The majority of patient with cancer will face acute or chronic pain during their oncology journey. According to a recent study, approximately 53% of all patients receiving treatment experience pain. Moreover, 59% to 64% of patients with advanced cancer report pain. Nearly one-third of all patients report experiencing pain post-curative treatment.
Jeannine Brant, PhD, APRN, AOCN®, an oncology clinical nurse specialist and nurse scientist at the Billings Clinic in Montana, discussed how to perform a complete pain assessment and navigate both pharmaceutical and non-pharmaceutical strategies to provide palliative pain management. She presented her strategies during a session at the 41st Annual Congress in San Antonio, TX.
“Pain is still a problem, nationally and internationally,” Brant said. She started out by discussing who most often reports pain, including patients with the following cancers.
- Head and neck cancer (70%)
- Gynecologic malignancies (60%)
- Gastrointestinal cancer (59%)
- Lung cancer (55%)
- Breast cancer (54%)
- Urogenital cancer (52%)
More than one-third of the pain reported in these cancers are rated as moderate to severe.
“How can we tell who is in pain? One of the biggest misconceptions is that we can look at someone and know if they are in pain. We really do not know,” Brant said. She then discussed assessment tools for pain reporting. The pain interview is the most important tool for healthcare providers. “A lot of times we do not conduct a physical examination at all. Oftentimes we cannot diagnose pain symptoms so we have to talk to the patient,” she said. Establishing a conversation with the patient and engaging in good verbal and non-verbal, non-judgmental dialogue is the best approach. Nurses should focus on the patient and explore fears, treatment expectations and goals, help to clarify the patient’s understanding, and communicate a therapeutic alliance.
There is of course the complicated issue of treating patients with chronic pain who also have a substance use disorder. In this case, nurses should withhold judgement, conduct an adverse child events test, discuss family and social support, ask about a history of depression, anxiety, and psychiatric disorders, screen for risk, and conduct a urine drug screening.
Brant then introduced the 4 A’s of chronic pain goals.
- Analgesia—decrease pain
- Treat underlying cause where possible
- Minimize medication use
- Activities of daily living—restore function
- Physical, emotional, social
- Correct secondary consequences of pain
- Postural deficits, weakness, overuse
- Maladaptive behavior, poor coping
- Adverse events—minimize side effects
- Manage untoward side effects
- Aberrant behaviors—prevent abuse and diversion
- Monitor at each visit
See tables for distinguishing somatic versus neuropathic pain
“Opioids are the mainstay of cancer pain,” Brant said. “Morphine is the gold standard,” unless the patient is renal-compromised, which can lead to over-sedation. Oxycodone is another option that has no renal implications, though is often prescribed with acetaminophen, but prescribers should be careful in this case if patients have hepatic problems. Methadone is also used, particularly for patients with preexisting substance abuse issues, though the drug still carries a stigma.
In addition to pain medication, non-pharmacologic treatment options are available, including
- Interventions that affect perception
- Anything that diverts the mind from pain
- Psychological intervention
- Spiritual intervention
She stressed that patient fear and anxiety can increase the perceived level of physical pain, and antidepressants can be a viable option rather than prescribing more pain medication to stabilize patient mood and control anxiety.
Brant concluded by briefly discussing the newly released Center for Disease Control and Prevention (CDC) Guideline for Prescribing Opioids for Chronic Pain—United States, 2016. “Because of the problems with opioid addiction in our country, the CDC has responded with some strict guidelines that include the following recommendations.”
- Try prescribing non-opioid options first
- Prescribe immediate-release, not long-acting opioids
- Talk to patients about opioid side effects
- Prescribe only for a few days (3—7 days for acute pain)
- Conduct drug screenings
- Include the patient in prescription monitoring programs
- Consider methadone
“A lot of patients are still struggling,” after a short-term opioid prescription Brant noted. “If you do not treat acute pain adequately, those are the patients who wind up developing chronic pain syndromes,” she concluded.
Brant, J. (2016). Complex pain management in oncology. Session presented at the ONS 41st Annual Congress, San Antonio, TX, April 30, 2015.