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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

CAREGIVER DISTRESS

PHYSICAL EMOTIONAL SOCIAL SPIRITUAL

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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

E N E C Core Curriculum L

Goals of Pain Assessment

Determine pain diagnosis

• Etiology of pain

• Nociceptive or neuropathic pain

• Acute, chronic, acute on chronic

• Response to pain interventions

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)

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Allodynia

Hyperalgesia

Tolerance

E N E C Core Curriculum L

Barriers to Pain Relief

• Importance of discussing barriers

• Specific barriers

– Professionals

– Health care systems

– Risk Evaluation and Mitigation

Strategy (REMS)

– Patients/families Paice, 2014; Pasero & McCaffery, 2011

E N E C Core Curriculum L

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 N E C Core Curriculum L

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”?

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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 +/- Non- opioids

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

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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

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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

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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)

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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 on *Twitter 9/9/2014

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.