Pain Management (Oncology)
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Pain is a subjective experience. Recognize that the patient experiencing pain is the expert regarding its occurrence and intensity and the effectiveness of interventions to relieve it.
Identify patients at high risk for adverse opioid-related outcomes (e.g., patients with sleep apnea, receiving continuous IV opioids, or on supplemental oxygen).undefined#ref6">6
Ensure that naloxone (Narcan®) is readily available to reverse the effects of oversedation, including respiratory depression for patients on opioids for pain.
Although pain has many definitions, it is best defined by those who experience it. Each patient is unique in reporting pain, its characteristics, expectations of what should be done to relieve it, and what interventions are effective or ineffective in relieving it. Pain is a complex experience with many components: physiologic (e.g., cause), sensory (e.g., location, intensity, quality), affective (e.g., anxiety, depression), cognitive (e.g., the meaning of pain to the patient), behavioral (e.g., responses to pain and interventions), and sociocultural (e.g., cultural beliefs).10 Adequate understanding of terminology surrounding pain and its management is key when caring for patients who experience pain (Table 1).
Pain is one of the most feared symptoms and unfortunately one of the more common symptoms experienced by patients with cancer.11 Its incidence depends on where the patient is in the cancer continuum, type of cancer, and stage. Up to 59% of patients with cancer report pain while undergoing active treatment and 33% of patients continue to experience pain following completion of curative treatment for their disease.11
Cancer pain may result from a tumor compressing or infiltrating nerves, organs, blood vessels, and connective tissue. Tumors may cause tissue necrosis, leading to infection and pain. Interventional and diagnostic procedures (e.g., a biopsy) result in pain. Pain may occur as a result of adverse effects from cancer therapies (e.g., postoperative pain, postantineoplastic drug therapy mucositis, arthralgia, myalgia, fibrosis from radiation).1
Neuropathic pain and nociceptive pain are syndromes that may affect patients with cancer.2 They result from different mechanisms, are characterized by different qualities and locations, and may respond to different treatment modalities. Patients with cancer may experience one or all types of pain simultaneously. Neuropathic pain results from abnormal processing of input by the peripheral or central nervous system.2 The pain is caused by compression of nerves by a tumor or adverse effects from chemotherapy drugs (e.g., taxanes). Neuropathic pain often is described as burning, numbness, or electric. It is less responsive to opioids alone, often requiring the addition of adjuvant medications (e.g., anticonvulsants).11 Nociceptive pain results from activation of peripheral nociceptors.2 The two types of nociceptive pain are somatic and visceral.2 Somatic pain results from activation of nociceptors in the periphery in the bone, joint, and connective tissues.2 Visceral pain results from activation of nociceptors in the abdominal or thoracic cavities.2 Nociceptive pain often is described as sharp, aching, or throbbing. It is responsive to opioids.11
Cancer pain may be acute or chronic. Examples of acute pain include arthralgias or myalgias, mucositis, and bone pain associated with pegfilgrastim administration.1,10 Chronic pain in patients with cancer is often caused by bone metastases or neuropathies caused by chemotherapy (e.g., taxanes).8 Patients may experience acute and chronic pain simultaneously. Cancer pain may be persistent or intermittent (i.e., breakthrough pain), which is episodic in nature. Persistent pain may be effectively managed with the administration of a long-acting or sustained-release opioid.11 Intermittent pain is sudden and brief and occurs when chronic pain is generally well controlled.1 It is treated with a short-acting, rapid-onset oral opioid or a transmucosal opioid.11
Lack of adequate assessment has been identified as one of the most common reasons for inadequate pain management.13 Because pain is a complex, multidimensional experience, conducting a thorough assessment is critical and must include the physiologic, behavioral, sensory, affective, sociocultural, and cognitive components (Box 1).10,11 Assessment of pain must occur before pain management intervention and on an ongoing basis at specific intervals.3,11 Reassessment of pain after any intervention is critical for evaluating the efficacy of that intervention. Reassessment also directs the plan of care, indicating whether the dose of a pharmacologic agent needs to be increased or decreased.11 Because pain is a subjective experience and is unique to the individual, the patient’s report of and description of pain is the key to accurate pain assessment. The nurse must set aside any biases and misconceptions and believe the patient (Table 2). Many different formal pain assessment tools are available to assess pain. Assessment tools provide practitioners with a standardized method of quantifying a subjective experience.
A number of modalities are available to treat pain.11 Strategies include 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 3). The effectiveness of many nonpharmacologic interventions, however, has not been established in randomized, clinical trials.11 A combination of therapies may have a synergistic benefit to patients in relieving or reducing their pain experience, which improves their functional ability and psychological well-being.
A number of barriers to effective pain management exist among practitioners, patients, and families and within the health care system (Box 2). Ineffective pain management may have a negative impact on the patient’s functional status and cause psychological distress. Evidence indicates that cancer survival is linked to symptom control, and pain management contributes to the improvement of quality of life.8
Nurses play a major role in helping patients achieve pain management goals and ensuring safe, comprehensive pain management. If the patient expresses concern regarding the accuracy of a medication, the medication should not be given. The concern should be explored, the practitioner notified, and the order verified.
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Ensure immediate access to naloxone in case the patient experiences respiratory depression.
Do not assume that the pain location or characteristics are always the same. Assess the location and characteristics with each pain assessment in case the patient experiences pain in a new way or different location.
Do not use medication that is cloudy or precipitated unless such is indicated by its manufacturer as being safe.
Use with caution in a patient with hepatic or renal impairment or with chronic alcohol use because of the risk of hepatotoxicity.
NSAIDs have a ceiling dose because of the risk of hepatotoxicity.
If opioid therapy is to be discontinued in a patient taking opioids for an extended period of time, gradually reduce the dose as prescribed to prevent withdrawal symptoms.
Long-acting (time-released) pain medication preparations must not be chewed, crushed, or cut in half because this causes rapid release of opioid with the potential for a fatal overdose.
Rationale: Adjunctive medications are used in addition to opioid therapy. Adjunctive medications may include NSAIDs, antidepressants, anticonvulsants, bisphosphonates, and topical agents.11
Rationale: Regular assessments determine variations, shifts, and timing of pain peaks and troughs, enabling adjustments to pain interventions.
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
Tewes, M. and others. (2021). Symptoms during outpatient cancer treatment and options for their management. Deutsches Arzteblatt International, 118(17), 291-297. doi:10.3238/arztebl.m2021.0028
*In these skills, a “classic” reference is a widely cited, standard work of established excellence that significantly affects current practice and may also represent the foundational research for practice.
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