1. Educational interventions for cancer pain Mike Bennett St Gemma’s Professor of Palliative Medicine University of Leeds, UK

2. How good is cancer pain management?

3. WHO ladder for cancer pain

4. Effectiveness of the ladder as a whole Early 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 >65% Ventafridda et al 1987 Around 25% of patients do not get adequate pain control

5. 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 (n=5000) 72% of European community patients 77% in UK t al 2009 Breivik et al 2009

6. Severity Secondary care settings (n=349) Using 0-10 rating scale (0=no pain, 10=worst) 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 (n=617 in UK) Average pain = 6.4 90% rated greater than 5/10 25% not receiving any analgesia

8. VOICES data 2011

9. 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

10. Will a better opioid or more knowledge of genetics solve the problem alone?

11. What are the problems?

12. Barriers to good cancer pain control

13. Key barriers Patients and carers reluctant to complain about symptoms fear pain and don’t 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

19. Educational interventions

21. 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

22. 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 Mar;23(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 2008;19(1):44-8. Patient satisfaction

23. Assessment Pain outcomes significantly improved with: Pain assessment presented to clinicians who use it in consultations (assessment alone doesn’t 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 1997;72(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 15;22(4):714-24.

24. 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 1999;17(1):361- 70. 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. 2005;16(6):972-80.

25. 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. 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 2008;9(10):873-82.

26. Educational interventions

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

28. Pain intensity Average pain intensity -1.1 [-1.80, -0.41] Maximum pain intensity -0.78 [-1.21, -0.35]

30. 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

32. (DVD video links)

34. Outcomes at 4 weeks PPQ subscale (knowledge and attitudes) Median % improvement = 34% (p = 0.04) belief in addiction to medicine (37% improvement, p=0.008) belief that pain will get better (30% improvement, p=0.008) Brief Pain Inventory (pain intensity) Median % improvement = 9.6% (p=0.02) Acceptability DVD acceptable and patients very satisfied with content But….uncontrolled, observational study

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

36. Type of interventions focus on pain assessment provision of information and advice on dosage sometimes by telecare and managing adverse effects of medication

37. Pain intensity at 3 month follow up Average pain intensity -0.49 [-0.79, -0.20]

38. Mechanisms of action Adverse events Data from 2 studies suggest > 50% reduction overall ? better medicines management Satisfaction Significant improvement with intervention Reduced consultations with GPs ? self efficacy, improved coping

39. 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

40. What are the most important components?

44. Kroenke paper

45. 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

46. 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)

47. Results

48. Average Average effects versus number of responders

49. Summary

50. 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

51. Thank you m.i.bennett@leeds.ac.uk