Pain Management (Oncology) - CE/NCPD

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ALERT

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OVERVIEW

Although pain has many definitions, it is best defined by those who experience it. The International Association of the Study of Pain (IASP) defines pain as an unpleasant emotional and sensory experience.³

There are six factors that affect a patient’s pain experience:

• Pain is a personal experience.
• Pain is not only linked to sensory neuron activity.
• Patients learn the concept of pain through previous experiences.
• Each patient’s pain experience should be respected for what the patient says it is.
• Pain can have functional, social, and psychological adverse effects.
• If the patient cannot verbally communicate, that does not mean the patient is not experiencing pain.³

Each patient is unique in reporting pain, its characteristics, expectations of what should be done to relieve it, and what interventions do or don not help. Understanding the terminology of pain and its management is key when caring for patients who experience pain (Table 1).

The pathophysiology of pain is often defined as neuropathic, nociceptive, and psychogenic.

• Neuropathic pain results from damage to the nervous system. This damage may be to the central nervous system (CNS) (i.e., spinal cord or brain),^1,3 such as cord compression or injury to the nerve roots in the body. Peripheral nerve damage is also a common side effect of many cancer treatments (i.e., chemotherapy, radiation, and surgery).⁵ Neuropathic pain may be described as burning, “pins-and-needles,” tingling, numbness, or electric shocks. It is less responsive to opioids alone, and often requires the addition of adjuvant analgesics, like anticonvulsants or antidepressants.⁵
• Nociceptive pain results from chemical, mechanical, or thermal injury of free nerve endings in tissues and organs.^1,3 Somatic and visceral are two types of nociceptive pain.⁵
  • Somatic pain is often described as sharp, pressure-like, or throbbing and is well localized.
  • Visceral pain tends to be a more diffuse aching.
• Nociceptive pain tends to respond well to opioids.
• Psychogenic pain is related to an underlying psychological, emotional, or behavioral factor. This type of pain can be experienced when there is no physical source and can be acute or chronic. Psychogenic pain is most commonly treated with psychotherapy, non-narcotic pain medication, and antidepressants.

Cancer pain is often classified as acute or chronic, or by how it varies over time (e.g., breakthrough or incidental pain).

• Acute pain is usually caused by tissue damage or injury. It occurs suddenly and goes away over time as the tissue heals.³
• Chronic pain lasts longer than 3 months. It may occur suddenly or gradually, and can range in severity from moderate to severe. Chronic pain can continue even after the underlying cause is treated.
• Breakthrough pain is when pain flares-up, or “breaks through,” despite being well-controlled with regularly scheduled, long-acting analgesics most of the time. It usually occurs quickly and can vary in intensity.
• Incidental pain occurs with certain activities or factors, such as exercise, or routine medical procedures that cause pain.⁵

Because pain is a complex, multidimensional experience, conducting a thorough assessment is critical and must include pathophysiologic, behavioral, sensory, affective, sociocultural, and cognitive components (Box 1).^4,5

Effective pain management begins with a comprehensive pain assessment. Each patient should be screened using a multidimensional pain assessment tool. Many tools are available to quantify the patient’s description of the intensity of the pain (e.g., numerical rating scale, categorical scale, visual analog scale), including tools appropriate for pediatric patients, patients with language or cultural differences, and patients with cognitive impairment.⁴ The details of a comprehensive pain assessment can be found in (Box 1).⁴

A number of modalities are available to treat pain, including treatment of the underlying cause (e.g., surgery, radiation, chemotherapy, targeted therapy, hormonal agents) and pharmacologic and nonpharmacologic interventions (e.g., acupuncture, exercise, guided imagery) (Table 2). A combination of therapies may have a synergistic benefit to relieve or reduce the pain experience, which improves the patient’s functional ability and psychological well-being.

Routine pain assessments and pain management are key parts of good cancer care. However, several barriers to effective pain management exist among practitioners, patients and families, and within the health care system (Box 2) (Table 3). Ineffective pain management often has a negative impact on the patient’s functional status and quality of life (QOL), which causes psychological distress, and more and more evidence shows that effective palliative care that is started early is linked to quality of life and survival – this includes pain management.⁴

SUPPLIES

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EDUCATION

• Give developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, preferred learning style, and overall neurologic and psychosocial state.
• Teach the patient and caregiver about the cause of pain and strategies related to its assessment, reassessment, and management, including pharmacologic and nonpharmacologic interventions.
• Teach the patient and family about common terms and concepts used in managing cancer-related pain (Table 1).
• Emphasize that the patient will likely need to work with the clinical team and try different treatments and combinations of treatments to find what works best for the pain.
• Discuss the patient’s and caregiver’s goal for pain management. Encourage establishing pain management goals that are realistic and achievable.
• Ask the patient and caregiver to report pain, including intensity, location, and characteristics (e.g., crushing, throbbing, stabbing).
• Teach the patient and caregiver to keep a pain diary to record pain intensity, duration, timing, and actions taken to reduce pain along with how well they worked.
• Teach the patient and caregiver to take “as needed” pain medication when pain starts and before diagnostic procedures, activities of daily living, other physical activities, and at bedtime.
• Teach patients to take long-acting pain medicines on schedule, as prescribed.
• Instruct the patient and caregiver about the possibility of breakthrough pain, the importance of reporting it, and how to treat it.
• Instruct the patient and caregiver on the importance of instituting a bowel regimen while on opioid therapy, including diet, fluids, activity, and stool softeners.

ASSESSMENT AND PREPARATION

Assessment

1. Determine if the patient has health literacy needs or requires tools or assistance to effectively communicate. Be sure these needs can be met without compromising safety.
2. Review the patient’s previous experience and knowledge of pain management associated with cancer and understanding of the care to be provided.
3. Screen the patient for opioid status (naive versus tolerant) and type of pain (acute versus chronic).²
4. Review the patient’s medical history, including preexisting comorbidities (e.g., diabetes, arthritis) and previous treatments (e.g., surgery, chemotherapy, radiation, immunotherapy, targeted therapies) that may be causing pain.
5. Find out the patient’s pain level using a validated pain assessment tool. Consider the patient’s age, condition, and ability to understand.⁶

   Screen all patients for pain at each point of contact.⁵

6. Determine the effectiveness of previous pain interventions (pharmacologic and nonpharmacologic) by asking the patient and referring to the patient’s pain diary, as applicable.
7. Determine the patient’s psychosocial, cultural, and spiritual beliefs and support system, which could affect the patient’s experience of pain.³

Preparation

1. Verify the patient’s actual admission weight in kilograms. Reweigh the patient if appropriate.² Do not use stated, estimated, or last documented weight.²

STRATEGIES

1. Clean hands and don appropriate personal protective equipment (PPE) based on the risk of exposure to bodily fluids or infection precautions.
2. Administer nonopioids (e.g., nonsteroidal antiinflammatory drugs [NSAIDs]) as ordered for mild pain.⁵

   Use with caution in a patient with hepatic or renal impairment or with chronic alcohol use because of the risk of hepatotoxicity.⁵

3. Administer opioids (e.g., hydrocodone, oxycodone) as ordered, typically for uncontrolled moderate to severe pain.⁵
   1. Short-acting opioids may be combined with an NSAID.
   2. The opioid dose is titrated until the patient’s pain is controlled.
   3. Patients who are opioid-tolerant typically require higher doses of opioids than those who are opioid-naive.⁵
4. Administer adjunctive medications as ordered.

   Rationale: Adjunctive medications are used in addition to opioid therapy (e.g., NSAIDs, antidepressants, anticonvulsants, bisphosphonates, and topical agents).⁵

5. Rate the patient’s pain again after allowing enough time for the medication to work based on the route and the patient’s condition. Watch for adverse reactions to the medication (e.g., respiratory depression).

   Severe, uncontrolled pain is a medical emergency and should be promptly addressed.⁵

6. Institute a prophylactic bowel regimen, including diet, fluids, activity, and stool softeners, to avoid constipation while the patient is receiving opioids.
7. Initiate nonpharmacologic interventions as prescribed by the practitioner and as applicable to the patient (Table 2).⁵

MONITORING AND CARE

1. Assess the effectiveness of the patient’s pain management plan on a regular basis, including before and after pain interventions and activities.

   Rationale: Regular assessments help determine variations, shifts, and timing of pain peaks and troughs, which allows for necessary and appropriate adjustments to pain management interventions.

EXPECTED OUTCOMES

• Adequate pain relief
• Achievement and maintenance of the patient’s pain management goals
• Increase in or maintenance of desired functional status and QOL
• Prevention or adequate management of expected adverse reactions to analgesics

UNEXPECTED OUTCOMES

• Inadequate pain relief
• Inability to achieve or maintain the patient’s pain goals
• Adverse reactions to analgesics
• Misuse or drug diversion

DOCUMENTATION

• Pain history, medication history, concomitant use of pain management interventions
• Patient’s perceptions and cultural and spiritual values about pain
• Weight in kilograms
• Patient’s response and behavior toward pain and interventions
• Patient’s pain levels using a validated pain assessment tool
• Patient’s opioid status (naive vs tolerant)
• Pain assessment for intensity and quality per patient experience, including breakthrough pain, treatment used, patient’s response to pain treatment, pain interference, and functional impairment, as applicable
• Unexpected outcomes and related interventions
• Education
• Psychosocial support provided, as applicable

SPECIAL CONSIDERATIONS

Pediatric Patients

• Pain should be assessed based on the patient’s developmental age using a developmentally appropriate pain scale (e.g., CRIES, Pain faces, 0-10 scale, FLACC, pain diary), physiologic and behavioral indicators, and caregiver observations.³

Older Adult Patients

• Often have chronic pain that is unrelated to cancer or its treatment.³
• High risk population for falls, polypharmacy, and drug interactions.
• Comorbidities, multiple medications, absorption and distribution changes, GI motility changes, and decreased hepatic and renal clearance may contribute to increased sensitivity to analgesics and central nervous system depressant effects.⁵
• Use lower doses and slower titration.⁵
• May have visual, hearing, motor, and cognitive impairments that interfere with the reporting, assessment, and management of pain.⁵
• May be at greater risk for adverse reactions to NSAIDs (e.g., gastric bleeding, renal toxicity, constipation).⁵

Patients with Cognitive Impairment

• Patients with cognitive impairment may not be able to verbally communicate their pain status. Evaluation may require assessing the patient’s behaviors and talking with caregivers about the patient’s behaviors associated with pain.

REFERENCES

1. Brant, J.M., Brant Isozaki, A. (2024). Chapter 45: Pain. In J.M. Brant, D.G. Cope, M.G. Saria (Eds.), Core curriculum for oncology nursing (7th ed., pp. 445-453). St. Louis: Elsevier.
2. Institute for Safe Medication Practices (ISMP). (2024). 2024-2025 Targeted medication safety best practices for hospitals. Retrieved July 5, 2024, from https://www.ismp.org/guidelines/best-practices-hospitals
3. Maloney-Newton, S., Hickey, M., Brant, J.M. (2024). Oncology symptoms. In Maloney-Newton, S., Hickey, M., Brant, J.M. (Eds.), Mosby’s oncology nursing advisor: A comprehensive guide to clinical practice (3rd ed., pp. 313-402). St. Louis: Elsevier.
4. National Cancer Institute (NCI). (2024). Cancer pain (PDQ)–Health professional version. Retrieved July 5, 2024, from https://www.cancer.gov/about-cancer/treatment/side-effects/pain/pain-hp-pdq
5. National Comprehensive Cancer Network (NCCN). (2024). NCCN clinical practice guidelines in oncology (NCCN Guidelines): Adult cancer pain (Version 2.2024). Retrieved July 5, 2024, from https://www.nccn.org
6. U.S. Department of Health and Human Services. (2019). Pain management best practices inter-agency task force report: Updates, gaps, inconsistencies, and recommendations. Retrieved July 5, 2024, from https://www.hhs.gov/sites/default/files/pmtf-final-report-2019-05-23.pdf

ADDITIONAL READINGS

Gress, K.L. and others. (2020). An overview of current recommendations and options for the management of cancer pain: A comprehensive review. Oncology and Therapy, 8(2), 251-259. doi:10.1007/s40487-020-00128-y

Ruano, A. and others. (2021). Psychological and nonpharmacologic treatments for pain in cancer patients: A systematic review and meta-analysis. Journal of Pain and Symptom Management, 63(5), e505-e520. doi:10.1016/j.jpainsymman.2021.12.021

Clinical Review: Kerrie L. Chambers, MSN, RN, CNOR, CNS-CP(E)

Published: August 2024