Educational interventions
for cancer pain
Mike Bennett
St Gemma’s Professor of Palliative Medicine
University of Leeds, UK
How good is cancer pain
management?
WHO ladder for cancer pain
Effectiveness of the ladder as a whole
Early evidence
• Many observational studies 1985-90
• Reported proportion of patients that achieved
adequate control
• 3220 patients studied
• 2361 (73%) achieved control
• One study documented pain scores
• 1229 patients; mean reduction in pain intensity >65%
Ventafridda et al 1987
• Around 25% of patients do not get adequate pain
control
Prevalence
• Systematic reviews
• 48% of patients with early stage cancer
• 59% undergoing cancer treatment
• 64-75% with advanced disease
Hearn and Higginson 2003
Van den Beuken-van Everdingen et al 2007
• Surveys (n=5000)
• 72% of European community patients
• 77% in UK
Breivik et al 2009
Severity
• Secondary care settings (n=349)
• Using 0-10 rating scale (0=no pain, 10=worst)
• Average pain = mean 3.7
• Worst pain = mean 4.8
• Two thirds of patients rate greater than 5/10
Klepstad et al 2002, Yates et al 2002
• Community settings (n=617 in UK)
• Average pain = 6.4
• 90% rated greater than 5/10
• 25% not receiving any analgesia
VOICES data 2011
Prescribing data
• Pain Management Index
• indicates appropriateness of analgesic prescription in
relation to level of pain
• negative score suggests under treatment
• Review of 26 studies
• Prevalence of negative PMI in 8 - 82% populations
studied
• weighted mean = 43%
• nearly 1 in 2 patients were ‘undertreated’
Deandrea et al Ann Onc 2008
Will a better opioid or more
knowledge of genetics solve the
problem alone?
What are the problems?
Barriers to good cancer pain
control
Key barriers
• Patients and carers
• reluctant to complain about symptoms
• fear pain and don’t know how to get help
• lack knowledge about strong opioid analgesia
• fear adverse effects leading to poor adherence.
• Healthcare professionals
• fail to assess pain adequately
• reluctant to prescribe and monitor effective analgesia
• provide insufficient education to promote self-management
• Healthcare systems
• fail to recognise patients with cancer pain
• communicate data on pain ineffectively
• prevent patients receiving timely analgesia
Patho-physiology:
 Site of cancer
 Metastases (bone)
 Co-morbidity
 Pain mechanism (neuropathic)
Patient factors:
 Physical ability / PS
 Attitudes / knowledge to pain and
analgesia
 Medication behaviour




Social context:
 Social support (living alone)
 Living in care home
 Attitudes + knowledge of carers
 Socio-economic status
Professionals:
 Assessment and examination
 Knowledge and attitudes
 Communication with other professionals
(between primary and secondary care)




Cultural and religious beliefs
Self-efficacy
Patient held record of drugs
Level of distress
Access to prescriber
Forward planning / anticipation
Information provision to patients
Non-pharmacological approaches
Health services:
 Access to drugs
 Palliative care advice 24/7
 OOH help at home
 Inpatient admission
 Gold Standards Framework
 Access to interventional pain management
 Practice based pharmacist
Policy:
 Education and training
 End of Life Care strategy
Educational interventions
Improving knowledge
• Classroom approaches for professionals
• significant benefits on knowledge
• ..but moderately strong evidence that there is no impact on patient
outcomes
• No clear changes in professional behaviours
Patient satisfaction
• Associated with these behaviours:
•
•
•
•
Physician stating importance of pain control
Receiving instructions to manage pain at home
Managing side effects
Allaying fears about addiction
Dawson R, Spross JA, Jablonski ES, Hoyer DR, Sellers DE, Solomon MZ. Probing the paradox of patients'
satisfaction with inadequate pain management. J Pain Symptom Manage. 2002 Mar;23(3):211-20
Reid CM, Gooberman-Hill R, Hanks GW. Opioid analgesics for cancer pain: symptom control for the living or comfort
for the dying? A qualitative study to investigate the factors influencing the decision to accept morphine for pain
caused by cancer. Ann Oncol 2008;19(1):44-8.
Assessment
• Pain outcomes significantly improved with:
• Pain assessment presented to clinicians who use it in
consultations
• (assessment alone doesn’t help)
Trowbridge R, Dugan W, Jay SJ, Littrell D, Casebeer LL, Edgerton S, Anderson J, O'Toole JB. Determining the
effectiveness of a clinical-practice intervention in improving the control of pain in outpatients with cancer. Acad Med
1997;72(9):798-800.
Velikova G, Booth L, Smith AB, Brown PM, Lynch P, Brown JM, Selby PJ. Measuring quality of life in routine oncology
practice improves communication and patient well-being: a randomized controlled trial. J Clin Oncol. 2004 Feb
15;22(4):714-24.
Management
• Pain outcomes significantly improved with:
• use of specific prescribing guidelines by clinicians
Du Pen SL, Du Pen AR, Polissar N, Hansberry J, Kraybill BM, Stillman M, Panke J, Everly R, Syrjala K. Implementing
guidelines for cancer pain management: results of a randomized controlled clinical trial. J Clin Oncol 1999;17(1):36170.
Cleeland CS, Portenoy RK, Rue M, Mendoza TR, Weller E, Payne R, Kirshner J, Atkins JN, Johnson PA, Marcus A.
Does an oral analgesic protocol improve pain control for patients with cancer? An intergroup study coordinated by
the Eastern Cooperative Oncology Group. Ann Oncol. 2005;16(6):972-80.
Patient barriers to good pain
control
• Poor knowledge and attitudes associated with
– Reluctance to start opioids
– Poor medication adherence
– Higher pain intensity
Gunnarsdottir S, Donovan HS, Serlin RC, Voge C, Ward S. Patient-related barriers to pain management:
the Barriers Questionnaire II (BQ-II). Pain 2002; 99(3):385-96.
Valeberg BT, Miaskowski C, Hanestad BR, Bjordal K, Paul S, Rustøen T. Demographic, clinical, and pain
characteristics are associated with average pain severity groups in a sample of oncology outpatients. J
Pain 2008;9(10):873-82.
Educational interventions
Interventions
• Explained causes of pain and promoted self management
• Addressed common fears about opioids
• Usually face-to-face coaching session combined with written
information
Pain intensity
Average pain intensity
-1.1 [-1.80, -0.41]
Maximum pain intensity
-0.78 [-1.21, -0.35]
Mechanisms of action
• Medication adherence
• No benefits, but poorly measured
• Interference from pain on daily activity
• Good evidence of no benefit
• Others
• ? reduced anxiety
• ? Improved coping / self efficacy
(DVD video links)
Outcomes at 4 weeks
• PPQ subscale (knowledge and attitudes)
• Median % improvement = 34% (p = 0.04)
• belief in addiction to medicine (37% improvement, p=0.008)
• belief that pain will get better (30% improvement, p=0.008)
• Brief Pain Inventory (pain intensity)
• Median % improvement = 9.6% (p=0.02)
• Acceptability
• DVD acceptable and patients very satisfied with content
• But….uncontrolled, observational study
• Any type of chronic pain
• 4 studies identified
• 400 patients randomised, 335 with follow up data
• Arthritis, knee pain, pain clinic, cancer pain
Type of interventions
• focus on pain assessment
• provision of information and advice on dosage
• sometimes by telecare
• and managing adverse effects of medication
Pain intensity at 3 month follow up
Average pain intensity
-0.49 [-0.79, -0.20]
Mechanisms of action
• Adverse events
• Data from 2 studies suggest > 50% reduction overall
• ? better medicines management
• Satisfaction
• Significant improvement with intervention
• Reduced consultations with GPs
• ? self efficacy, improved coping
Implications for practice
• Screening for misunderstandings about pain
and opioids
• address these aspects with advice and information
• role for pharmacists and specialist nurses?
• Effects of education on cancer pain similar to:
• adding paracetamol to opioids
• pain reduced by 0.4 to 0.6 points on BPI
• adding gabapentin to opioids
• Pain reduced by 0.8 points on BPI
Stockler et al 2004
Caraceni et al 2004
What are the most important
components?
Kroenke paper
Intervention
• Care management
• Telephone calls from nurse (linked with physician) to
• Assess symptom response and medication adherence
• Provide specific education
• Adjust treatment according to protocol
• Baseline, follow-up calls at 1, 4, and 12 weeks
• Additional calls triggered by automated monitoring
Intervention
• Automated monitoring
• Interactive voice recording / web based surveys
• Twice weekly in first 3 weeks; weekly, monthly
• Medication management
• Protocol provided to clinicians (single clinician per patient)
Results
Average effects versus number of responders
Average
Average
Summary
• For your next patient with cancer pain
• Pay them attention
• State importance of pain management
• Assess their pain systematically and use this in your
management plan
• Check and address fears about cancer pain and barriers to taking
opioids
• Use specific prescribing guidelines
• Educate patients on how to take their drugs
• especially older people
• try to involve a pharmacist in this process
• Review and monitor their pain control
Thank you
m.i.bennett@leeds.ac.uk