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Concerns about medication and medication adherence in patients with chronic pain recruited from general practice
  1. Susan Broekmans1,
  2. Steven Vanderschueren1,2
  1. 1The Leuven Center for Algology and Pain Management, University Hospitals Leuven, Leuven, Belgium
  2. 2Department of Internal Medicine, University Hospitals Leuven, Leuven, Belgium
  1. Correspondence to Susan Broekmans
    University Hospitals Leuven - The Leuven Center for Algology and Pain Management, Weligerveld 1 Pellenberg 3212, Belgium; susan.broekmans{at}

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Implications for nursing practice and research

  • Patient concerns and beliefs about medication are associated with overuse and underuse of medication.

  • Identifying and addressing these concerns may improve adherence.

  • Further research is needed to examine whether training of healthcare practitioners (including nurses) has an effect on patients' concerns and medication adherence.


Chronic non-malignant pain is a long-lasting condition, with a complex pathophysiology, often accompanied with dysfunctional pain behaviour. Chronic pain affects about 19% of the population in Europe.1 Due to the complex nature of chronic pain, its treatment needs a multidisciplinary and multimodal approach. Still, medication remains a cornerstone of chronic pain treatment. Yet, medication non-adherence, both underuse and overuse of medication, is frequent among chronic pain patients.2 McCracken et al showed previously that patients' concerns about medication predicted both the extent and direction of non-adherence in secondary and tertiary care.3 The current study examines the associations between concerns about medication and non-adherence reported by patients with non-malignant chronic pain encountered in primary care.


The sample consisted of 239 patients with chronic pain. Patients were contacted through 20 general practitioners (GPs) from South West England. A total of 664 chronic pain patients (CPP) were asked for their permission to be contacted directly by the research team. After one follow-up reminder, 239 completed questionnaires (overall response rate 36%) were received.

Concerns and beliefs about pain were assessed using the Pain Medication Attitudes Questionnaire (PMAQ), a 47-item questionnaire including 7 subscales: concerns about addiction, concerns about withdrawal, concerns over side effects, mistrust in doctors, perceived need of medication, concerns over scrutiny from others and worries about tolerance. Items were rated on a 6-point numerical scale (0=never true to 5=always true).

Medication adherence was assessed by patients' self-report. Underuse of medication was assessed by two questions about the frequency with which patients took less medication than prescribed and missed doses. Overuse was assessed by asking about the frequency of taking more medication than prescribed and taking extra doses. Participants responded to these questions on a 5 point scale (0=never, 4=always).

Finally, participants reported the frequency of 10 common adverse effects of analgesics.

Correlation analyses were conducted to explore the relations between patient concerns, level and direction of non-adherence and frequency of side effects experienced. Multiple regression analyses were calculated to examine combined and unique relations of the PMAQ scores with measures of medication adherence.


Almost half of the participants indicated that they took less medication (48%) and/or missed prescribed doses at least some of the time (52%). Approximately a quarter of the participants indicated that they either took more (24%) or an extra dose (31%) at least some of the time. The average rate of general non-adherence was 38%.

Patient concerns about medication are more predictive of non-adherence than level of pain or the frequency of side effects. Underuse correlated positively with mistrust of prescribing doctor and negatively with concern about withdrawal. Overuse correlated positively with perceived need for medications and concerns about side effects.


Although the operational definition of non-adherence remains unclear (the findings do not correspond with measurement described in the methodology), the results of this study show once more that medication non-adherence is common in CPP. The findings confirm that medication concerns are strong predictors of non-adherence in primary care patients. Medication concerns differed depending on the direction of non-adherence. This finding accentuates the need to approach underuse and overuse as two separate forms of medication non-adherence in CPP. This research makes an important contribution by illustrating which concerns predict underuse or overuse, respectively. The authors suggest that appropriate training and professional development of GPs might diminish concerns and increase medication adherence. Patient–doctor communication is indeed crucial in addressing adherence. Previous research showed that training doctors to better communicate has a positive effect on medication adherence.4 Therefore, addressing and alleviating concerns about analgesic medication may promote concordance between patient and caregivers.


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  • Competing interests None.

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