Contribution from IAHPC Board Member Michael Bennett

Improving cancer pain management through interventions that change behaviour

According to recent reviews, despite the availability of the WHO analgesic ladder, pain due to cancer remains prevalent and largely under-treated. The analgesic ladder is a reasonably effective intervention for cancer pain and results in around 75% of patients receiving satisfactory pain control. There’s no doubt that the development of better drugs with fewer adverse effects would be welcome, but substantial improvements in pain control can also be achieved by addressing the common barriers to good pain management. Barriers are often due to attitudes and behaviours towards pain and analgesia of both patients and healthcare professionals. Our research group has been reviewing and testing the effectiveness of various types of interventions - below is a summary of what we have found.

Studies of educational interventions directed at patients (e.g. leaflets, videos or DVDs, and face-to-face explanations with nurses) suggest that improving knowledge and reducing fears can result in clinical benefits. Here, changes in the patient’s knowledge seem to bring about beneficial changes in their behaviour however the causal mechanisms are not clear. Potential mechanisms include reduced anxiety, improved communication, increased adherence to medication regimens, and better management of adverse effects. The attention from healthcare practitioners (a non-specific effect) along with the delivery of the educational interventions is also likely to be important in achieving improvements in cancer pain management.

In contrast, educational interventions directed at professionals, for example classroom style teaching, can improve knowledge and attitudes, but these changes don’t seem to result in changes in professional behaviour that benefit patients. Benefits can be achieved through more targeted educational interventions within the clinical setting. These include clearly stating the importance of pain management, instruction in the systematic assessment of pain, teaching how to prescribe medications using clearly defined protocols and guidelines and consultation with experts.

The degree of benefit of educational interventions directed at patients or professionals may appear to be modest – about a 1 point reduction in average pain intensity using a 0-10 pain scale. However, this is similar in magnitude to some pharmacological interventions. Randomized clinical trials show an average improvement of 0.5 to 1 point reduction in pain intensity when paracetamol or gabapentin is added to a patient’s regimen which also includes an opioid. Taking a few minutes to address the fears of patients and an explanation of how to use strong analgesic drugs can result in a similar improvement of pain compared to prescribing an additional drug. In practice, of course, optimal cancer pain management will result from good control of the cancer, skillful prescribing of analgesics, and improved behaviours of both patients and professionals through educational interventions.

Future research studies are needed to understand how to deliver these educational interventions effectively in daily practice while combining several of them at the same time. These studies should focus on a multi-level approach which modifies the behaviour of both professionals (nurses and physicians), as well as patients and carers.

Dr. Mike Bennett is an IAHPC Board member, he resides in England and his biography is at
http://www.hospicecare.com/Bio/bennett.htm .