Pain Management (Oncology) - CE/NCPD

ALERT

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.

OVERVIEW

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.

SUPPLIES

See Supplies tab at the top of the page.

EDUCATION

• Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, 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.
• Advise the patient and caregiver that each individual’s experience of pain is unique and that pain has physical, psychological, cultural, and spiritual components.
• Discuss the patient’s goal for pain management.
• Encourage patient and caregiver involvement in establishing pain management goals that are realistic and achievable.
• Describe the importance of pain assessment and reassessment in evaluating the effectiveness of interventions.
• Encourage the patient and caregiver to report pain, including intensity, location, and characteristics (e.g., crushing, throbbing, stabbing).
• Instruct the patient on the use of an organization-approved 0-to-10 pain scale.
• Instruct the patient and caregiver regarding the frequency of pain assessment.
• Reassure the patient and caregiver that reporting pain will not have negative consequences (e.g., labeling the patient as difficult, drug seeking).
• Instruct the patient and caregiver to keep a diary of pain intensity, duration, timing, and actions used to reduce pain and their effectiveness.
• Teach the patient and caregiver specific pharmacologic and nonpharmacologic strategies that will be used to achieve pain management goals.
• Identify the patient’s preferences for nonpharmacologic pain treatment modalities.
• Teach the patient and caregiver to request pain medication, especially if it is ordered to be given as needed, including before a diagnostic procedure, before activities of daily living or other physical activities, and at bedtime.
• Instruct the patient and caregiver about the possibility of breakthrough pain and the importance of reporting it if it does occur.
• Teach the patient and caregiver about around-the-clock dosing, dosing for breakthrough pain, and as-needed dosing schedules.
• Instruct the patient regarding potential adverse effects of medications used for pain control (Box 3).
• Explain the need to assess for and implement safety measures (e.g., fall precautions).
• Instruct the patient and caregiver about drug dependence, tolerance, pseudoaddiction, and addiction (Table 1).
• Provide the patient and caregiver with written information about pain to reinforce oral instructions.
• Emphasize to the patient and caregiver that almost all pain can be effectively managed.¹¹
• Explain that achieving pain management goals may take time.
• Determine pain goals with the patient and caregiver (e.g., reduction in intensity, increased ability to perform activities of daily living).
• Instruct the patient and caregiver on the importance of instituting a bowel regimen while on opioid therapy, including diet, fluids, activity, and stool softeners.
• Encourage questions and answer them as they arise.

ASSESSMENT AND PREPARATION

Assessment

1. Perform hand hygiene before patient contact. Don appropriate personal protective equipment (PPE) based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids.
2. Introduce yourself to the patient.
3. Verify the correct patient using two identifiers.
4. Assess the patient’s medical history, including preexisting comorbidities (e.g., diabetes) and previous treatments (e.g., surgery, chemotherapy, radiation, immunotherapy, targeted therapies) that may cause pain.
5. Obtain information about the patient’s cancer and disease location, prognosis, treatment and its effects, and treatment goals.
6. Assess the patient’s and the caregiver’s understanding of pain, pain assessment, reassessment, and pharmacologic and nonpharmacologic management strategies.
7. Assess the patient’s pain status using criteria per the organization’s practice. Consider the patient’s age, condition, and ability to understand.⁶
8. Determine the effectiveness of previous pain interventions (pharmacologic and nonpharmacologic) by asking the patient and referring to the diary of pain experiences, if kept.
9. Assess the patient’s psychosocial, cultural, and spiritual beliefs and support system, which could affect the experience of pain.
10. Verify the patient’s opioid status (naive versus tolerant).⁵
11. Assess the patient for specific contraindications to receiving pain medication and advise the practitioner accordingly.
12. Assess the total amount of pain medication used on a daily basis, including regularly scheduled and breakthrough pain medications.
13. Assess the patient for any adverse reactions associated with pharmacologic interventions (e.g., respiratory depression, somnolence, confusion).
14. Assess the patient’s willingness to implement pharmacologic and nonpharmacologic approaches to reduce pain.
15. Assess the patient for conditions that would influence the route of opioid administration (e.g., inability to swallow, lack of venous access).
16. If the patient is receiving opioids, assess the date of the last bowel movement and effectiveness of the prophylactic bowel regimen.

Preparation

1. Review medication reference information pertinent to the medication’s action, purpose, onset of action and peak action, normal dose, and common side effects and implications.
2. Ensure that all appropriate antidotes, reversal agents, and rescue agents are readily available.⁵

   Ensure immediate access to naloxone in case the patient experiences respiratory depression.

3. Verify the patient’s actual admission weight in kilograms. Reweigh the patient if appropriate.⁵ Stated, estimated, or historical weight should not be used.⁵
4. Ensure the patency and condition of IV access before administering parenteral pain medications, if applicable.
5. Collect appropriate supplies for medication administration.

STRATEGIES

Assessing Pain

1. Perform hand hygiene. Don appropriate PPE based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids.
2. Verify the correct patient using two identifiers.
3. Explain the strategies and ensure that the patient agrees to treatment.
4. Assess pain using an organization-approved 0-to-10 pain scale or a similar standardized pain scale or assessment tool (Figure 1).¹¹ Assessment should include:
   1. Onset, location, duration, characteristics (e.g., crushing, aching, burning), and other words that the patient uses to describe pain

      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.

   2. Aggravating and alleviating factors
   3. Related symptoms caused by the pain
   4. Previous pharmacologic and nonpharmacologic pain management strategies
   5. Level and duration of relief achieved
5. Assess the patient for signs and symptoms of pain (e.g., facial grimacing, guarding, restless or decreased movements, depression, inability to concentrate, sleep disturbances).
   1. Focus the physical examination on the area of pain and any areas of referred pain.
   2. Obtain vital signs.
      1. Acute pain may cause vital sign alterations (e.g., elevated pulse and blood pressure).
      2. In many cases, patients with chronic pain do not have vital sign alterations.
6. Discard supplies, remove PPE, and perform hand hygiene.
7. Document the strategies in the patient’s record.

Pharmacologic Interventions for Managing Pain

1. Perform hand hygiene. Don appropriate PPE based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids.
2. Verify the correct patient using two identifiers.
3. Explain the strategies and ensure that the patient agrees to treatment.
4. Obtain the medication, check the practitioner’s order, verify the expiration date, and inspect the medication for particulates, discoloration, or other loss of integrity.

   Do not use medication that is cloudy or precipitated unless such is indicated by its manufacturer as being safe.

5. Ensure the six rights of medication safety: right medication, right dose, right time, right route, right patient, and right documentation. Use a bar code system or compare the medication administration record to the patient’s identification band.
6. Label all medications, medication containers, and other solutions. The only exceptions are medications that are still in their original container or medications that are administered immediately by the person who prepared them.⁷
7. Administer nonopioids (e.g., nonsteroidal antiinflammatory drugs [NSAIDs]) as ordered, typically for mild pain.¹¹

   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.

8. Administer opioids (e.g., hydrocodone, oxycodone) as ordered, typically for moderate to severe pain not controlled with nonopioids alone.¹¹

   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.

   1. The oral route is the preferred administration route in patients who have a functioning gastrointestinal (GI) tract and are not experiencing nausea or vomiting.^10,11 Opioids are also available in the liquid or sublingual form, and many are concentrated so the amount the patient has to swallow or absorb is nominal.

      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.

   2. Transdermal patches (e.g., fentanyl) are an alternative administration route for patients who are unable to tolerate the oral route.¹²
   3. Subcutaneous administration may be an alternative route if the patient is unable to tolerate the oral route or has inadequate venous access. However, only small volumes can be administered subcutaneously, and absorption may be impaired.¹²
   4. If the patient is experiencing a pain crisis, the IV route is used because of the rapid onset of action.¹¹
   5. Intramuscular (IM) administration should be avoided because repeated injections may cause fibrosis or sterile abscesses. In addition, absorption may be impaired. IM administration is contraindicated in patients with bleeding or clotting abnormalities (e.g., leukemia, thrombocytopenia, disseminated intravascular coagulation).¹²
   6. Short-acting opioids may be combined with an NSAID.
   7. The dose is titrated until the patient’s pain is controlled.
   8. Patients who are opioid-tolerant typically require higher doses of opioids than those who are opioid-naive.¹¹
9. If a dose change is indicated based on assessment, obtain the practitioner’s order for change. Include the patient’s current pain regimen, assessment, goal, relief level, duration, and most recent cumulative daily dosing of pain medications in the report to the practitioner.
10. Notify the practitioner of any adverse reactions the patient is experiencing.
11. Ensure that an order for breakthrough or rescue medication has been written by the practitioner. (A breakthrough dose is usually 10% to 20% of the scheduled 24-hour dose administered every hour.)¹¹
12. Administer adjunctive medications as prescribed.

    Rationale: Adjunctive medications are used in addition to opioid therapy. Adjunctive medications may include NSAIDs, antidepressants, anticonvulsants, bisphosphonates, and topical agents.¹¹

13. Reassess the patient’s pain status, allowing for sufficient onset of action per the medication, route, and the patient’s condition. Assess for adverse reactions to the medication (e.g., respiratory depression).
14. Institute a prophylactic bowel regimen, including diet, fluids, activity, and stool softeners, to avoid constipation while the patient is receiving opioids.
15. Discard supplies, remove PPE, and perform hand hygiene.
16. Document the strategies in the patient’s record.

Nonpharmacologic Interventions for Managing Pain

1. Perform hand hygiene. Don appropriate PPE based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids.
2. Verify the correct patient using two identifiers.
3. Explain the strategies and ensure that the patient agrees to treatment.
4. Verify that prescribed nonpharmacologic pain control interventions are appropriate for the patient.¹¹
5. Initiate nonpharmacologic interventions as prescribed by the practitioner (Table 3).
6. Anticipate that the practitioner may refer the patient for other types of intervention.
   1. Radiation therapy for reducing pain associated with bone metastases or tumors pressing on nearby nerves, bones, or organs
   2. Surgery for relief of obstruction, stabilization of bone
   3. Interventional strategies (e.g., nerve block, epidural infusion, neurostimulation, neuroablative procedures)
   4. Physical therapy for strengthening, conditioning, and pain control
   5. Palliative care for additional symptom management and support
7. Discard supplies, remove PPE, and perform hand hygiene.
8. Document the strategies in the patient’s record.

MONITORING AND CARE

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

   Rationale: Regular assessments determine variations, shifts, and timing of pain peaks and troughs, enabling adjustments to pain interventions.

2. Monitor the patient for immediate adverse and allergic reactions to the medication. Recognize and immediately treat respiratory distress and circulatory collapse, which are signs of a severe anaphylactic reaction. Follow the organization’s practice for emergency response.
3. Assess, prevent, anticipate, and manage non-immediate adverse reactions (e.g., constipation) resulting from pain medications (Box 3).
4. Notify the prescribing practitioner for a plan adjustment if current pain management is not effective.
5. Reassess the patient’s and caregiver’s understanding of the pain plan.
6. Assess the home situation and support system to ensure patient safety at home.

EXPECTED OUTCOMES

• Adequate pain relief
• Achievement and maintenance of the patient’s pain management goals
• Increase in or maintenance of desired functional level
• 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
• Injury sustained from a fall
• Respiratory arrest
• Unmanaged constipation or other adverse reactions
• Misuse or drug diversion
• Death

DOCUMENTATION

• Pain assessment per the organization’s practice
• Pain history, medication history, concomitant drug use
• Patient’s perceptions and cultural and spiritual values about pain
• Pain level before and after pain intervention
• Patient’s weight in kilograms
• Patient’s response and behavior toward pain and interventions
• Pain score, usually followed by a slash, and pain scale used (e.g., 7/10, if patient rates pain as 7 on an organization-approved 0-to-10 pain scale)
• Patient’s opioid status (naive vs tolerant)
• Patient’s response to medication, including any adverse reactions
• Unexpected outcomes and related interventions
• Education and response to education
• Psychosocial support provided

SPECIAL CONSIDERATIONS

Pediatric Patients

• Pain is one of the most frequently encountered symptoms among children with cancer, with almost all experiencing pain at some point along their cancer journey.³
• Infants and children are sensitive to pain, feel pain, and remember pain. Failure to attempt pain relief for infants is abusive and unethical.
• Pain should be assessed using an appropriate pain scale (several are available for infants or neonates), physiologic and behavioral indicators, and caregiver observations.

Older Adult Patients

• 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.¹¹ These effects may result in pain peaks of greater duration and longer duration of relief. A slower, gradual dose titration may result in pain relief with minimal adverse reactions.¹¹
• Older adult patients may have visual, hearing, motor, and cognitive impairments that interfere with the reporting, assessment, and management of pain.¹¹
• Older adult patients may be at greater risk for adverse reactions to NSAIDs (e.g., gastric bleeding, renal toxicity, constipation).¹¹
• Topical NSAIDs have demonstrated efficacy and safety for chronic musculoskeletal pain and may be an option for older adult patients unable to tolerate oral NSAIDs.⁹

Cancer Survivors

• A functional assessment provides a better evaluation of pain management strategies than a pain-intensity rating scale in cancer survivors receiving long-term opioid therapy.⁸

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 obtaining data from caregivers regarding the patient’s behaviors associated with pain.

Patients with Substance Use Disorders

• Assessment and management of pain in patients with substance use disorders can be difficult.⁴
• Patients with substance use disorders should receive the same pain assessment and management strategies as all other patients.
• The goal of pain management in patients with a history of heavy substance use is still pain relief and improvement in functional status.
• The patient’s report of pain should be believed.

REFERENCES

1. Aman, M.M. and others. (2021). The American Society of Pain and Neuroscience (ASPN) best practices and guidelines for the interventional management of cancer- associated pain. Journal of Pain Research, 14, 2139-2164. doi:10.2147/JPR.S315585 (Level VII)
2. Brant, J.M. (2020). Chapter 44: Pain. In J.M. Brant, D.G. Cope, M.G. Saria (Eds.), Core curriculum for oncology nursing (6th ed., pp. 401-408). St. Louis: Elsevier.
3. Duffy, E.A. and others. (2019). Perspectives on cancer pain assessment and management in children. Seminars in Oncology Nursing, 35(3), 261-273. doi:10.1016/j.soncn.2019.04.007
4. Edwards, C.V. and others. (2022). The impact of substance use on health care utilization, treatment, and outcomes in patients with non-small cell lung cancer. Journal of Thoracic Disease, 14(10), 3865-3875. doi:10.21037/jtd-21-1992 (Level VI)
5. Institute for Safe Medication Practices (ISMP). (2022). 2022-2023 Targeted medication safety best practices for hospitals. Retrieved May 31, 2023, https://www.ismp.org/guidelines/best-practices-hospitals (Level VII)
6. Joint Commission, The. (2017). R³ report: Requirement, rationale, reference. Pain assessment and management standards for hospitals. Retrieved May 31, 2023, from https://www.jointcommission.org/-/media/tjc/documents/standards/r3-reports/r3_report_issue_11_2_11_19_rev.pdf (classic reference)* (Level VII)
7. Joint Commission, The. (2023). National Patient Safety Goals for the hospital program. Retrieved May 31, 2023, from https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2023/npsg_chapter_hap_jan2023.pdf (Level VII)
8. Manthri, S., Geraci, S.A., Chakraborty, K. (2020). Overview of cancer survivorship care for primary care providers. Cureus, 12(9), e10210. doi:10.7759/cureus.10210
9. Nalamachu, S., Gudin, J. (2020). Characteristics of analgesic patch formulations. Journal of Pain Research, 13, 2343-2354. doi:10.2147/JPR.S270169
10. National Cancer Institute (NCI). (2023). Cancer pain (PDQ)–Health professional version. Retrieved May 31, 2023, from https://www.cancer.gov/about-cancer/treatment/side-effects/pain/pain-hp-pdq (Level VII)
11. National Comprehensive Cancer Network (NCCN). (2023). NCCN clinical practice guidelines in oncology (NCCN Guidelines): Adult cancer pain (Version 1.2023). Retrieved May 31, 2023, from https://www.nccn.org (Level VII)
12. Ostendorf, W.R. (2023). Chapter 31: Medication administration. In P.A. Potter and others (Eds.), Fundamentals of nursing (11th ed., pp. 624-708). St. Louis: Elsevier.
13. Shkodra, M., Caraceni, A. (2022). Treatment of neuropathic pain directly due to cancer: An update. Cancers, 14(8), 1992. doi:10.3390/cancers14081992

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

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.

Elsevier Skills Levels of Evidence

• Level I - Systematic review of all relevant randomized controlled trials
• Level II - At least one well-designed randomized controlled trial
• Level III - Well-designed controlled trials without randomization
• Level IV - Well-designed case-controlled or cohort studies
• Level V - Descriptive or qualitative studies
• Level VI - Single descriptive or qualitative study
• Level VII - Authority opinion or expert committee reports