Health service issues in pain management
The way that healthcare services are organised can have a significant impact on pain management. Despite the fact that there is good evidence supporting many of the treatments for pain, there is still an 'evidence – practice gap' for cancer pain, [1] and patients continue to unnecessarily experience pain that could be effectively treated. 

What is known
The majority of pain can be effectively controlled with available treatments, and using the approaches described in the World Health Organisation three-step analgesic ladder. [2, 3] However barriers to patients receiving effective treatments include:

• Inadequate recognition and assessment of pain by healthcare providers [4] 
• Clinician knowledge and attitudes that result in poor or inadequate prescribing of analgesics. [5]

A systematic review which studied interventions to address these problems did not show any consistent improvement in patients’ pain severity, although patient satisfaction increased. [4] A meta-analysis of 19 studies suggested that palliative care teams have a small but significant positive impact on patients’ pain, although the quality of the studies was very variable. [6]

The prevalence of uncontrolled pain is an important quality indicator for health services. However because there is significant diversity in approaches to pain assessment it is difficult to systematically compare health service outcomes in relation to this indicator. [7,8]

What it means in practice

• Pain in palliative care patients should be actively identified, carefully assessed, and treated promptly. [9]  
• Pain assessment should be integrated into routine clinical care, and documented using appropriate assessment tools that facilitate regular reassessment. [1,10] 
• Patients and their families should be involved in the pain management plan, eg, by the use of pain diaries. [9] 
• The best practice approach to pain management is proactive, with round the clock prescription of analgesics, provision for extra medication for 'breakthrough pain' and regular reassessment of pain and side effects of medications. Inappropriate practices such as regular use of intramuscular injections, or sole reliance on 'as needed' analgesics should be avoided. [9] 
• Use of validated pain assessment tools and routine screening allow quality of care to be monitored. [1]

Finding out more
Guidelines

• Guideline for the management of cancer pain in adults and children. American Pain Society (Clinical practice guideline, no. 3) 2005 

Link to prescribing information
NB Prescribing information may not yet have been updated to include the most recent evidence.

• Online Palliative Medicine Handbook 
  Click on “Notes on Prescribing”
  This prescribing information is from the UK and some medications may not be available in Australia
• Therapeutic Guidelines for Palliative Care
  An Australian source of prescribing information not available directly online through CareSearch, but can be accessed online in most hospitals, or purchased.

Overview article

• Pain Relief as a Human Right  International Association for the Study of Pain, Clinical Updates, September 2004
• American Pain Society recommendations for improving the quality of acute cancer pain management. [9]

Related CareSearch pages
Pain assessment tools
Opioid analgesics
Adjuvants and radiotherapy
Non-pharmacological approaches to pain management

References

1. National Institute of Clinical Studies. Institutional approaches to pain assessment and management. Prepared by the Health Technology Assessment Unit, University of Adelaide: 2003.  
2. Azevedo Sao Leao Ferreira K., Kimura M, Jacobsen Texeira M. The WHO analgesic ladder for cancer pain control, twenty years of use. How much pain relief does one get from using it? Supportive Care in Cancer. 2006 Nov;4(11):1086-93. 
3. Hanks GW, Conno F, Cherny N, Hanna M, Kalso E, McQuay HJ, et al., Morphine and alternative opioids in cancer pain: the EAPC recommendations. British Journal of Cancer. 2001 Mar 2;84(5):587-93.  
4. Goldberg GR, Morrison RS. Pain management in hospitalised cancer patients: A systematic revieW. Journal of Clinical Oncology. 2007 May 1;25(13):1792-1801. 
5. Jacobsen R, Sjogren P, Moldrup C, Christup L. Physician-related barriers to cancer pain management with opioid analgesics: a systematic review. Journal of Opioid Management. 2007 Jul-Aug;3(4):207-14. 
6. Higginson IJ, Finlay IG, Goodwin DM, Hood K, Edwards AG, Cook A, et al. Is there evidence that palliative care teams alter end-of-life experiences of patients and their caregivers? Journal of Pain and Symptom Management. 2003 Feb;25(2):150-168.  
7. Lorenz KA, Lynn J, Dy S, Wilkinson A, Mularski RA, Shugarman LR, et al. Quality measures for symptoms and advance care planning in cancer: a systematic review. Journal of Clinical Oncology. 2006 Oct 20;24(30):4933-8.  
8. Gordon DB, Pellino TA, Miaskowski C, McNeill JA, Paice JA, Laferriere D, et al. A 10-year review of quality improvement monitoring in pain management: recommendations for standardized outcome measures. Pain Management Nursing. 2002 Dec;3(4):116-30.  
9. Gordon DB, Dahl JL, Miaskowski C, McCarberg, B, Todd KH, Paice JA, et al. American Pain Society recommendations for improving the quality of acute cancer pain managemenT: American Pain Society Quality of Care Task Force. Archives of Internal Medicine. 2005 Jul 25;165(14):1574-1580. 
10. Qaseem A, Snow V, Shekelle P, Casey DR Jr, Cross JT Jr, Owens DK, et al. Evidence-based interventions to improve the palliative care of pain, dyspnea, and depression at the end of life: a clinical practice guideline from the American College of Physicians. Annals of Internal Medicine. 2008 Jan 15;148(2):141-146. 

This page was created on 23 May 2008 and is due for review in May 2010