Pain management should include a thorough assessment of the type and severity of pain, the underlying causes, any associated co-morbidities or psychological problems, and — where necessary — an interdisciplinary therapeutic approach that aims both for pain relief and the restoration of physical, social and emotional functioning. Limitations in training among non-pain specialist physicians and other health professionals are an important barrier to improving patient care. For example, recent survey data confirm that European primary care physicians find chronic non-malignant pain a challenge to treat [
53]. Key aspects of professional education include evidence-based guidelines and structured under- and post-graduate education.
Evidence-based guidelines for the management of chronic pain
The WHO three-step analgesic ladder for cancer pain relief has been widely influential [
54]. The principle of offering appropriate analgesia in a timely fashion as articulated in the WHO ladder for cancer pain remains valid today, although the optimal approach remains a matter of debate and research [
55]. The WHO has recently published guidelines for the management of persistent pain in children with medical illnesses [
56] and is developing guidelines for non-malignant pain in adults [
57]. Numerous other national and international guidelines for the pharmacological treatment of non-cancer and cancer pain exist [
58‐
65]. While some guidelines for chronic non-cancer pain are evidence-based, for example those by Attal et al. on the pharmacological treatment of neuropathic pain [
59], others are based primarily on expert opinion owing to a lack of well-designed, randomized and controlled trials in this area.
Impact of guidelines: do they make a difference?
Of course, the impact of guidelines is dependent on their implementation and levels of adherence among practitioners, and improving this is an important aim [
66‐
69]. For example, evidence from the USA [
68] and Europe [
69] suggests that many primary care physicians are non-compliant with guidelines for chronic low back pain (LBP). Adherence to the WHO cancer pain guidelines should provide adequate pain control in the majority of patients [
70,
71], and yet pain remains common among cancer patients [
25,
26]. Researchers in Norway recently found that approximately 60% of persistent opioid users with chronic non-malignant pain receive concomitant regular benzodiazepines or benzodiazepine-related hypnotics, in conflict with guidelines [
66].
Evidence from Germany suggests that an active approach to implementing LBP guidelines, using physician education interventions and motivational counselling may be more effective than simple postal dissemination of the guideline [
72,
73]. Certainly, guideline implementation and adherence among practitioners is likely to be aided by enhanced collaboration between professional societies and healthcare providers, policymakers, reimbursement authorities and health technology assessment authorities. However, further research is required to establish the optimal means of guideline implementation.
Pre- and post-graduate education in pain medicine for healthcare professionals
Substantial advances have been made in recent years in the scientific understanding of pain and its origins. One of the principal challenges in converting this progress into benefits to patients is the education of healthcare professionals regarding the optimal diagnosis and management of an increasingly complex variety of pain syndromes. All physicians should receive a basic education in pain management at undergraduate level, as recently re-iterated by the WHO in its 2011-updated recommendations on achieving balance in availability and treatment of pain with opioids [
52]. In 2013, the European Federation of IASP Chapters (EFIC®) published its pain management core curriculum for European medical schools [
74]. In reality, the provision of undergraduate pain education varies within and between countries and important deficiencies have recently been identified [
75]. In part, this variation reflects international differences in the organization and governance of universities. In Germany, the content of medical education curricula is defined federally and a pain examination is now mandatory [
76]. The provision of dedicated undergraduate pain modules is particularly common in France owing to a central policy [
75]. However, standardized requirements are less feasible in countries where universities independently determine their own curricula (e.g. Austria, Norway and most Nordic countries, Spain, Italy, and Israel).
Specialized post-graduate education is also required to develop the expertise necessary to effectively manage patients with chronic pain. Two levels of post-graduate education can usefully be distinguished: 1) a diploma-based competency in pain management available to all types of physicians, and 2) accreditation of fully-fledged, cross-disciplinary pain medicine specialist qualification and role. Post-graduate pain management courses are now available in many countries [
77]. In Italy, for example, a recent law (2010) means that physicians wanting to work in pain therapy can attain a specialist post-graduate Masters qualification in pain therapy or palliative care [Dr Massimo Allegri, personal communication]. These are likely to be particular useful for general practitioners, orthopaedic specialists and medical oncologists, the groups responsible for managing many patients with chronic pain [
1,
26]. In order to ensure high standards, pain medicine qualifications should preferably be regulated by regional or European-wide accreditation of courses, e.g. through the European Union of Medical Specialists (UEMS) [
77], or EFIC. IASP and EFIC are already active in providing Pain Schools, e-learning resources [
78], and grants to support education initiatives in Eastern Europe [
79].
Pain medicine is now recognized as a speciality, sub-specialty or competency-based training in several European countries (e.g. Finland, Germany, Ireland, Israel, Norway, Sweden, UK and others). However, in many others advanced pain medicine as an area of modern medicine that requires special training and experience remains under-recognized among health managers and policymakers, and within the medical profession itself. This may be in part because the true burden of pain is still poorly documented, and because pain crosses so many fields of medicine. Only pain specialists have a patient-centred, multidisciplinary overview of all aspects of pain management. Pain specialists have important roles in the development and implementation of local, national and international guidelines, leading the development of pain care services, assessing and improving the value of pain care services through further research, advising governments and health authorities with regard to policy matters affecting pain (e.g. regarding access to controlled medicines), and leading public education. The pain field would also benefit from the development of best practices (e.g. protocols and policies) designed to raise standards of care. A good example is the guidelines on diagnosis and management of complex regional pain syndrome by the UK National Institute of Excellence (NICE) and Royal College of Physicians [
80].
Pain education must also be properly covered within the under- and post-graduate education of other healthcare workers, including psychologists, nurses and pharmacists. In each case this requires interdisciplinary co-operation between pain societies, professional societies of allied healthcare professionals, educational institutions and healthcare systems.
Education of patients and the public
Various cognitive and educational barriers among patients may interfere with pain management by reducing adherence with treatment regimens [
81,
82]. Suggested components of public education include how to prevent common types of pain, how and when patients should self-treat pain, when patients should consult a doctor, what they can expect from therapy and how they can access further forms of support. From a public awareness perspective, it is important to stress that severe chronic pain is not acceptable and is not a part of normal ageing.
The provision of pain education for patients varies internationally. Efforts to improve this situation include an initiative to provide collaborative recommendations on improving education for older adults [
83]. EFIC and IASP run annual Year Against Pain events in an effort to increase public awareness of pain issues in the public and media, as well as the medical community (
http://www.efic.org/index.asp?sub=F8AMLHLAP9216P).
Patient education or coaching measures helped to improve pain, functioning, well-being and therapy adherence in some studies in patients with LBP [
84,
85] and cancer pain [
86‐
88]. However, a recent systematic review concluded that the available data on education interventions in LBP were of low quality and showed no intermediate- or long-term effect on pain and disability compared with active non-educational interventions [
89]. Mass media campaigns based on education alone are unlikely to result in positive and persisting behavioural change and need to be supported by other approaches, for example based on social marketing, policy and legislation [
90]. In Norway, a mass media campaign on LBP (involving written educational materials sent to all households, television, radio and cinema advertisements and posters in health clinics) had only a limited effect on the beliefs of survey respondents among the general public, as compared with controls not exposed to the campaign [
67,
91]. Furthermore, it did not significantly affect sickness behaviour (i.e. sickness absence, surgery rates for intervertebral disc herniation and imaging examinations) or change the beliefs of physicians, physiotherapists and chiropractors regarding LBP, even though an additional educational initiative was directed at these groups [
92]. These results suggest that a considerable investment would be needed to improve public understanding and behaviour with regard to chronic pain.