Chapter 10: Pain Medicine 2026

Dr Matthew Brown

Why do this Quality Improvement Project

The ability to effectively recognise and manage cancer-related pain is a core requirement for all pain medicine services. It is recognised, however, that not all services will have the resources or expertise to manage the most complex cases of cancer-related pain. Understanding and benchmarking a pain service’s individual features and performance helps drive quality for the target patient population and provides ideas on implementation of changes to improve care. 

Background 

Pain is one of the most feared consequences of cancer¹ and remains common with almost 70% of patients with advanced, metastatic or terminal disease experiencing pain. ²

Pain experienced by cancer patients may result from multiple factors, including the presence of primary or metastatic tumours, as well as therapeutic interventions such as surgery, radiotherapy, chemotherapy, or a combination thereof.³ Concurrent physical deconditioning, pre-existing medical conditions and psychological distress can all further contribute to and exacerbate pain. 

Despite the high incidence of cancer pain, effective management is often challenging, and significant gaps exist in the provision of cancer pain services across the UK.⁴

The provision of effective cancer pain management is fundamentally important, and a holistic approach involving all members of the multidisciplinary team is required.

Best practice

Best practice is outlined in Core Standards for Pain Management Services, Edition 2.⁵ 

• People with a history of cancer should be routinely screened for pain at every healthcare visit.
• If cancer-related pain is identified, a structured assessment should be carried out to classify its cause, intensity, and impact on quality of life.
• Based on this assessment, a multimodal pain management plan must be developed in partnership with the patient, explaining the likely causes and prognosis of their pain, outlining treatment options, and incorporating their preferences and goals for care.
• Treatment should be tailored and multimodal, combining medication with non-drug approaches such as rehabilitation, psychological support, and oncological or interventional therapies.
• Patients should be given guidance on self-management, and their pain plans must be reviewed regularly to monitor progress and adjust long-term care.
• If pain persists or side effects from treatment are intolerable, timely referral to specialist services, including multidisciplinary pain teams and advanced techniques, is essential.

Suggested data to collect 

Cancer pain management

• proportion of cancer patients who are screened for pain when attending your hospital. Standard = 100%
• proportion of cancer patients with pain who receive a structured pain assessment. Standard = 100%
• proportion of patients with cancer pain who receive a tailored pain management plan with regular reviews. Standard = 100%
• Proportion of patients with cancer pain for whom outcome data is collected. Standard = 100%
• For level 3 or 4 centres: Proportion of patients reviewed at cancer pain MDT
• For level 3 centres: Proportion of patients where appropriate onward referral of complex cancer pain cases to a level 4 centre? Standard = 100%

QI methodology

Understand the Features of Service

• Understand what level of cancer pain service your department offers.
  • if the service is deemed to be level 3 or 4, is a regular cancer pain MDT conducted?
  • If the service is deemed to be level 3, is there a robust and functioning link for onward referral of complex cancer pain cases to a level 4 centre?
  • If the service is deemed to be level 4, are there dedicated direct clinical programmed activities (DCC) for assessment and management of cancer pain? 

Define your current mechanisms for managing patients with cancer-related pain. Collect baseline data to understand how the process is working and where potential gaps exist.  Engage in stakeholder interactions with the MDT and patients and consider qualitative analysis of the system. Once the gaps have been identified, you could use a Pareto chart to understand which are the most commonly occurring, and an effort impact matrix could also be used to prioritise which gap/issue to address first. 

To address any gaps identified, a SMART (Specific, Measurable, Achievable, Relevant, Time-bound) aim could be identified, and measures (process, outcome and balancing) agreed. Consider if baseline measurement is available, if not consider collecting, to understand the systems pre intervention state and the variation within it. 

A driver diagram can be used to describe what drivers contribute to the aim and build a common theory of change and ideas for improvement.

Implement change ideas in a structured way, consider using the IHI model for improvement along with its integration of Plan/Do/Study/Act cycles to support repeated review of interventions.

References

1. Foley KM. The Treatment of Cancer Pain. New England Journal of Medicine 1985; 313: 84–95 
2. Van Den Beuken-Van Everdingen MHJ, Hochstenbach LMJ, Joosten EAJ, Tjan-Heijnen VCG, Janssen DJA. Update on Prevalence of Pain in Patients with Cancer: Systematic Review and Meta-Analysis. Journal of Pain and Symptom Management Elsevier Inc; 2016; 51: 1070–90 
3. Magee D, Bachtold S, Brown M, Farquhar-Smith P. Cancer pain: where are we now? Pain Management 2019; 9: 63–79 
4. Copley S, Carty S, Brown M, Mishra S, Clarke EK, Srivastava D. Bridging the GAP: a critical analysis of pain management services in the United Kingdom. Br J Anaesth [Internet] 2025; Available from: https://linkinghub.elsevier.com/retrieve/pii/S0007091225001692
5. Core Standards for Pain Management Services in the UK: Second Edition. 2021