Introduction
“Pain is defined as a sensory and emotional experience that is generally associated with tissue damage or inflammation” (Hatfield, 2006, p. 34). Assessment of acute pain, especially in cancer patients requires special attention and strategies to assure accurate information is collected on which to base the plan of care. (Mendoza, 2006) Pain control is considered vital for reasons which may include. First, unmitigated pain leads to unwarranted suffering, due it the fact that it leads to loss of appetite and sleeplessness (Anderson, 2008). It can further weaken already debilitated patients. Cancer causes mental effects that are at times too much for the patient to bear (Hatfield, 2006).
In some instances pain leads to lose of hope in terminal cancer patients because they feel that this is the painful destruction from an incurable disease. Chronic unrelieved pain can lead patients to reject active treatment and when the pain is severe or they are depressed, to consider or commit suicide. Ensuring good quality of life (QOL) in these patients is paramount and has been in the major focus of research (Gowin, 2008). QOL like pain has been conceptualized as a multi-dimensional phenomenon that requires a multidisciplinary care (Simons, 2008). “The aim of palliative care is to achieve quality of life and a dignified death, preferably in the place of the patients choosing” (Chemy, 2008, p. 5). This paper seeks to identify the different approaches used to assess and manage pain in cancer patients. The barriers associated with the pain assessment and management, particularly older cancer patients will be identified, and appropriate recommendations given.
Cancer Pain Assessment
“As with all pain syndromes, accurate, thorough, and systematic assessment of cancer pain is crucial to identifying the underlying etiology and developing a treatment plan” (Chemy, 2008, p. 12). different techniques have been advanced to assess pain resulting from cancerous cells.
As stated in the cancer controls and prevention by Armstrong, the principles of cancer assessment are; The tools used should be valid for the patient’s age and cognitive abilities, with more attention toward the patient’s language needs; The medications that are currently taken by the patient should be recorded and this should include efficacy and adverse effects associated: always consider the common syndromes associated with cancer pain when conducting physical examination and history; Assess the functional impairment and the need for safety measures; Incorporate a psychological evaluation into the assessment, including determination of the patient’s family goals of care; Use pain diary while tracking the effectiveness of the therapy and evaluate the changes in pain; Prescribe a diagnostic evaluation, For example laboratory testing, MRI, and CT when needed and only if it assist in the treatment plan and finally Evaluate for the presence of symptoms, as pain is always highly with fatigue, constipation mood disturbances and other symptoms (2010).
To evaluate the patient’s history we look at the “suffering in the advanced cancer patient” by Chemy. According to which the following essential components: The parts(s) of the body in which the pain is being felt; the pain intensity; the quality of the pain which can be further classified as nociceptive, visceral and neuropathic; The temporal patterns associated with the pain should be identified; the aggravating and alleviating factors should be identified; the meaning of pain, presence of suffering or existential distress should be investigated; the cultural factors of the patient finally the medication history ( 2008).
Unidimensional scales include the numeric rating scale (e.g 0 to 10, a verbal descriptor scale (for example ‘no pain’, ‘moderate pain’, ‘severe pain’) or the use of visual scale (for example 10 cm line with anchors such as ‘no pain’ on the left and the ‘severe pain on the right; the patient should indicate the place on the line that best represent the intensity of his/her pain) (Hueng, 2007). An array “of scales use drawings of faces (from smiling to distress) for patients who may find it difficult to use the above tools” (Brura, 2005, p. 20). Several tools are also available for pediatric assessment (Danaei, 2010).
There are several multidimensional assessment tools too. “The brief pain inventory (BPI) is a valid, clinically useful pain assessment tool that has been used extensively in people with cancer” (Corn, 2006, p. 24). This may comprise the following “a diagram to note the location of the pain, questions that regard the intensity of the pain (current average, average and worst using a 0 to 10 scale) and items that evaluate impairment due to pain” (Chemy, 2008, p. 23).
Symptom assessment tools can also be used. Researches conducted show that “a significant correlation between pain, depression, fatigue and other typical symptoms that are seen in people suffering from cancer” (Armstrong, 2009, p. 18). These symptoms that occur together are often referred to as symptom clusters (Boffetta, 2010). The utilization “of multi-dimensional scales incorporating the most common symptoms would ensure systematic assessment” (Hueng, 2007, 16). Several instruments that measure symptom clusters are available. (Travell, 2009)
Pain Management for Cancer Patients
There are several ways through which the relief of pain can be achieved. These methods include: Explaining the situation to the patients to help him/her cop with it; The pathological process that leads to the pain can be modified to relieve the patient; The painful threshold can be elevated; the pain pathways can be interrupted to prevent actual feeling of pain and the finally the lifestyle of the patient can be modified (Portenoy, 2005). For instance through immobilization. If the disease-modifying treatment is being prescribed, this does not mean that analgesics should not be used (Simons, 2008). Best results are usually obtained when a multi-modality approach that combines two or more treatments is adopted. The use of analgesics and other drugs is simply one way of elevating the patient’s pain threshold. Thus reducing perception of pain (Pepper, 2008).
Goals of good pain management
- 50% pain relief is considered a good pain relief initially
- Relief at night when the patient wants to sleep
- Relief at rest during the day
- Relief on movement, this is not always completely possible.
Analgesics are the most commonly used drugs to manage pain in TB patients in the long term care facilities. The oral route is the preferred route for analgesics, including morphine. If patients are unable to take the drugs orally, the preferred alternative routes are rectal and subcutaneous (Parter, 2007). Persistent pain always requires preventive therapy. This implies that analgesics should be given regularly and prophylactically, “as needed” medication is irrational and inhuman (Mersky, 2008, p. 78). The WHO recommends the following ladder that guides the use of analgesics.
- Step 1: Non narcotics, NSAIDS
- Step 2: Mild opiods
- Step3: Strong opiods (morphine)
(Brura, 2005).
Morphine is still the gold standard analgesic for use in moderate to severe cancer pain. It may be started with 10 mg 4 hourly doses as per the patient’s physical status, age and pain intensity. Individual variation does occur (Mendoza, 2006). Proper titration of morphine requires regular follow up. It is also important to control side effects, for example, constipation, nausea and vomiting, pruritis and rarely respiratory depression (Lepore, 2005). There is no upper dose limit in an otherwise systematically fit patient. Codeine may be used where morphine I not accessible. Codeine plus ibuprofen or paracetamol combination tablets may be prescribed effectively and are available as over the counter (OTC) drugs. (Kadluber, 2007) Pharmacologically, pain in cancer can be divided into: 1. Opioid responsive, this refers to pain which is relieved by opioids. 2. Opioid semi-responsive, this is pain that is best relieved by concurrent use of opioids and an adjuvant drug (Corn, 2006). 3. Opioid resistant, this is pain which is not relieved by opioids but by other drugs, for example, NSAIDS (Bone metastasis) (Lepore, 2005).
For the individual: The right dose of an analgesic is the does that relieves the pain. European Association for Palliative Care (EAPC) recommends that morphine given by mouth every four hours and the same dose for breakthrough pain given as often as required. If pain returns consistently before the next regular dose is due, the regular dose should be increased. A double dose at bedtime is a simple and effective way of avoiding being woken by pain (Parter, 2007). As the death approaches, pain diminishes. Patients may withdraw and may stop eating and drinking altogether. These days may be a time of intense personal and spiritual work and the focus of palliative care should be changed (Travell, 2009). A dying patient’s need for analgesics may sometimes increase. In such cases where high doses of opioid are needed benzodiazepines and/or large doses of neurologic such as haloperidol may be added. Monitor treatment: The response to treatment must be monitored to ensure that benefits of treatment are maximized and adverse effects are minimized.
Use of adjuvants and drugs: A laxative is almost always necessary with opioid prescription. More than 50% of patients need an antiemetic. NSAIDS drugs should be added with H2 receptor blockers or proton pump inhibitors. (Armstrong, 2009) COX-2 NSAIDS currently available in many parts of the world in form of celecoxib and Roficoxib may be safer as they do not cause gastritis and platelet dysfunction. However even COX-2 be used with caution in renal-compromised patients (Cella, 2006). Tricyclic antidepressants (TCA) are very useful adjuvant in majority of patients to provide psychological uplift. Amitirpyline 25 mg at bedtime is usually the starting dose (Danaei, 2010). It should be avoided in cardiac patients. Side effects are dryness of mouth, giddiness in the morning. Some patients continue to experience pain on movement despite analgesics (Boffetta, 2010). Surgery, chemotherapy, radiotherapy and anesthetic approaches (nerve blocks) may sometime be useful in controlling the pain optimally (Mendoza, 2006). Physiatic and pschologic methods are used as good complimentary tools in relieving pain. The situation may also be improved by suggesting modifications to the patient’s way of life by using various rehabilitative methods (Parter, 2007).
Palliative care can also be offered from home, where the patients are treated for pain and given emotional and spiritual support by their family members in the last days of their life (Mendoza, 2006). Home based palliative care makes the patients to be more comfortable as they are in constant touch with their loved ones. However, this can be challenging in times of acute pain when physicians are required to assess and provide medical assistance (Armstrong, 2009. The home-based care is often complimented by visitations from nurses who train family members on how to assess the pain and offer solutions.
Barriers and Recommendations to Pain Assessment and Management
Cancer suffers are in most cases older patients, who often present with multiple barriers to pain assessment. The barriers can be outlined in several categories as follows: Awareness of the patient associated barriers that interfere with effective assessment and management of pain is important in creating a plan of care that will enhance comfort in the older cancer sufferer (Armstrong, 2009). People from different cultures have different belief systems. This has led to misconceptions and fears being exhibited by patients, especially those suffering from cancer. (Brura, 2005) If the presence of the misconceptions can be established, then a physician or any other medical practitioner may have an easy time in developing a more open communication. This will enhance determination of the presence of pain and increase the patient’s chances of agreeing to the treatment plans (Mersky, 2008). The selected assessment approaches should take into account, the culture and beliefs of the patient. The barriers that are related to the patient may come in the following forms: (1) the fear by the patient and his/her family members that he/she can get addicted to pain medication is common (Parter, 2007). Education on the differences between physical dependence and tolerance to analgesia and addiction should be provided.
A second associated fear is that the use of opioids may lead to respiratory depression and arrest (Mersky, 2008). “Pain is a strong stimulant and although opioid analgesics can lead to initial sedation, this can be mistaken for opioid overdose but can be desirable state, allowing the older person to rest/sleep once pain relief is achieved” (Chemy, 2008, p. 45) (2) Other cancer patients may show fear towards the diagnostic investigation that is needed to assess the pain, being hospitalized for “diagnostic testing or therapy, and loss of independence and consequences of a serious diagnosis” (Parter, 2007, p. 114). Another common misconception is the fear that if the pain medications are used early, then they may not work when the pain worsens (Portenoy, 2005). If the concerns that lea to this fears can be established then the health provider will be better placed to discuss possible solutions with the patient. (3) “Older patients may often believe that their primary care provider is omniscient and will know if they any problems that can be treated and will treat them if they can” (Jacobson, 2005, p. 15). In this case the patient does not want to appear as a bother to the physician (4) “Presence of multiple comorbid medical problems complicates assessment in older cancer patients, who often suffer multiple pain conditions.” (Travell, 2009, p. 22). This complicates the pain evaluation and treatment process especially when the different conditions require distinct pharmacological interventions.
It is generally observed that health care providers are least prepared to assess pain in the older patients suffering from cancer. This is due to the fact that the medical courses offered have not been keen on educating them about pain approaches in relation to age changes.
Some barriers are brought about by the design of the health care. “Careful and regular evaluation for the presence of pain and its relief following intervention is key” (Gowin, 2008). Unfortunately, the provision of palliative care and pain management has not been featured prominently on the priorities of Long term care (LTC) facilities (Travell, 2009). Thus, the institutions need to increase their commitment in ensuring that proper techniques of assessing pain are developed for older cancer patients, especially those who are nearing the end of their lives. “Access to hospices of services and appropriate diagnostic services will enhance pain assessment” (Chemy, 2008, p. 66).
Conclusion
Pain assessment and management is very important for patients who are suffering from terminal cancer. (Cella, 2006) Appropriate methods based on the patient’s factors should be used to assess the pain and proper management planned to help the patient in the best way possible. It is important that the patient receive adequate care just like the others who are not faced with terminal diseases. Emotional and spiritual support is also very important in the patient’s last days.
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