ReviewA systematic review on barriers hindering adequate cancer pain management and interventions to reduce them: A critical appraisal
Introduction
Pain is one of the most frequent and distressing symptoms in cancer. Pain is present in 36–61% of patients depending on cancer type, stage of disease and patient setting, e.g. in- or outpatients.1, 2, 3 Of patients with advanced cancer 64% experience pain.4 Management of cancer pain is considered to be complex. In 1986, the World Health Organisation (WHO) published the analgesic ladder.5 The WHO analgesic ladder categorises analgesics into three steps that, depending on the pain intensity, progress from non-opioid analgesics to weak opioids and then to strong opioids. Analgesics should be prescribed ‘around-the-clock’ (ATC) for continuous pain and ‘as needed’ (PRN) for breakthrough pain.5 The WHO analgesic ladder has been generally accepted as the foundation of cancer pain treatment. The fact remains, however, that despite the existing guidelines and knowledge about pain and pain management, cancer pain relief is still inadequate.6
Cleeland et al. developed the ‘Pain Management Index’ (PMI), a tool to assess the congruence between severity of pain and medication prescribed.7 The PMI relates the patients’ worst pain intensity (categorised as none, mild, moderate or severe) to the most potent analgesic prescribed (no analgesics; non-opioid analgesics; weak opioids; strong opioids). It is calculated by subtracting the worst pain from the most potent analgesic prescribed. Negative PMI scores are considered to indicate suboptimal medication prescription and scores of zero or greater are considered indicating acceptable analgesic potency.7 According to the PMI, 43% of patients, outpatients as well as inpatients, are treated inadequately.8
However, although almost half of the patients are treated inadequatly,8 it has been proposed that effective treatment of pain should be feasible for 70–90% of oncology patients.6 Numerous barriers have been documented that prevent patients from receiving effective pain treatment and avert physicians from providing adequate pain management. The first aim of this paper is to identify the major barriers hindering adequate pain management, patient – related barriers as well as professional – related barriers. The second aim is to critically review RCTs on interventions aiming to overcome these barriers with respect to the methodological quality of these studies and the effect on clinically relevant outcome measurements.
Section snippets
Methods
Relevant literature published in English was searched on PubMed from 1986 to April 2007. The search was limited to adults, cancer and humans. The terms ‘pain management’ and ‘barrier∗ or concern∗’ were used as keywords to identify relevant titles and abstracts. We restricted the search to patients and health care providers. We found 121 articles of which 40 were relevant. Additionally, we conducted a search using the medical subject headings terms of ‘pain management’ and ‘health knowledge,
Patient-related barriers
Patients often impede their own treatment due to misconceptions about analgesics and their side-effects, non-adherence to treatment regimens, and poor communication of their pain and their concerns about pain to health care providers.11, 12 In 1993, Ward et al. designed a 27-item questionnaire containing eight barriers, the Barriers Questionnaire (BQ).13 The BQ is a self-report instrument designed to measure the extent to which patients have barriers reflecting two general factors: beliefs that
Discussion
According to the multidisciplinary task force of the American Pain Society (APS), the adequacy of cancer pain management will only improve when a multidisciplinary and multilevel approach will be chosen. All the cancer patients should be routinely screened for pain during their visit in the clinic and their pain intensity should be documented and frequently reassessed. When the patients are in pain, this should be adequately treated with a multidisciplinary evidence-based pain protocol. As a
Conflict of interest statement
None declared.
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