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*Département d'Anesthésie, Hôpital Antoine Béclère, Clamart and Clinque de Reudon la Foret;
Unité d'Evaluation, Hôpital Louis Mourier—Département de Santé Publique, Faculté Bichat, Paris; and
Centre d'Evaluation et de Traitement de la Douleur, Hôpital Ambroise Paré, Boulogne, France
Address correspondence and reprint requests to François Larue, MD, Département d'Anesthésie, Hôpital Antoine Béclère, 157 rue de la Porte de Trivaux, 92141 Clamart Cedex, France. Address e-mail to larue{at}ext.jussieu.fr
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Abstract |
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Implications: The results of two representative surveys conducted over a 6-yr interval show significant improvements of knowledge and attitudes regarding pain and its management in the French general population. However, these results point to the need for additional specific information that should be provided through patient-physician interactions.
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Introduction |
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Barriers at the national policy level include restrictive laws and regulations limiting the medical use of narcotics (1), insufficient support for pain management programs by health authorities, nonrecognition of pain management activities by financing authorities (2), and insufficient education of healthcare professionals (3).
Barriers in the provision of health services include the underassessment of patients' pain by health professionals (4–6), divergent perceptions of patients' needs among health professionals (7), and physicians' reluctance to use potent analgesics and overestimation of the effectiveness of other prescribed treatments (8). Continuous quality improvement programs have been advocated by the American Pain Society since 1991 (9–15) to address these health service problems.
Patients themselves may be reluctant to report pain or to take analgesic medications, particularly morphine (16–18). Furthermore, patients may report satisfaction with the management of their pain, even as they declare they are suffering from severe pain, and although their analgesic prescriptions seem to be inadequate (14,15,19). This may be related, in part, to methodological shortcomings of patient satisfaction surveys. Nevertheless, such findings suggest that patients actually expect to experience pain in some medical situations or consider that pain management is not a priority with respect to other components of care (18). Furthermore, patients receiving inadequate on-demand analgesic treatment may still be satisfied, particularly if they have been told that pain treatment would be provided (20).
Public expectations regarding pain and its management can be influenced by information provided through the media, and/or through direct education messages provided by health professionals. Appropriate education of the public may reduce patients' reluctance to express pain and to increase their demand for adequate pain management. This should incite health institutions and professionals to improve pain management practices. Information and education of the general public may also help to influence policy makers.
Major policy initiatives achieved in France since 1993 include the publication of guidelines (21–23), the inclusion of pain management in the core curriculum of all French medical schools, and some easing of the regulations constraining opioid prescriptions. National health and political authorities designated improving pain management as a key objective of public health policy.
During the same period, the French media gave recurrent attention to pain management issues, publicizing the results of epidemiological studies and delivering numerous messages regarding the recognition of pain and the use of analgesics, including morphine. This study attempts to assess the evolution, between 1990 and 1996, of the French population's demand for adequate pain management, knowledge regarding pain and its treatment, and attitudes toward morphine use in the treatment of postoperative and cancer pain.
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Methods |
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For each survey, a random sample of the French general population aged 
18 yr was constructed following a two-stage stratified procedure. Strata specification concerning region and city size and the age, sex, and profession of the head of the family were derived from the 1982 and the 1990 census results. Sampling areas were defined with respect to region and city size. Within each sampling area, people were selected using a random assignment procedure from the national telephone database. Once the strata specification for each specific age-sex subgroup was reached within a sampling area, people were selected from the next sampling area. This procedure—stratification with random quotas—is equivalent to stratification after sorting the population (24). When selected people were unavailable or refused to respond, a similar procedure involving random selection with repeated call-backs was followed until the desired sample size was reached in each stratum. In 1996, 2061 of the people who could be reached when called refused to answer the survey, leading to an effective response rate of 33% (3242 additional people were unavailable at the first call). Refusals were not related to the topic of the survey: most of the nonrespondents refused to talk with the interviewer even before being told the title or purpose of the survey. Although detailed information had not been recorded in the 1990 survey, the overall response rate was similar.
The telephone surveys were conducted by professional interviewers. Each interview took an average of 8 min to complete. The structured questionnaires included close-ended questions and multiple choice questions. Questionnaires focused on postoperative pain, cancer pain, and morphine use and addressed the following issues: the respondents' personal experience of surgery and postoperative pain (two questions); their fear of postoperative pain (one question); whether the attention given to postoperative analgesia would influence their choice of a surgical team (one question); the respective ability of professionals and patients to assess postoperative pain (one question); whether they or their relatives had suffered from cancer (one question); the occurrence of pain at early and advanced stages of cancer (two questions); the ability of treatments to relieve pain due to advanced cancer (one question); the influence of pain control on the compliance to antineoplastic treatment (one question); whether pain medications should be provided to cancer patients on-demand or by the clock (one question); morphine's image and agreement with giving morphine to postoperative and/or cancer patients (three questions); whether patients should be informed that they are receiving morphine (one question); and whether they would themselves be afraid of becoming addicted to morphine if prescribed for pain relief (one question). The questionnaire used in the 1996 survey was identical to that used in 1990, with two additional questions: 1) whether the respondent's knowledge about the treatment of pain had increased during the past 5 yr and 2) which information sources had been influential in producing this improvement.
The statistical significance of differences between responses to the 1990 and 1996 surveys was assessed by using simple 
2 statistics computed on 2 x 2 contingency tables for dichotomous variables and 2 x C contingency tables for categorical variables. The interrelations among the 1996 answers to questions regarding sources of improved knowledge were assessed through factor analysis. This factor analysis, with oblique rotation allowing for correlated factors, produced two well defined factors representing mass media and health professionals.
In addition, predictors of 1996 respondents agreeing with giving morphine to postoperative and cancer patients were identified through two multiple logistic regressions. Results are presented in terms of adjusted odds ratios with 95% confidence intervals. Each adjusted odds ratios indicates how each predictor influences the probability of the dependent variable, controlling for the influence of the other variables included in the logistic regression model. Assessment of the statistical significance of each logistic regression model was based on likelihood ratio statistics. All analyses were performed with SPSS® 6.1 (SPSS Inc., Chicago, IL).
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Results |
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The respondents' awareness of the occurrence of pain in the course of cancer improved: 65% (656 of 1006) thought that pain is rare at early stages of cancer in 1996, compared with 49% (490 of 1001) in 1990; 84% (845 of 1006) thought that pain is frequent at advanced stages of cancer, compared with 72% (724 of 1001) in 1990. The proportion of respondents who believed that pain can be partly or totally relieved for advanced cancer patients increased moderately, as did the proportion who believed that adequate pain control improves compliance with cancer treatments. However, less than one third of the respondents knew that analgesic medications should be administered to cancer patients by the clock rather than on demand, and this had not changed over the years.
In 1996, morphine was more often associated with pain relief (80% [806 of 1006] vs 44% [442 of 1001]) than with drug abuse, imminent death, or euthanasia. The proportion of people who were not afraid of becoming addicted to morphine if prescribed for pain relief increased from 26% (263 of 1001) in 1990 to 69% (699 of 1006) in 1996. The proportion of respondents who believed that patients must be systematically informed that they receive morphine also increased, from 39% (393 of 1001) in 1990 to 53% (532 of 1006) in 1996.
However, the proportion of respondents who agreed that morphine can be prescribed to patients with pain increased only slightly, from 79% (790 of 1001) to 83% (833 of 1006) for cancer patients, and from 44% (444 of 1001) to 52% (527 of 1006) for postoperative patients.
Table 3 shows that 58% (558 of 968) of the 1996 respondents believed that their knowledge regarding the treatment of pain had improved over the past 5 yr. The source of information most frequently associated with this improvement was television (59% [330 of 558]), followed by written press articles (47% [263 of 558]) and by interaction with physicians (45% [252 of 558]). The results of the factor analysis performed to analyze relationships among information sources suggest that respondents who cited physicians as their primary source of information were also more likely to mention other health professionals, whereas those who cited television were more likely to mention other mass media.
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Discussion |
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The 1996 respondents had significantly less experience with cancer than the 1990 respondents. Therefore, one would expect that they would be less aware of pain management issues through direct exposure to cancer pain situations. Improvements with respect to the general public knowledge or attitudes toward effective pain management are thus likely to be underestimated.
Although fear of postoperative pain was reported as a major concern by few of the respondents, most of the 1996 respondents claimed that they would choose healthcare facilities according to the priority given to pain management. This marked increase in the importance of pain management issues in the demand for adequate care should influence institutional and professional practices in an increasingly competitive environment.
The general public knowledge with respect to cancer pain management improved significantly over the six-year period separating the two surveys. The proportions of respondents who associated morphine with pain relief and who were not afraid of becoming addicted to morphine if they had to take it for pain relief increased substantially. However, most of the 1996 respondents were still unaware of the necessity of taking analgesic medications by the clock rather than on demand. Although such knowledge may seem more detailed than what the lay public might obtain through mass media communication, this misconception may reflect insufficient recognition that pain can and should be prevented. A large proportion of the 1996 respondents, particularly the less educated, would also still be reluctant to have morphine prescribed for postoperative pain. Overall, marked improvements in the general public's knowledge and attitudes contrast with specific areas of inaccurate information. The striking evolution of the image of morphine is not yet sufficient to influence the perception of its indication in nonmalignant situations.
This contrast points to the continuing need for greater involvement of health professionals in providing information and education to the public and, specifically, to their patients. It seems that information provided through mass media has been effective in familiarizing the public with the effectiveness of adequate pain management. However, some mass media messages may be ambiguous, misinterpreted, or insufficient to alleviate personal fears or misconceptions. It seems likely that increased awareness of pain management choices among the public will generate increased demand on health professionals to provide adequate care, starting with adequate and precise information to address each patient's needs.
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Acknowledgments |
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We express our gratitude to François Cornu, Monique Couturier, Dominique Duverneuil, and Marc Mullier for their assistance in setting up the surveys, and to Susan Wright for her careful editing of the original manuscript.
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References |
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