        The Clinical Evaluation of Chemotherapeutic Agents in Cancer.
        in: MacLeod C.M. Evaluation of Chemotherapeutic Agents. 1st ed. Columbia University Press, New York, NY1949: p 196
        • Kim J.E.
        • Dodd M.
        • West C.
        • Paul S.
        • Facione N.
        • Schumacher K.
        • Tripathy D.
        • Koo P.
        • Miaskowski C.
        The PRO-SELF pain control program improves patients’ knowledge of cancer pain management.
        Oncol Nurs Forum. 2004; 31: 1137-1143
        • Krueger A.B.
        • Stone A.A.
        Assessment of pain: A community-based diary survey in the USA.
        Lancet. 2008; 371: 1519-1525
        • Kwekkeboom K.L.
        • Wanta B.
        • Bumpus M.
        Individual difference variables and the effects of progressive muscle relaxation and analgesic imagery interventions on cancer pain.
        J Pain Symptom Manage. 2008; 36: 604-615
        • Li L.W.
        From caregiving to bereavement: Trajectories of depressive symptoms among wife and daughter caregivers.
        J Gerontol B Psychol Sci Soc Sci. 2005; 60: P190-198
        • Li L.W.
        Longitudinal changes in the amount of informal care among publicly paid home care recipients.
        Gerontologist. 2005; 45: 465-473
        • Masters Steedman S.
        • Middaugh S.J.
        • Kee W.G.
        • Carson D.S.
        • Harden R.N.
        • Miller M.C.
        Chronic-pain medications: Equivalence levels and method of quantifying usage.
        Clin J Pain. 1992; 8: 204-214
        • Mercadante S.
        Malignant bone pain: Pathophysiology and treatment.
        Pain. 1997; 69: 1-18
        • Miaskowski C.
        • Cleary J.
        • Burney R.
        • Coyne P.
        • Finley R.
        • Foster R.
        • Grossman S.
        • Janjan N.
        • Ray J.
        • Syrjala K.
        • Weisman S.
        • Zahrbock C.
        Guideline for the Management of Cancer Pain in Adults and Children. Vol. 3. American Pain Society, Glenview, IL2005
        • Miaskowski C.
        • Dodd M.
        • West C.
        • Schumacher K.
        • Paul S.M.
        • Tripathy D.
        • Koo P.
        Randomized clinical trial of the effectiveness of a self-care intervention to improve cancer pain management.
        J Clin Oncol. 2004; 22: 1713-1720
        • Miaskowski C.
        • Dodd M.J.
        • West C.
        • Paul S.M.
        • Tripathy D.
        • Koo P.
        • Schumacher K.
        Lack of adherence with the analgesic regimen: A significant barrier to effective cancer pain management.
        J Clin Oncol. 2001; 19: 4275-4279
        • Mitera G.
        • Zeiadin N.
        • Kirou-Mauro A.
        • Deangelis C.
        • Wong J.
        • Sanjeevan T.
        • Sinclair E.
        • Danjoux C.
        • Barnes E.
        • Tsao M.
        • Sahgal A.
        • Chow E.
        Retrospective assessment of cancer pain management in an outpatient palliative radiotherapy clinic using the Pain Management Index.
        J Pain Symptom Manage. 2010; 39: 259-267
        • Rainville P.
        • Duncan G.H.
        • Price D.D.
        • Carrier B.
        • Bushnell M.C.
        Pain affect encoded in human anterior cingulate but not somatosensory cortex.
        Science. 1997; 277: 968-971
        • Raudenbush S.
        • Bryk A.
        Hierarchical Linear Models: Applications and Data Analysis Methods.
        2nd ed. Sage Publications, Thousand Oaks, CA2002
        • Raudenbush S.W.
        Comparing personal trajectories and drawing causal inferences from longitudinal data.
        Annu Rev Psychol. 2001; 52: 501-525
        • Rustoen T.
        • Moum T.
        • Padilla G.
        • Paul S.
        • Miaskowski C.
        Predictors of quality of life in oncology outpatients with pain from bone metastasis.
        J Pain Symptom Manage. 2005; 30: 234-242
        • Schumacher K.L.
        • Koresawa S.
        • West C.
        • Dodd M.
        • Paul S.M.
        • Tripathy D.
        • Koo P.
        • Miaskowski C.
        The usefulness of a daily pain management diary for outpatients with cancer-related pain.
        Oncol Nurs Forum. 2002; 29: 1304-1313
        • Singer J.D.
        • Willett J.B.
        Applied Longitudinal Data Analysis: Modeling Change and Event Occurrence.
        1st ed. Oxford University Press, New York, NY2003
        • Speer D.C.
        • Greenbaum P.E.
        Five methods for computing significant individual client change and improvement rates: Support for an individual growth curve approach.
        J Consult Clin Psychol. 1995; 63: 1044-1048
        • Sprangers M.A.
        • Schwartz C.E.
        Integrating response shift into health-related quality of life research: A theoretical model.
        Soc Sci Med. 1999; 48: 1507-1515
        • Valeberg B.T.
        • Miaskowski C.
        • Hanestad B.R.
        • Bjordal K.
        • Moum T.
        • Rustoen T.
        Prevalence rates for and predictors of self-reported adherence of oncology outpatients with analgesic medications.
        Clin J Pain. 2008; 24: 627-636
        • West C.M.
        • Dodd M.J.
        • Paul S.M.
        • Schumacher K.
        • Tripathy D.
        • Koo P.
        • Miaskowski C.
        The PRO-SELF(c): Pain Control Program–an effective approach for cancer pain management.
        Oncol Nurs Forum. 2003; 30: 65-73
      1. WHO: Cancer Pain Relief, 2nd ed. Geneva, World Health Organization, 1996

        • Yau V.
        • Chow E.
        • Davis L.
        • Holden L.
        • Schueller T.
        • Danjoux C.
        Pain management in cancer patients with bone metastases remains a challenge.
        J Pain Symptom Manage. 2004; 27: 1-3