Syrjala, K.L., Abrams, J.R., Polissar, N.L., Hansberry, J., Robison, J., DuPen, S., . . . DuPen, A. (2008). Patient training in cancer pain management using integrated print and video materials: A multisite randomized controlled trial. Pain, 135(1–2), 175–186.

To test the hypothesis that patients who received standardized training about pain would have fewer barriers to treatment, report lower pain, and be more likely to take prescribed opioids than patients who received a control training unrelated to pain

Patients were stratified by institution and ethnicity and then randomly assigned to control and treatment groups. Pain training included a videotape and review, with a nurse, of a handbook. The nurse focused on the concerns of the individual patient. Patients completed a checklist of eight common barriers to pain control, indicating those that he or she had wondered about. The nurse helped the patient  apply information to the patient's own situation. To assist in communication about pain, the patient then completed a checklist of things to tell the doctor. Patients were encouraged to use the checklist in communicating with the doctor and to complete a checklist any time pain was not well controlled or when other symptoms occurred. Control group patients received interventions similar in format, but these focused on nutrition. After 72 hours patients in both groups received telephone contact that reinforced training. By telephone investigators gathered patients' ratings of pain, nausea, and eating symptoms. Patients' initial training took 30–45 minutes. Follow-up calls lasted about 10 minutes. Patients completed outcome assessments at baseline and at one, three, and six months. At each time point, physicians and nurses rated patients' usual and worst pain, using the same 0–10 scale that patients used.

• Eighty-eight patients completed the study.
• Mean patient age was 55.5 years. Age range was 27–80 years.
• In the intevention group, 58% of patients were female and 42% were male. In the control group, 71% were female and 29% were male.
• The sample included multiple cancer diagnoses. Breast cancer was the most frequent diagnosis: Of all patients, 23%–31% had breast cancer. In the sample 77% had metastatic or systemic disease, and most had advanced-stage disease with a life expectancy of at least six months at the time of study entry. Of all patients, 90.5% were Caucasian. More than 50% of patients had attended some college or had earned a college degree. Baseline Eastern Cooperative Oncology Group performance status was similar in both groups, at a mean of 1.03–1.30.

• Multisite
• Outpatient
• Six urban and rural oncology clinics in the United States

Randomized blind controlled trial

• Barriers Questionnaire (BQ)
• Brief Pain Inventory (BPI)
• Memorial Symptom Assessment Scale (MSAS)
• Functional Assessment of Cancer Therapy-General (FACT-G)
• ECOG Performance Status (total daily morphine equivalent doses for pain control calculated from tables in Cancer Pain Guidelines)

From baseline the group that received training about pain had a greater decrease in barrier beliefs about cancer pain (p < 0.001), with a 0.3 point decrease, and a greater average decrease in usual pain (0.8 decrease, p = 0.03). At one month, the pain-training group reported 25% lower mean pain ratings. The pain-training group used higher doses of opioids than did the control group (p = 0.001). There were no significant differences between groups regarding worst pain, pain interference with function, or overall symptom severity. Authors noted differences between groups at one month, but there were no differences at three and six months. The pain-training group had greater narrowing of the gap between the patient’s self-assessment of pain and the nurse’s pain ratings (p = 0.001). The institution providing care was significantly associated with change in barriers to pain treatment (p < 0.001) and change in worst pain (p < 0.001). From baseline, pain interference with function (p = 0.02) was higher for nonwhites. Researchers found that, frequently, doses of medications were not re-evaluated and that patients had not told physicians about side effects or that they had stopped taking analgesics. Chart reviews presented no evidence of patients using the checklists in clinic visits or in communication with nurses and physicians.

The training intervention appeared to have only a short-term positive effect on patients' management of pain. Observations regarding related communications between patients and their professional care teams, along with significant differences in outcome by institution, point to the impact of providers in effective pain management.

• The study had a small sample size, with fewer than 100 patients.
• The sample included few nonwhite participants, and findings showed significant differences regarding ethnic covariates. These facts suggest that findings cannot be generalized to various ethnic groups.
• Although the study design included blinding of providers and those who obtained study data, authors suggest that contamination across the two groups was likely.
• Authors did not discuss patient supports or caregiver involvement in pain management.
• Authors did not describe the characteristics associated with the significant institution-related differences in outcomes.

Findings suggest that a training component may help patients self-manage pain and communicate with care providers. However, the single intervention in this study had only short-term effects that varied by institution. This points to the importance of the engagement of care providers in ongoing pain management and the need for future research to study combined patient-provider efforts. Consistent reinforcement of patient education and use of communication aids may improve long-term outcomes.