Flemming, K. (2010). The use of morphine to treat cancer-related pain: A synthesis of quantitative and qualitative research. Journal of Pain and Symptom Management, 39(1), 139–154. 

• To examine the context of the use of morphine to manage cancer-related pain
• To establish how the views of healthcare professionals, patients, caregivers, and prescribers affect the use of morphine in practice
• To provide a case study and critique of critical interpretive synthesis (CIS) to synthesize a diverse body of evidence

• Databases searched were MEDLINE on OvidSP (1950–2008), CINAHL (1982–2008), EMBASE (1980–2008), PsycINFO (1967–2008), Health Management Information Consortium, and Social Sciences Citation Index accessed via Web of Science (1956–2008).
• Authors designed a search strategy that combined recognized search terms related to morphine (predominantly, terms used by the Cochrane Pain, Palliative and Supportive Care Group for oral morphine for cancer pain) with terms to identify qualitative research. Authors supplemented electronic searching with manual searches and contact with experts.
• Studies were included if they
  • Described results of original qualitative research.
  • Referred to the use of opioids for cancer pain.
  • Were published in English.
• Authors did not cite exclusion criteria.

Electronic searches retrieved a total of 2,886 records. After screening by title, 255 abstracts were retrieved for initial review. Of these the author obtained 30 articles for full review. Reference chaining yielded another 10 articles. A final sample of 19 resources met criteria and were analyzed. The author used a quality-appraisal checklist. Findings from each qualitative report were identified and compared with recommendations regarding effectiveness. Two resources provided the framework of comparison: Cochrane Systematic Review of Oral Morphine for Cancer Pain and the European Association for Palliative Care recommendations regarding use of opioids for cancer pain.

• The sample, across studies, included 465 patients.
• Study samples included male and female patients and self-identified African Americans.
• Samples included caregivers, nurses, patient and caregiver triads, and nursing and medical students. Patients included those who adhered and did not adhere to prescribed regimens, reluctant opioid takers, and older individuals in the community.

The study resulted in the synthesis of four arguments.

• Concerns about opiods:
  • Morphine was the drug of choice.
  • Patients, caregivers, and professionals had deep concerns about starting and continuing morphine therapy. The introduction of morphine was perceived as an accompaniment to worsening disease and death—a last resort.
  • The addictive potential of morphine was a barrier to its use, and anxieties about addiction influenced patients, caregivers, healthcare professionals, and medical and nursing students.
• Opioid use as a balancing act and trade-off:
  • Patients grappled with wanting pain relief while wanting to maintain functionality in their lives. They thought that, if they took opioids to relieve pain, they could experience adverse effects.
  • Adverse effects were viewed as a burden and were either tolerated to achieve relief or avoided by not taking medication.
  • The adverse effect most frequently mentioned was mental clouding and sleepiness.
  • After pain was so severe that taking opioids was the only alternative, the trade-off with side effects became acceptable. This was often when death was imminent. In many cases, patients took the opioids out of concern for others who were witnessing their pain.
• Existential meaning of cancer and cancer pain: Patients identified the meanings that follow.
  • Severe pain negated patients’ will to live.
  • Pain was a reminder of the presence of the cancer.
  • Severe pain indicated worsening disease and impending death.
  • Pain was vicious and exceeded any sense of control.
  • Patients feared that pain would increase before death.
  • Pain was tied up with all the emotions, fears, and uncertainties about the cancer diagnosis.
  • Taking opioids meant the cancer was out of control.
  • Fear of pain with dying was greater than the fear of dying itself.
  • Death would be a release from pain.
  • Cancer pain is a personal and private experience that no one else can understand.
• Intersubjectivity of pain: Cancer pain affects more than just the person experiencing it; it affects health professionals, caregivers, and the patient. Themes in this area follow.
  • Role and influence of health professionals:
    • Fears and concerns about addiction and adverse effects were implicitly or explicitly communicated to patients.
    • Teamwork involving nurses, physicians, patients, and caregivers was crucial to effective pain management.
  • Role of caregivers:
    • Feelings of conflict over how much control to assume in managing analgesia and how much control to give to nurses and the patient.
    • Dose-juggling responsibilities.
    • Despite education, caregivers were skeptical about problems of addiction.
    • They experienced fear, suffering, and helplessness and futility in the setting of unrelieved pain.
  • Management of pain by the patient:
    • Patients described a parallel existence—striving to live while strategizing to have a comfortable death.
    • Use of regular analgesia did not fit with some individuals’ self-image and led to conflict and guilt.
    • Various physical and cognitive strategies to manage pain were used. Most involved input from caregivers. This was a positive benefit for both.

Patients were selective about their disclosure of pain severity. The degree of confidence and trust in providers influenced reporting about pain, treatment choices, and use of opioids. Negative feeling toward providers led to reluctance to report pain.

This review provides a wealth of powerful and meaningful information that healthcare professionals can use to improve how they work with patients and caregivers in the management of cancer-related pain. Findings suggest that many professionals still have concerns about addiction with the use of opioids in the treatment of chronic cancer pain and that these professionals intentionally or unintentionally communicate these concerns, adversely influencing patients' and caregivers' experiences. Findings point to the importance of aggressive management and prevention of adverse side effects from opioids, to have a positive effect on the patient’s sense of the trade-offs involved with opioids. Findings support the concept that a team approach involving providers, caregivers, and patients and trust among team members are crucial to effective pain management.

Nurses can use the themes to guide open discussion and to anticipate potential issues regarding the use of opioids for pain management.