In a prospective study of 313 Dutch cancer patients with chronic pain, the practice of pain treatment was evaluated by means of Donabedian's structure-process-outcome framework. The practice of pain treatment was assessed by: (1) structural resources, describing the setting in which pain treatment is provided; (2) process components, which describe the clinical practice; and (3) outcome measures, which refer to patients' pain intensity, patient satisfaction, or composite pain management index scores. Results showed that 31.4-59.8% of the cancer pain patients received less than optimal pain treatment. Although pain education and refresher courses for health care providers are scarce, structural resources were not the major cause of the suboptimal level of pain treatment. Rather, the major cause was the process components. Only 36.4% of the patients received strong opioids; 23.1% received analgesics "as needed." Patients' pain knowledge was far from optimal (54.8 on a 0-100 scale), and written pain information was given to only 15.8% of the patients. After discharge, only 36.8% of the district nurses were informed about patients' pain. These results emphasize that continuing efforts to improve the practice of pain treatment are needed.

To treat cancer pain, physicians often decide to jump directly from step 1 of the World Health Organization (WHO) analgesic ladder to step 3. The use of transdermal fentanyl in patients with cancer pain who had either used no opioid before, or only codeine, is evaluated in the present trial. Both opioid-naive (N = 14) and codeine-using (N = 14) patients started with transdermal fentanyl in the lowest available delivery rate (25 microg/hr). Immediate-release oral morphine was present as "rescue" medication. Transdermal fentanyl provided good to excellent pain relief in the majority (68%) of these patients. During the study, 5 patients continued with 25 microg/hr, and the others used a higher dose. Clinically relevant respiratory depression was not observed. The common side effects of opioids were found; constipation was mentioned by 3 patients (11%). Transdermal fentanyl appeared a safe analgesic in these opioid-naive cancer pain patients. In this study, WHO step 2 could be skipped without untoward complications.

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