Educational interventions for cancer pain

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Educational interventions for cancer pain

• Mike Bennett
• St Gemmas Professor of Palliative Medicine
• University of Leeds, UK

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How good is cancer pain management?
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WHO ladder for cancer pain
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Effectiveness of the ladder as a wholeEarly
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
  gt65
• Ventafridda et al 1987
• Around 25 of patients do not get adequate pain
  control

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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 (n5000)
• 72 of European community patients
• 77 in UK
• Breivik et al 2009

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Severity

• Secondary care settings (n349)
• Using 0-10 rating scale (0no pain, 10worst)
• 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 (n617 in UK)
• Average pain 6.4
• 90 rated greater than 5/10
• 25 not receiving any analgesia

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VOICES data 2011
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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

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Will a better opioid or more knowledge of
genetics solve the problem alone?
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What are the problems?
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Barriers to good cancer pain control
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Key barriers

• Patients and carers
• reluctant to complain about symptoms
• fear pain and dont 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

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Educational interventions
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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

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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
  Mar23(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 200819(1)44-8.
  

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Assessment

• Pain outcomes significantly improved with
• Pain assessment presented to clinicians who use
  it in consultations
• (assessment alone doesnt 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 199772(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 1522(4)714-24.

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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
  199917(1)361-70.
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• 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.
  200516(6)972-80.

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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.
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• 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 20089(10)873-82.

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Educational interventions
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Interventions

• Explained causes of pain and promoted self
  management
• Addressed common fears about opioids
• Usually face-to-face coaching session combined
  with written information

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Pain intensity
Average pain intensity
-1.1 -1.80, -0.41
Maximum pain intensity
-0.78 -1.21, -0.35
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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

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(DVD video links)
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Outcomes at 4 weeks

• PPQ subscale (knowledge and attitudes)
• Median improvement 34 (p 0.04)
• belief in addiction to medicine (37 improvement,
  p0.008)
• belief that pain will get better (30
  improvement, p0.008)
• Brief Pain Inventory (pain intensity)
• Median improvement 9.6 (p0.02)
• Acceptability
• DVD acceptable and patients very satisfied with
  content
• But.uncontrolled, observational study

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• Any type of chronic pain
• 4 studies identified
• 400 patients randomised, 335 with follow up data
• Arthritis, knee pain, pain clinic, cancer pain

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Type of interventions

• focus on pain assessment
• provision of information and advice on dosage
• sometimes by telecare
• and managing adverse effects of medication

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Pain intensity at 3 month follow up
Average pain intensity
-0.49 -0.79, -0.20
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Mechanisms of action

• Adverse events
• Data from 2 studies suggest gt 50 reduction
  overall
• ? better medicines management
• Satisfaction
• Significant improvement with intervention
• Reduced consultations with GPs
• ? self efficacy, improved coping

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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

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What are the most important components?
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Kroenke paper
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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

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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)

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Results
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Average effects versus number of responders
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Summary
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• 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

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Thank youm.i.bennett_at_leeds.ac.uk