Kravitz, R.L., Tancredi, D.J., Jerant, A., Saito, N., Street, R.L., Grennan, T., & Franks, P. (2012). Influence of patient coaching on analgesic treatment adjustment: Secondary analysis of a randomized controlled trial. Journal of Pain and Symptom Management, 43, 874–884.

To estimate the effect of patient-centered tailored education and coaching (TEC) on the likelihood of analgesic treatment adjustment during oncology visits; to estimate the influence of treatment adjustment on subsequent cancer pain control

Patients with at least a moderate baseline pain received TEC or control just prior to a scheduled oncology visit. Just after the visit, they reported on whether the physician recommended a new pain medication or a change in the dose of an existing medication. Pain severity and pain-related impairment were measured 2, 6, and 12 weeks later. TEC included assessing knowledge, attitude, and preferences; correcting misconceptions; teaching about pain control and communication with providers; planning communication; and rehearsing communication with physicians. Sessions occurred one hour before initial clinic visits and were conducted on an individual basis. Sessions were recorded on audiotape. Control patients received the Natiional Cancer Institute booklet on pain control. Patients completed questionnaires immediately after a clinic visit.

• The sample was composed of 258 patients.
• Patients' age range was 18–80 years.
• Of all participants, 21.4% were male and 78.6% were female.
• Diagnoses in the sample included lung, breast, prostate, head and neck, esophageal, colorectal, bladder, and gynecologic cancer.
• Patients reported a score of 4 or higher, on a 0–10 scale, when asked to cite worst pain during the past two weeks or pain during the same period that interfered at least moderately with functioning.
• Potentially eligible patients were identified using computer-generated lists. Consenting patients received an enrollment packet by mail and were promised $80 compensation for completing the trial.

Settings included three health systems—academic medical center, health maintenance organization, and Veterans Affairs hospital—and one private practice, all in Sacramento, California.

• Phase of care: active treatment
• Clinical applications: elder care, palliative care

Randomized controlled trial

• Medical Outcomes Study Pain Impairment Scale
• Postvisit questionnaire regarding pain medication changes

• Patients assigned to TEC were more likely than controls to report a change in the analgesic treatment regimen (60% vs. 36%, p < 0.01).
• Significant effects persisted after adjustment for baseline pain, study site, and physician (adjusted odds ratio 2.61, 95% CI 1.55, 4.40, p < 0.01).
• In a mixed-effects repeated-measures regression, analgesic change was associated with a sustained decrease in pain severity (p < 0.05).

TEC increases the likelihood of self-reported, physician-directed adjustments in analgesic prescribing. Treatment intensification is associated with improved cancer pain outcomes.

• The study had low accrual rates.
• Invesigators obtained data about independent and dependent variables by means of patients' self-reports. The study shows poor concordance between patients' reports and medical record review.
• Authors did not assess appropriateness of physicians' decisions.
• Regression effects that may cause between-group comparisons may appear to be larger than they would be if analgesic change were randomly assigned.
• Time points at which pain severity were measured are unclear.

A routine oncology visit is an opportunity to adjust a patient’s analgesic regimen. Available evidence suggests that clinicians often miss opportunities to intensify analgesic regimens appropriately. Oncologists are often unaware of patients’ pain. Patients may be reluctant to discuss pain because of misconceptions about pain management or fear of distracting the physician. The findings of this study suggest that interventions to counter this reluctance, and to improve pain management, include education, including role-playing, that helps patients plan communication with physicians.