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Health Service Issues

The way healthcare services are organised has 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, [1-2] and patients continue to unnecessarily experience pain that could be effectively treated.

What is known

Barriers to patients receiving effective pain management include:

  • Inadequate recognition and assessment of pain by healthcare providers
  • Clinician knowledge and attitudes that result in poor or inadequate prescribing of analgesics. [3]

A systematic review which studied a range of interventions to address these problems did not show 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 included was very variable. [5] Several studies suggest that education of professionals has the potential to improve outcomes for patients. [6] A systematic review of models of service delivery for cancer pain supports multidisciplinary pain consultation service, with referral via a clinical pathway, and also use of a clinical pathway as a separate intervention. [7] Use of a pain algorithm has been shown to improve pain outcomes. [29] Nurse-led interventions including pain assessment, interdisciplinary collaboration, and medicines management, as well as educational interventions including the use of protocols, led by specialist nurses, can improve patients’ understanding of their condition and their pain control. [8]

A number of population groups have been identified in the literature as being at higher risk for under-treatment of pain. These include nursing home residents and patients with cognitive impairment, [9-12] patients in intensive care units, [13] and members of minority ethnic communities. [14-15] 

Patient-related barriers to use of opioids are also important. [16-17] These include cognitive, emotional and communication barriers, all of which have been shown to affect patients’ adherence to medications. As palliative care is increasingly provided in the community, family caregivers also play an important part in pain assessment and pain management. Gaps in caregivers’ knowledge and education have been identified. [18-19]

The prevalence of uncontrolled pain is an important quality indicator for health services, and validated quality indicators are available. [20-22] However, because of diversity in approaches to pain assessment, it is difficult to compare health service outcomes in relation to pain. [21]

What it means in practice


  • Pain in palliative care patients should be actively identified, carefully assessed, and treated promptly. [23] 
  • Pain assessment should be integrated into routine clinical care, and documented using appropriate assessment tools that facilitate regular reassessment. [23] Use of validated pain assessment tools and routine screening allow quality of care to be monitored. [23, 27-28]
  • The best practice approach to pain management is proactive. This requires prescribing long-acting opioids to provide background analgesia whenever pain is a recurrent problem, and providing extra medication for 'breakthrough pain, [24] with 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. [23] Evidence-based protocols and educational processes within institutions should be developed to improve the quality of care. [25-26]
  • Patients and their families should be involved in the pain management plan, eg, by the use of pain diaries. [23] Caregivers need specific training in problem-solving skills regarding pain management. [19] Provision of education to patients and families can improve pain outcomes. [30]
  1. Deandrea S, Montanari M, Moja L, Apolone G. Prevalence of undertreatment in cancer pain. A review of published literature. Ann Oncol. 2008 Dec;19(12):1985-91. Epub 2008 Jul 15.
  2. National Institute of Clinical Studies. Institutional approaches to pain assessment and management. Adelaide: Health Technology Assessment Unit, University of Adelaide; 2003. (1.50MB pdf) 
  3. Jacobsen R, Sjogren P, Moldrup C, Christup L. Physician-related barriers to cancer pain management with opioid analgesics: a systematic review. J Opioid Manage. 2007 Jul-Aug;3(4):207-14.
  4. Goldberg GR, Morrison RS. Pain management in hospitalised cancer patients: A systematic review. J Clin Oncol. 2007 May 1;25(13):1792-801.
  5. 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? J Pain Symptom Manage. 2003 Feb;25(2):150-68.
  6. Irajpour A. Interprofessional education: a facilitator to enhance pain management? J Interprof Care. 2006 Dec;20(6):675-8.
  7. Brink-Huis A, van Achterberg T, Schoonhoven L. Pain management: a review of organisation models with integrated processes for the management of pain in adult cancer patients. J Clin Nurs. 2008 Aug;17(15):1986-2000.
  8. Courtenay M, Carey N. The impact and effectiveness of nurse-led care in the management of acute and chronic pain: a review of the literature. J Clin Nurs. 2008 Aug;17(15):2001-13.
  9. Duncan JG, Forbes-Thompson S, Bott MJ. Unmet symptom management needs of nursing home residents with cancer.Cancer Nurs. 2008 Jul-Aug;31(4):265-73.
  10. Hall S, Kolliakou A, Petkova H, Froggatt K, Higginson IJ. Interventions for improving palliative care for older people living in nursing care homes. Cochrane Database Syst Rev. 2011 Mar 16;(3):CD007132.
  11. Paroz S, Santos-Eggimann B. Measuring the diffusion of palliative care in long-term care facilities - a death census. BMC Palliat Care. 2009 Jan 16;8:1.
  12. Herman AD, Johnson TM 2nd, Ritchie CS, Parmelee PA. Pain management interventions in the nursing home: a structured review of the literature. J Am Geriatr Soc. 2009 Jul;57(7):1258-67. Epub 2009 Jun 3.
  13. Espinosa L, Young A, Walsh T. Barriers to intensive care unit nurses providing terminal care: an integrated literature review. Crit Care Nurs Q. 2008 Jan-Mar;31(1):83-93.
  14. Anderson KO, Green CR, Payne R. Racial and ethnic disparities in pain: causes and consequences of unequal care. J Pain. 2009 Dec;10(12):1187-204.
  15. Shavers VL, Bakos A, Sheppard VB. Race, ethnicity, and pain among the U.S. adult population. J Health Care Poor Underserved. 2010 Feb;21(1):177-220.
  16. Jacobsen R, Moldrup C, Christrup L, Sjogren P. Patient-related barriers to cancer pain management: a systematic exploratory review. Scand J Caring Sci. 2009 Mar;23(1):190-208. Epub 2008 Sep 10.
  17. Flemming K. The use of morphine to treat cancer-related pain: a synthesis of quantitative and qualitative research. J Pain Symptom Manage. 2010 Jan;39(1):139-54. Epub 2009 Sep 24. 
  18. Docherty A, Owens A, Asadi-Lari M, Petchey R, Williams J, Carter YH. Knowledge and information needs of informal caregivers in palliative care: a qualitative systematic review. Palliat Med. 2008 Mar;22(2):153-71.
  19. Meeker MA, Finnell D, Othman AK. Family caregivers and cancer pain management: a review. J Fam Nurs. 2011 Feb;17(1):29-60.
  20. 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. J Clin Oncol. 2006 Oct 20;24(30):4933-8.
  21. Pasman HR, Brandt HE, Deliens L, Francke AL. Quality indicators for palliative care: a systematic review. J Pain Symptom Manage. 2009 Jul;38(1):145-56.
  22. 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. Ann Intern Med. 2008 Jan 15;148(2):141-6.
  23. 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. Arch Intern Med. 2005 Jul 25;165(14):1574-80.
  24. Davies AN, Dickman A, Reid C, Stevens AM, Zeppetella G; Science Committee of the Association for Palliative Medicine of Great Britain and Ireland. The management of cancer-related breakthrough pain: recommendations of a task group of the Science Committee of the Association for Palliative Medicine of Great Britain and Ireland. Eur J Pain. 2009 Apr;13(4):331-8. Epub 2008 Aug 15. 
  25. Dy SM. Evidence-based approaches to pain in advanced cancer. Cancer J. 2010 Sep-Oct;16(5):500-6.
  26. Dy SM, Asch SM, Naeim A, Sanati H, Walling A, Lorenz KA. Evidence-based standards for cancer pain management. J Clin Oncol. 2008 Aug 10;26(23):3879-85.
  27. 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 Manag Nurs. 2002 Dec;3(4):116-30.
  28. Lorenz KA, Dy SM, Naeim A, Walling AM, Sanati H, Smith P, et al. Quality measures for supportive cancer care: the Cancer Quality-ASSIST Project. J Pain Symptom Manage. 2009 Jun;37(6):943-64. Epub 2009 Apr 8. 
  29. Du Pen AR, Du Pen S, Hansberry J, Miller-Kraybill B, Millen J, Everly R, et al. An educational implementation of a cancer pain algorithm for ambulatory care. Pain Manag Nurs. 2000 Dec;1(4):116-28.
  30. Bennett MI, Bagnall AM, José Closs S. How effective are patient-based educational interventions in the management of cancer pain? systematic review and meta-analysis. Pain. 2009 Jun;143(3):192-9. Epub 2009 Mar 12.

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Last updated 18 January 2017