Sharon A Stephen, PhD, ARNP, ACHPN September 23, 2014
Case-based presentation selected to discuss: Pain assessment Barriers to adequate pain relief Pharmacologic interventions Non-Pharmacologic interventions Role of the oncology nurse
Primary aim is to treat the underlying cause of the pain, the cancer In addition, always treat the pain itself Marilyn Birchman 2012
PHYSICAL EMOTIONAL SOCIAL SPIRITUAL CAREGIVER DISTRESS
Subjective sensation Pain is whatever the person says it is when they experience it (Pasero & McCaffery, 2011) Unpleasant Both a sensory & emotional experience
Nociceptive Sources: organs, bone, joint, muscle, skin, connective tissue Examples: arthritis, tumors, gall stones, muscle strain Character: dull, aching, pressure, tender Responds to traditional pain medicines & therapies Neuropathic Source: peripheral nerve or CNS pathology Examples: postherpetic neuralgia, diabetic neuropathy, spinal stenosis Character: shooting, burning, electric shock, tingling Requires different types of medications than nociceptive pain
Goals of Pain Assessment Determine pain diagnosis Etiology of pain Nociceptive or neuropathic pain Acute, chronic, acute on chronic Response to pain interventions E L N E C Core Curriculum
Comprehensive (OLDCART) Precise location(s) & pattern of radiation Intensity Quality of pain (characteristic) Effect of treatment Impact on function Seek out symptoms clusters (insomnia, fatigue, anxiety, depression)
Allodynia Hyperalgesia Tolerance
Barriers to Pain Relief Importance of discussing barriers Specific barriers Professionals Health care systems Risk Evaluation and Mitigation Strategy (REMS) Patients/families Paice, 2010; Pasero & McCaffery, 2011 E L N E C Core Curriculum
Sound Familiar? A Case Study Patient History Max, 37-year-old male with metastatic colorectal cancer Iraqi War Veteran- lost his leg in combat Married with 2 children Oncologist is anxious to start chemotherapy No discussion by the surgeon or oncologist about goals of care Issues Related to Pain Incisional pain poorly managed Stump phantom pain has never been addressed Patient is afraid of narcotics addiction Wife is afraid he will become tolerant of drugs Surgeon is sending him home with oxycodone and lorazepam E L N E C Core Curriculum
Stop and Consider: Providing Care for Max Is Max a candidate for palliative care? What are the barriers regarding Max s pain relief? Are there culture issues related to him being a Veteran? Is there an ethical issue regarding poor pain management? Are there additional medications Max s should be instructed to take? How could his diagnosis + pain issues affect him physiologically, and spiritually? Are you comfortable sending him home with a pain score of 8? E L N E C Core Curriculum
56 y/o female with metastatic bladder cancer C/o persistent back pain New patient visit for treatment planning Ambulatory but function limited by pain, fatigue & weakness Depressed Poor social support Unemployed CNA
Previous experience with pain medication What medications? What doses? Efficacy? Side effects? Attitudes?
Step 1: Non-opioids Step 2: Opioids +/- Non-opioids Step 3: Opioids +/- Adjuvants +/- Nonopioids AGS, 2009; APS, 2008; Pasero & McCaffery, 2010; Paice, 2010
For mild to moderate pain Best for nociceptive pain Dosing Scheduled dose for continuous pain Watch out for APAP in combination products AGS, 2009
Inflammation (Bone pain) Effective for mild to moderate pain Caution in renal, hepatic, gastric, cardiovascular problems Risk of adverse events (GI bleeding) increases with age AGS, 2009; Paice, 2010
Effective for pain regardless of pathophysiology Safe for older adults when carefully initiated & titrated; start low, go slow Many routes; oral route best for most effective pain relief AGS, 2009; Paice, 2010
Sedation Nausea and vomiting Constipation Urinary retention Confusion Dysphoria, hallucinations Myoclonus (rare, on low doses) Respiratory depression (rare)
Does not go away with time Nearly universal side effect of opioids & other analgesics Prevention is essential Laxative needs to be scheduled
Methods for switching from one opioid to another or administration routes (po to IV) Use of equianalgesic tables is necessary Double check calculation with PharmD or RN Keep in mind the issue of incomplete cross-tolerance Reduce dose by 30-50% when changing drugs
Sustained release medications Immediate release for breakthrough pain Distinguish types of breakthrough pain
Medications developed and marketed for another medical condition (e.g., depression) but found also to be effective for pain Target neuropathic pain
Anticonvulsants Antidepressants Local anesthetics Corticosteroids
Minimal systemic side effects Indicated for neuropathic pain but can be effective in musculoskeletal pain as well Lidocaine gel, EMLA & Lidoderm
Intra-articular steroid injections Epidural steroid injections Neurolytic blocks Neuroablative procedures Eisenberg, 1995; Furlan, 2001; Wong et al, 2004
Radiation therapy Palliative surgery Chemotherapy
Physical treatments (heat, cold, exercise, TENS) Integrative treatments Massage therapy Music Acupuncture Cognitive/psychological interventions Hypnosis Imagery Support groups Redirecting thinking/distraction NCI www.cancer.gov Pain (PDQ)
Pain relief is contingent on adequate assessment & use of both drug & nondrug therapies Pain extends beyond physical causes to other causes of suffering & existential distress Interdisciplinary team crucial in chronic and/or refractory pain
7 tips for managing cancer pain Control pain before it becomes severe Patients should seek out the best pain relief Quantify your pain Call your nurse or doctor about pain Remember that you have many treatment options Do not let fear of addiction prevent you from taking medication to manage pain Follow directions when taking pain medications BettyFerrellPhD (2014) City of Hope Breakthroughs. Accessed using Twitter
McPherson, M.L. (2010). Demystifying opioid conversion calculations: A guide for effective dosing. Bethesda, MD:ASHP. NCCN Guidelines, Adult Cancer Pain. http://www.nccn.org Pain Resource Center (prc.coh.org) Pasero & McCaffery (2011). Pain assessment & pharmacologic management. Elsevier Mosby UpToDate. Assessment of cancer pain, updated 7/10/2014 http://www.uptodate.com/contents
The End-of-Life Nursing Education Consortium (ELNEC) Project is a national end-of-life educational program administered by City of Hope National Medical Center (COH) and the American Association of Colleges of Nursing (AACN) designed to enhance palliative care in nursing. The ELNEC Project was originally funded by a grant from the Robert Wood Johnson Foundation with additional support from funding organizations (the National Cancer Institute, Aetna Foundation, Archstone Foundation, and California HealthCare Foundation). Materials are copyrighted by COH and AACN and are used with permission. Further information about the ELNEC Project can be found at www.aacn.nche.edu/elnec.