Pain Management in the Cancer Patient

How Pain Develops

When something in the body is not working properly, the body's nerve cells sense pain at the site of the damage or injury and send a signal to the brain, which triggers a response

Pain

• Pain is one of the most feared consequences of cancer.

• All pain is real regardless of cause, and most pain is caused by a combination of physiologic and psychogenic factors.

• Pain assessment has several purposes:

  • Determine baseline for treatment and intervention

  • Determine which intervention is best for patient

  • Enable the evaluation of intervention

Cancer Patient’s Pain

• 33%-88% of all cancer patients experience pain.

• 45% of adult oncology patients have moderate to severe pain daily

• Pain during radiation therapy does not follow a standard pattern

  • Pain as a result of XRT begins towards the end of treatment and resolves withing a few weeks after, but is unpredictable

• Staff attitude towards pain plays a role in the assessment and treatment of CA patient pain

Pain Transmission: Includes several body structures

• Nerve endings

• Nerve fibers

• The Brain

• Pain is caused by various stimuli

  • The three types are:

• Mechanical

  • Physical forces such as pressure, stretch, or cutting. They are often activated by excess pressure or mechanical deformation of tissues.

• Thermal

  • Detect noxious heat or cold. They are sensitive to temperatures that can damage tissue, such as a hot stove or extreme cold.

• Chemical

  • Respond to substances released during injury, inflammation, or disease.

Pain - Acute

• It is new, can be sudden, usually transient

• may come from diagnostic or surgical procedures, or trauma

• may be accompanied by anxiety or emotional distress.

• for the most part, results from disease, inflammation, or injury to tissues.

• the cause of acute pain can usually be diagnosed and treated, and the pain is self-limiting, that is, it is confined to a given period of time and severity.

• When new pain is related to growth or impact of a tumor, it is considered an emergency

• in some rare instances, it can become chronic.

Pain - Chronic

• is widely believed to represent disease itself.

• it can be made much worse by environmental and psychological factors.

• pain that persists over a longer period of time than acute pain (usually 3 months or more)

• is resistant to most medical treatments. It can—and often does—cause severe problems for patients.

• In a cancer patient, sources can be the result of the tumor invading bone, soft tissue, viscera, blood and nerves

  • Other sources of chronic pain can be the result of surgeries, chemotherapy and radiation treatments

Types of Pain

• Pain that is caused by organic disease and disorders is known as: Somatogenic pain

• Somatogenic pain, or organic pain, arises from somatogenic lesions resulting from trauma, infection, or other external factors.

• Somatogenic pain is divided into two main categories:

  • Nociceptive pain

  • Neuropathic pain

  • Nociplastic (also called Mixed)

Nociceptive Pain

• Pain quality: sharp, stinging, dull, throbbing

  • ex. osteoarthirits, bone fractures, burns, physiological pain to brain

Neuropathic Pain

• Paint quality: burning, stabbing, numbness or tingling, hypersensitivity

  • ex. diabetic neuropathy, HIV/AIDS, multiple sclerosis

Nociplastic Pain

• Pain quality: sharp, dull, tingling or numbness; non-specific

  • ex. fibromyalia, IBS, migraine, interstitual cystitis

Types of Pain

Psychogenic pain

• Psychogenic pain is not an official diagnostic term. It is used to describe a pain disorder attributed to psychological factors. Such things as beliefs, fears, and strong emotions can cause, increase, or prolong pain.

• It often does not have an organic explanation

Somatic Pain

Pain experienced in the skin, muscles, bones and joints

Visceral Pain

The pain of organs, in the thoracic or abdominal cavities

Both somatic and visceral pain can be _____ or _____. The two classification systems have full overlap.

• Nociceptive

• Neuropathic

Types of Pain (Based on Duration, Source/Origin, Location)

Specifics on Cancer Pain

• Is a legitimate pain

• Can be acute or chronic

• There may be several etiologies

• Pain unrelated to cancer

  • *Combination of these exists

Common Sites of Cancer Pain

• Bones: long bones, vertebrae, pelvic

• Lymph nodes

• pleura

• skin

• liver

• bowel

  • *more than one site

Skeletal Related Events that Cause Pain

• radiation to bone

• fractures

• bone surgery

• spinal cord compression

Pain associated with Cancer Treatment

• Radiation therapy can cause pain

  • (Wells: Supportive Care, Table 9.1, pg 163; and Table 9.2, pg 165)

• Where?

  • Skin, H&N, Chest, Abdomen, Pelvis

  • Pneumonitis and fibrosis

  • Myelopathy (Dz of spinal cord)

    • Lhermitte’s sign (shock-like feeling down spinal column)

Factors Affecting Responses to Pain

• Depression

• Anxiety

• Meaning of pain

• Past experience with pain

• Culture

• Religion

• Gender

• Genetic

• Staff – training and attitude

Patient barriers to effective pain management

• Fear of addiction

• Don’t want family to know

• Fear of side effects

• Fear nothing available when pain gets bad

• Don’t want to distract MD

• Fear disease worsening

• Punishment for past indiscretions

health care provider and health care system barriers

• HC Providers -

  • Fear of legal repercussions

  • Inadequate knowledge

  • Poor pain assessment

  • Fear of patient addiction

  • Concern about drug tolerance

  • Fear of masking symptoms

  • Patient’s pain report is not believed

• HC Systems

  • Pain relief not valued

  • Limited access to care (i.e. pain medications)

  • Insurance issues

  • Insufficient pain care providers

  • Limited formulary

Pain relief plan

Set goal intensity with the patient and the family

Purposes of pain assessment

• Establishes a baseline for treatment and intervention

• Helps Clinical Teams focus on which interventions are best for the patient.

• Enables the evaluations of the interventions

Six dimensions to consider when assessing pain

1. Physiologic: Organic cause of pain

2. Sensory: Intensity, location, and quality

3. Affective: Depression and anxiety

4. Cognitive: Influence on thought processes

5. Behavioral: Observable behavior (verbal, nonverbal, moans, grimaces, complaints)

6. Sociocultural: Factor that influences response to pain

Three types of pain in cancer patients

1. Pain associated with direct tumor involvement

2. Pain associated with cancer therapy

3. Pain unrelated to the tumor or its treatment

Two factors related to the cause of pain

1. Duration—refers to whether pain is acute or chronic

2. Pattern of pain—three separate patterns

Sensory Dimension

• Consists of pain location, intensity, and quality

  • Location—ask patient where pain is or ask patient to point to area of pain

  • Intensity—goal is to translate pain into description of numbers or words to provide objective description

  • Quality—how it actually feels (e.g., hot, burning, aching, throbbing, sharp, tender, stabbing, heavy, shooting, gnawing, splitting)

Affective

anxiety and depression are factors that affect a patient’s response to pain and ability to tolerate and cope with pain

Cognitive

pain influences thought processes and/or the way people view themselves

Behavioral

• Factors such as physical exercise, time spent in bed, and ability to do chores have been used to measure pain behavior; the Karnofsky

  • Performance Status is used for this

Sociocultural factors that influence pain are

• ethnic; cultural; demographic; spiritual; and related factors such as age, gender, and race

• Tools to assess pain must be simple, short, and relevant for the patient.

• Tools include the McGill Pain Questionnaire, Brief Pain Inventory, and Memorial Pain Assessment Card.

Pain assessment should be

• systematic

• organized

• ongoing

When evaluating a cancer patient’s pain

• Believe the patient’s complaint of pain

• Take a careful history of the patient’s pain complaint

• Evaluate the patient’s psychological state

• Perform a careful medical and neurologic examination

• Order and review appropriate diagnostic studies

• Treat the pain to facilitate the appropriate workup

• Reassess the patient’s response to therapy

• Individualize the diagnostic and therapeutic approaches.

When to assess pain

• on admission

• regularly

• after pain interventions

• before and after procedures

• with new pain

When to Assess: continued

• It is very important to assess for pain in a patient not only while they are lying still in bed or sitting in a chair, but with activity!!!

• Remember: pain is cyclical, not linear and not static!

• Also, pain often intensifies at night (nothing to distract patient)

There are two ways of measuring pain:

• physical

• functional

  • (both types of assessment are carried out by a physician based on what the patient reports)

Pain Assessment Tools

Reading – Oncology Nursing Secrets: Pain Management pg. 391-395 Washington, pg 45-50

• Pain intensity rating scales

• Facial expression scale

• Pain map

• Pain diary

Patients at Risk for Under-treatment of Pain

• Infants

• Children

• Elderly

• Confused (including psych pts)

• Mental status changes

• Non-verbal

• Non-English speaking

• Prior addicts

• Neuro patients

How do we treat pain?

• Two groups

  • Non-opioids (non-narcotic)

  • opioids (narcotic)

Non-Opioid Analgesics

• Tylenol (side effect: Liver failure)

  • NOTE: this is an acetaminophen this is not an NSAID

• NSAID’s (Non-steroidal anti-inflammatory drug)

  • Ibuprofen: Motrin, Advil

  • Naproxen: Aleve

• Topicals (Zostrix)

  • *Often given in combination with opioids

Major side effects of NSAIDs (Non steroidal anti-inflammatory drug)

• Decreased platelet aggregation*

• GI bleeding*

• Renal failure

• Have a ceiling effect

• Maximum dose: 4-6 grams in 24 hours

• *Concern in pts with low platelets

Opioids

• multiple formulations

• avoid term “narcotics”

• pure forms relatively inexpensive

Demerol (opioid)

• acute pain only

• short duration of action (2-3 hours)

• SE; seizures

• this should not be used for cancer pain

morphine (opioid)

• Gold standard for cancer pain-

• Many formulations

• Easy to titrate

• Cheap

• Potential SE: renal toxicity

i.e. opioids

• Oxycodone

• Hydrocodone

• Hydromorphone

• Codeine

• Propoxyphene

Opioids - Routes of administration

• By mouth

• IV

• IM (intramuscular)

• Topical-

• Epidural

• Transdermal

• Transmucosal

• Nebulized

• Intrathecal

Opioid Side Effects

• Constipation

• May lead to obstruction and impaction

• Sedation (confusion)

• Itching (Pruritus)

• N and V (nausea and vomiting)

• Urinary retention

• Dry mouth

• Respiratory depression

Addiction definitions

1. Psychological dependence on the use of substances for their psychic effects…characterized by compulsive use despite harm.”

   1. FSMB Model Guidelines for the Use of Controlled Substances 1998.

2. “…a primary, chronic, neurobiologic disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm and craving…”

   1. AAPM, APS, and ASAM, Feb 2002.

5 C’s of addiction

• Chronic

• Impaired Control over drug use

• Compulsive use

• Continued use despite harm

• Craving

Pseudoaddiction

• Drug-seeking behavior due to unrelieved pain; actually pain-relief seeing behavior

• Due to underprescribing by MD’s or overestimation of drug efficacy by RN

  • *>50% of chronic pain pts found it necessary to change MDs in their quest for pain relief

Physical Dependence:

• “Physiologic state of neuroadaptation which is characterized by the emergence of a withdrawal syndrome if the drug is stopped or decreased abruptly or if an antagonist is administered.” FSMB

• “Physical dependence is an expected result of opioid use [and] does not equate with addiction.”

Opioid Withdrawal

• Symptoms are usually experienced shortly before the time of the next scheduled dose

• Although unpleasant, withdrawal from narcotics is rarely life threatening.

Addicted comparison

• Addicted

  • Chemically dependent persons (addicts) use drugs to escape or avoid reality

  • Do not have pain

  • QOL declines

  • Take drugs even though they are harmful

• Not Addicted

  • Persons with pain us drugs to participate in reality

  • QOL improves

  • Drug are not causing them harm

Drug Tolerance

• Addicts virtually always evidence tolerance (chronic opioid users also)

• Tolerance is unpredictable and can persist months to years after abstinence

• Shortened duration and a decrease intensity of analgesia, euphoria and sedation, which creates the need to consume progressively larger doses to attain the desired effect.

• Definition

  • A state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drug’s effects over time.

Adjuvants

These are drugs whose original use was not analgesic

• Antidepressants

• Anticonvulsants

• Stimulants (Ritalin)

• Corticosteroids

• Local anesthetics

Bone pain

• Radiopharmaceeuticals can be used

  • Metastatic osteoblastic bone lesions

  • Palliation of bone pain

  • Specific criteria for use

  • Strontium-89

  • IV over 2 minutes by radiation oncologist

  • SE:  bone marrow depression

Pain from Bone Metastasis

• what is Zometa (zoledronic acid) (May be used for pain from bone melts)

  • Biphosphanate (Rx hypercalcemia)

  • Bone specific, not tumor specific

  • Inhibits bone resorption (regardless of tumor type)

  • Preserves bone architecture and strength

  • Reduces number and size of bone mets in tumor-induced osteolysis

  • Anti-androgenic and anti-pain effects (UNK reasons)

Non-Pharmacological: Mechanical Strategies

• Alternatives to conventional treatments-

• What are they and do they work?

• Non-Pharmacological, Mechanical Strategies include

  • Massage*

  • Heat and cold

  • Therapeutic touch

  • Acupressure*

  • Acupuncture*

  • Hyperbaric oxygen treatment (HBO)

  • *Not with low platelets

  • ** No chiropractic strategies

• Behavioral Interventions include:

  • Relaxation techniques

  • Distraction

  • Imagery/Visualization

  • Music

  • Humor

  • Prayer

  • Biofeedback

  • Hypnosis

Treating cancer pain with radiatoin therapy

• Curative treatment

• Palliative treatment

  • Relieve pain

  • Control symptoms

  • Delay tumor growth

How does XRT relieve cancer pain?

• Cytotoxic effect of XRT on normal bone cell

  • inhibits the release of chemical mediators of pain, such as prostaglandins.  This effects explains the fact that some patients get rapid pain relief, often within 24 hours of the first treatment.

• The Cytotoxic effect of XRT on abnormal cells

  • prevents any further bond destruction, reduces the size of the tumor and enables re-absorption of bone to take place.  This effect explains the pain relief achieved between 2 and 8 weeks after radiotherapy.

Common uses of XRT for pain

• Bone metastasis

• Spinal cord and brachial plexus involvement

• Liver and pancreatic pain – but XRT not used this way very often anymore

Responses to XRT for pain

• Pain from direct invasion

  • Pain relief within 24-48 hours

• Pain from indirect stimulus (edema, compressed or obstructed organs)

  • Pain relief 2-3 months

• XRT dose and frequency controversial

More Invasive Techniques

• Nerve blocks

• Neurosurgical procedures

  • Deep brain stimulation

  • Chemical or surgical ablation

  • Joint injections

  • Vertebroplasty