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. 
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.  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.  Several studies suggest that education of professionals has the potential to improve outcomes for patients.  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.  Use of a pain algorithm has been shown to improve pain outcomes.  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. 
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,  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. 
What it means in practice
- Pain in palliative care patients should be actively identified, carefully assessed, and treated promptly. 
- Pain assessment should be integrated into routine clinical care, and documented using appropriate assessment tools that facilitate regular reassessment.  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,  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.  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.  Caregivers need specific training in problem-solving skills regarding pain management.  Provision of education to patients and families can improve pain outcomes.