Reducing the Barriers to Pain Management in Albania: Results from an Educational Seminar with Family Doctors

Introduction

The first palliative care (PC) service in Albania was established in 1994 with a team of two physicians and one nurse in the Albanian capital, Tirana. In 2012 palliative care is now provided by three NGOs, Ryder Albania Association, Caritas Albania, and Mary Potter Palliative Care Association, in 6 of the 36 cities all over the country; one service in the capital is financed from the National Health Care Insurance Institute. The services only provide home care for terminal cancer patients. These providers can cover about 30% of the nation's needs, so the vast majority of patients do not have access to qualified PC. ¹ There are few doctors and nurses who are qualified to provide PC and pain management. This may be a consequence of (1) very little information on PC, pain treatment, and opioid treatment in the undergraduate curricula of nurses and physicians; (2) only a few training and educational opportunities on opioid treatment; (3) limited literature in our native language on PC, opioids, and pain management, with only a few translated brochures and a manual of training; (4) phobia and myths on opioid usage among professionals; and (5) little knowledge of PC, pain treatment, and opioid treatment in the public, which further impedes access to adequate PC.

One of the main components of PC is the availability of opioids (weak and strong) and the medicines of the essential list established by the World Health Organization (WHO). ² In Albania two strong opioids are available, morphine and fentanyl. Morphine consumption is very low compared to the need, and in a European comparison, Albania is ranked only 39th among the 42 reported countries: the total opioid consumption for Albania is calculated as 152 daily dosages (DDD) per million inhabitants per day, whereas the average for Europe is 6756 DDD. ³ Some of the factors accounting for the low level of morphine consumption are limited use of opioids in the perioperative setting, use only by the four PC providers, limited forms of opioids available (only slow release and injectable morphine), lack of provider education, and opioid phobia in the general population and among health professionals. Cost of medication is also a hindrance, as fentanyl is not reimbursed by the health care insurance and is too expensive for most patients: the average price for a fentanyl patch in Albania is US$35 compared to US$.50 for a loaf of bread and an average yearly income in 2009 of US$6,300).

In Albania, 24 (83%) of the WHO list of essential medicines for PC² are available. Medicines are reimbursed from the Institute of Health Insurance. Thus availability of these medicines should not be difficult for patients requiring PC, but many of the barriers cited above prevent access.

In this setting, providers led by the National Association of Palliative Care (NAPC) engaged in developing PC and opioid availability. Education of physicians is the first step. Seminars on opioid treatment for family doctors have been planned and organized by the NAPC. The Barriers Questionnaire (BQ-II) was used to assess barriers on opioid management before the seminar, and to evaluate the effect of the seminar on these barriers.

Methods

The NAPC organized six seminars in six cities between March and July 2012. Participants were recruited from representatives of the NAPC and from Regional Health Directories, selecting for family doctors working in both urban and rural areas. In all, 227 family doctors participated in groups ranging in size from 28 to 47 attendees. The one-day seminars were scheduled for eight hours, with the content focused on (1) chronic cancer and noncancer pain; (2) indications, application, and routes of morphine and other strong opioids; (3) opiophobia among health professionals; and (4) communication with patients and care givers in PC. Each topic took two hours and was taught by experts in the field, who used a range of teaching methods including exercises, interactive discussions, and debates. Most of the participants reported that they did not have any previous training in opioid treatment.

BQ-II is a standardized questionnaire ⁴ containing 27 items loading on four factors: physiology (12 items), fatalism (3 items), communication (6 items), and harmful effects with 6 items. All of the questions of BQ-II are scored on a numerical scale ranging from 0 (do not agree at all) to 5 (agree very much), resulting in a maximum sum score of 135.

The BQ-II was translated from English to Albanian first by one of the authors (AX) and then back translated from Albanian to English. The back translation was then compared with the original. As no major differences emerged, the translated version was used for the study.

The BQ-II was presented to the participants before and after the seminar to evaluate their perceptions and attitudes on pain treatment before the seminar and the changes in these attitudes after the seminar intervention.

Results

The BQ-II was administered to all 227 family doctors; 189 physicians (83%) completed the survey. The questionnaire demonstrated major barriers in the participating physicians with mean scores of ≥3 for 10 of 27 items (see Table 1). The danger of addiction to pain medicines as well as the fear that many people with cancer get addicted to pain medicine received the highest scores (mean 4.1). Fatalism and communication items were rated with lower scores (see Table 1).

The results at the end of the seminar showed significant improvement, with lower barriers for the total sum score as well as for all subscales. The total mean scores also were reduced significantly, from 2.4+0.6 before the seminars to 1.6+0.7 after the seminars.

Only five items did not show significant improvements after the seminars. No significant improvement was seen for one item on the physiology subscale (makes you say or do embarrassing things); one item on the harmful effects subscale (weakens the immune system); and three items on the communication subscale (doctors might find it annoying to be told about pain, reports of pain could distract a doctor from curing the cancer, if I talk about pain people will think I'm a complainer). Four of these items had low scores already in the preseminar test, so these barriers were perceived as minor problems in Albania. Only the item about the weakened immune system had higher preseminar mean values and did not improve during the seminar. (The role of opioids in the immune system is still under evaluation. ⁸ )

Differences between seminars were not significant for the four subscales, but ANOVA for the total sum score showed significantly less barriers in one city (Korca, mean 52.7) compared to the other cities (means between 62.3 and 67.3).

Discussion

The provision of PC requires a set of skills and expert knowledge, as well as underlying attitudes that are in line with the core values of the field, such as trust and respect for patient autonomy and dignity. ⁵ PC training programs need to transfer knowledge, teach skills, and change attitudes in order to be effective. Evaluation of PC training programs requires comprehensive tools.^{6, 7}

The situation in Albania, lacking PC or pain management training, called for a more focused and narrowed-down approach. The curricula of the faculty of medicine and the faculty of nursing include very few topics on opioids, most of which are outdated. One-day seminars were developed on opioid management of cancer pain. Acceptance of the seminars was evident when the series of seminars had to be extended from an initial number of three to six seminars.

Barriers against opioid therapy were assessed with a standardized questionnaire before and after the seminars. The results showed the high effectiveness of the intervention, with all sum subscores and the total sum score improved significantly.

The results in our study were comparable to those found among patients in other countries. In Icelandic ⁹ as well as in Norwegian patients ¹⁰ the mean score was 2.2±0.8; in Danish cancer patients it was 2.3±0.7. ¹¹ In the U.S. study of Gunnarsdottir and colleagues ⁴ the mean total score was lower (1.5±0.7) compared to this study, with a mean total score of 2.4±0.6 before the seminars, but comparable to the score after the seminar (1.6±0.7).

Among the limitations of this study is the use of BQ-II with physicians, since it was designed as a self-assessment instrument for patients. BQ-II is a reliable and valid measure of patient-related barriers to cancer pain management, but the psychometric properties of the instrument are not known when used for physicians. However, a previous version of BQ-II has been used for the evaluation of an educational intervention in homecare nurses. ¹² In that study the nurses receiving a structured educational training on the management of pain and opioid-related side effects in patients with cancer; these nurses had a significant increase in their knowledge, a more positive attitude about pain management, fewer perceived barriers to pain management, and an increase in perceived control over pain compared to the nurses who did not receive the intervention. In addition, the BQ-II has been validated in English, Norwegian, Icelandic, and Danish, but the Albanian version has not been validated.

The postseminar results were assessed immediately after the training, and there is no information on the medium- or long-term effectiveness of the intervention. There is also no information on whether the reduction of barriers led to an increase in morphine prescriptions. However, the reduction of barriers including the misunderstanding about tolerance and addiction, should encourage the participating physicians to prescribe opioids to those patients who need them.

In conclusion, barriers to the use of opioids were high in family physicians in Albania, but we found a significant reduction in these barriers following one-day training, demonstrating the effectiveness of the intervention (Table 2). More research on the sustainability of the training effect is needed.