Download - Publications Repository

This is an author produced version of an article that appears in:
BRITISH JOURNAL OF COMMUNITY NURSING
The internet address for this paper is:
https://publications.icr.ac.uk/7074/
Published text:
N Hutton, A McGee, C Dunbar (2008) A guide to cancer pain
management, British Journal of Community Nursing, Vol.
13(10), 464-470
Institute of Cancer Research Repository
https://publications.icr.ac.uk
Please direct all emails to:
[email protected]
TOPIC HEADER
A guide to cancer pain management
Natalie Hutton, Anne McGee, Catherine Dunbar
Natalie Hutton is Senior New Media Development Officer at The Institute of Cancer Research. Anne McGee is a former
Specialist Nurse in Palliative Care at St Catherine’s Hospice and Clinical Nurse Specialist in Pain Management at The
Royal Marsden NHS Foundation Trust. Catherine Dunbar is Manager of the Interactive Education Unit, The Institute of
Email: [email protected]
Cancer Research, Sutton
P
ain management remains a problematic area in the
treatment of cancer patients (Jacobson et al, 2007)
(Azevedo São Leão Ferreira et al, 2006) and an
important responsibility of nurses serving these patients in
the community. Many cancer patients experience pain at
some point during the course of their disease, even if they
receive analgesic treatment. Although it is estimated that
up to 90% of cancer pain can be managed (WHO, 2008)
(WHO, 1996), half of all patients in Western countries still
do not receive adequate pain relief (Hanks, 1995). Cancer
patients now have improved survival rates and many will
spend a large proportion of their final years at home,
increasing pressure on community nurses as the main care
coordinators and providers of holistic cancer-related pain
management (Kennedy, 2005).
Community nurse role in the
management of cancer pain
It is essential that nurses working in the community have
the knowledge and support to provide optimal pain relief
to their cancer patients. This involves understanding the
current barriers to optimal management, the importance
of regular pain assessment and the multiple therapies available to provide effective management. Underpinning this,
communication between General Practitioners, nurses
and other teams (hospice and hospital) involved with the
patient’s care is essential, as is communication between
nurses and their patients, carers or other family members
during consultation and assessment.
Barriers to effective
pain management
Pain is subjective and a number of barriers exist to its effective management (Pargeon and Hailey, 1999) (Glajchen,
2001) (Gunnarsdottir et al, 2003). Between 55–95% of
patients with advanced or terminal disease report pain
(Brescia, 1993) yet many still receive inadequate treatment.
Healthcare professional barriers
Healthcare professionals can harbour attitudes and misconceptions that affect their assessment and use of pain relief
measures (Box 1).
These issues are present across healthcare disciplines
(Thomason, 1998). When assessing the intensity of the
patient’s pain, healthcare professionals can be influenced
British Journal of Community Nursing Vol ?, No by their own personal perceptions and prejudices. These
affect how they respond to patients’ self-reporting, or
non-reporting, of their pain and can lead to inadequate
use of non-pharmacological measures or prescriptions of
medication. Some professionals still worry that patients
will become tolerant or addicted (Box 2) to opioids. They
may also be reluctant to prescribe opioids for fear that
the patient may need increasingly higher doses of these
analgesics to control pain, or that they could experience
serious side effects.
Patient barriers
Patients also fear opioid tolerance or addiction and can
associate these drugs with hopelessness or death. They may
also be concerned about side effects and worry that the
safeguards for the close monitoring of these in hospital
are not available in the community. This can cause some
patients to hide, or fail to report, their pain while others
may not comply with prescribed medication. By listening
to patient concerns and using good communication skills,
community nurses are in an ideal position to help reassure
patients about the drugs they are taking and to encourage
compliance. Sometimes older patients may simply forget to
take analgesics or have problems accessing prescriptions for
analgesic drugs. Even getting tablets or liquid analgesics out
of bottles can be difficult for older patients. Such problems
Abstract
Most, if not all, cancer patients require care from community teams at
some stage during their disease trajectory. For many of these patients,
community nurses and General Practitioners are the main point of contact.
Pain is reported by between 55-95% of patients with advanced or terminal
disease. Optimal pain control positively impacts on the physical, emotional
and functional well-being of the patient. Despite the existence of guidelines
(WHO, 1996) (SIGN, 2000) and a wealth of literature on cancer pain
management, half of all patients in Western countries still do not receive
adequate pain relief. This article looks at the reasons behind this and
provides community nurses with an overview of up-to-date information on
pain pathophysiology and management, so that the control of cancer pain
can be optimized in the community.
KEY WORDS
Cancer pain w Pain pathways w Assessment w Management
TOPIC HEADER
Box 1. Common health care professional
misconceptions surrounding pain
Patients should expect pain
Patients in pain always have observable signs
Patients will always tell you when they are in pain
One type of intervention, for example analgesia, is sufficient to relieve pain
Addiction and respiratory depression are problems with
opioid use
(Carr and Mann, 1998)
can often be resolved by community nurses who are used
to caring for older patients and liaising with community
pharmacists.
Organizational barriers
There are also a number of organizational barriers to effective pain management. These include issues surrounding
who takes responsibility and for what. For example, while
GPs normally take responsibility for the ongoing prescribing and titration of analgesics, community nurses have a
vital role in evaluating their effectiveness, monitoring side
effects and reporting back to the GP. Good interdisciplinary cooperation is therefore necessary to provide optimal
pain control for the patient (Dows, 1998).
Understanding pain
Understanding the different types of pain and the mechanisms behind them can help professionals prescribe the
right treatments. Pain can be broadly classified as either
nociceptive or neuropathic. Nociceptive pain can be
further subdivided into somatic pain, which is produced
in structures of the body, such as the skin or muscles,
and visceral pain, which is produced in internal organs.
Box 2. Definitions of common terms
Drug tolerance: a condition whereby higher doses of a
drug are required to maintain the same effect as
produced during initial use of that drug. Tolerance often
leads to physical dependence.
Drug dependency: when a patient becomes
physiologically or psychologically dependent on a drug,
but without the damaging effect to the patient’s
well-being, or compulsive use associated with addiction.
Drug addiction: the compulsive use of a drug, which
damages the users’ physical and psychological health,
and adversely affects their social behaviour.
Breakthrough pain: a temporary flare of moderate to
severe pain intensity that occurs on a background of
otherwise stable pain control.
Adjuvants: non-analgesic drugs that are used with or
without analgesics to improve pain control.
Box 3. Pain gating system
In 1965, Melzack and Wall first proposed a gating
mechanism theory to explain the regulation of pain
perception. It is now generally accepted that there are
‘gates’ present at each level of the spinal cord as well
as at a number of sites in the brain.
The theory proposes that a pain message can only pass
through the ‘gate’ if it is open (Godfrey, 2005). Input from
primary afferent neurones, which bring pain messages
from the tissues to the spinal cord, affect gate opening
and closing. This is due to the balance of stimulation
of the different types of primary afferent nerve fibres
involved in pain pathways. Ad fibres transmit ‘sharp’
nerve injury type pain whereas C fibres transmit ‘dull’ or
‘throbbing’ pain. Ad and C fibres open the gates to allow
transmission of pain, whereas fast conducting Ab fibres
can close the gates. Ab fibres are found concentrated in
the skin and are stimulated by touch or pressure. When
activity of the Ab fibres is greater than that of Ad and C
fibres, the gate closes and the pain intensity perceived
by the brain is reduced. This may be why some patients
feel benefits from massage to the affected area, although
other factors, such as relaxation and distraction, may
also contribute to pain relief experienced through this
therapy.
Nociceptive pain occurs when tissue damage, caused by
tumour growth, results in the release of locally produced
pain-producing substances. Neuropathic pain occurs when
tumour growth damages the peripheral and/or the central
nervous system. The words patients use to describe their
pain can indicate what type of pain they have. For example
nociceptive, somatic pain is typically described as ‘dull’ or
‘throbbing’, whereas visceral pain may be poorly localized and be described as ‘cramping’. Neuropathic pain is
often described as ‘severe burning’, ‘shooting’, ‘tingling’ or
‘numbing’. Often both nociceptive and neuropathic mechanisms are involved, so the pain is described as mixed.
Nociceptive and neuropathic pain involve similar pain
pathways. There are four processes involved in these
pathways; transduction, transmission, modulation and
perception (Figure 1).
Understanding pain pathways
and perception
Understanding the phase of modulation in pain pathways
can help understand why some therapies work and help
community teams prescribe the right treatments. It is
known that when pain messages pass through the central nervous system and onto the brain to be perceived,
these messages can be inhibited or enhanced by pathways
descending from the brain. The descending pathways from
the brain and the pathways of the incoming pain messages
interlink with a complex gating system (Box 3) in the spinal cord. Cognitive activities, such as anxiety, excitement
and anticipation, can cause pain signals to be modified
via descending pathways in such a way as to enhance the
pain stimulus, which can increase the intensity of pain per-
British Journal of Community Nursing Vol ?, No
TOPIC HEADER
Figure 1. The four phases of the pain pathway. 1) Transduction: A noxious stimulus, such as a pin prick, acts on
a specialised pain receptor, commonly called a nociceptor. Above a certain threshold level, the stimulus causes a
change in electrical potential across the nerve’s cell membrane, known as an action potential. 2) Transmission: The
action potential propagates along the nerve. This relays the message from the nociceptor to the spine and brain,
which form the central part of the nervous system (CNS). 3) Modulation: The message is modified (inhibited or
enhanced) by other activity in the CNS, coming from other sensory fibres, such as those stimulated by touch, or
from the descending pathways from the brain. 4) Perception: The brain perceives the sensation as painful. The
main areas involved in pain perception are the thalamus, sensory cortex and limbic system.
ceived (Carr and Mann, 2000) (Gebhart, 2004). Conversely,
the administration of opioids or cognitive activities, such as
distraction, suggestion and relaxation, can inhibit the pain
stimulus via descending pain pathways, which can reduce the
intensity of pain perceived. The gating system is also influenced by incoming messages from sensory fibres. Specific
sensory fibres that respond to touch or pressure are activated
by the application of warmth, coolness, massage or transcutaneous electrical nerve stimulation (TENS) to the skin.This
can result in the closure of the pain gates in the spinal cord,
therefore reducing perceived pain intensity.
Pain assessment
Inadequate pain assessment is an important contributory factor to the under-treatment of cancer pain (Davis and Walsh,
2004). As pain is not static and changes during the course
of the disease, it should be reassessed frequently. The initial
assessment provides a baseline measure of a patient’s pain
against which changes can be measured, such as the success
of treatment (White, 2004). Subsequent assessment enables
any side effects of treatment or breakthrough pain (Box 2) to
be documented (Carr and Mann, 2000). Regular assessments
also convey interest in the patient and builds trust between
British Journal of Community Nursing Vol ?, No the patient and assessor (Oldham and Bacon, 2001).
At the initial assessment a full medical history should
be taken, including drug allergies and drug history. This
should be followed by a history of the pain, including
location, intensity, description, onset and duration. The
assessment should then identify factors that may aggravate
or relieve the pain, as these can lead to changes in function
or behaviour. For example, the patient may be prevented
from carrying out normal activities, such as gardening
or playing with children, because movement may aggravate the pain. Being prevented from carrying out these
activities can make some people feel helpless, hopeless or
depressed. It is therefore important to take into account
psychosocial factors such as these, which can affect mood
and interpersonal relationships, in the assessment. A complete understanding of the features of pain can also help
the assessor empathize with the patient (Ward, 2000).
There are a number of pain assessment tools that can be
used to facilitate the assessment process. Most include body
diagrams to reference the pain location and numbered scales
to mark pain intensity. Useful pain assessment tools include:
The Brief Pain Inventory (Cleeland, 1991) (Cleeland and
Ryan, 1994) and the McGill Pain Questionnaire (Melzack,
TOPIC HEADER
Freed
Box 4. Syringe driver set-up support
om fr
,
om ca
ine l Opioid fo
ncer
r mod
rph tany
o
pain
erate
. m en
t
o
e.g ne, f
sever
P
a
o
e pain ±N
in pe
od
c
on
y
rsist
ox
±Adju -opioid
ing o
, Opio
vant
id fo
ine
r inc
de
r
o
m
rea
c
ild
g.
e.
tam
ce
ra
pa
,
rin
sp D
. a AI
e.g a NS
or
ol
Pain
Non
to m
pers
oder
istin
-opi
oid
±A
Pain
sing
ate p
g or
ain ±Non
-op
incr
±Adju
easi
djuv
3
ng
io
vant id
ant
2
1
The World Health Organization (WHO) guidelines on the relief of cancer pain (WHO,
1996) recommend a three-step analgesic ladder to prescribe analgesic treatment, based
on whether the pain is mild, moderate or severe
Figure 2. WHO analgesic pain ladder.
1983). Like other assessment tools, each has their own
associated advantages and disadvantages. Therefore, it is
important to use the tool which is most appropriate for the
patient. With patients who are mildly or moderately cognitively impaired, the patient’s own reporting of their pain
should still be the primary source for a pain assessment
(Rao and Cohen, 2004). In those with severe cognitive
Table 1. Some common adjuvant drugs
and their uses in pain management
Adjuvant
Common use
Example drugs
Anticonvulsants
Neuropathic pain Gabapentin and pregabalin
are licensed for neuropathic
pain in the UK (Hall and
Sykes, 2004). Sodium
valproate and
Carbamazepine are also
used, though are not
licensed
Antidepressants
Neuropathic pain Amitriptyline
Venlafaxine
Muscle relaxants Bone disease
Diazepam
Baclofen
Clonazepam (also a useful
drug for neuropathic pain)
Biphosphonates
Bone pain, especially Pamidronate
that caused by multiple Clodronate
myeloma, breast or
prostate cancer
(Fulfaro et al, 1998)
(Wong and Wiffen, 2002)
Corticosteroids
Bone pain, spinal cord Prednisolone
compression, headache Dexamethasone
from raised intra-cranial
pressure and
visceral pain
Subcutaneous opioids may be useful for treating patients
in the terminal stages of illness who have become too
unwell to take drugs orally. A syringe driver is commonly
used to deliver analgesics, such as morphine, at set
flow rates as it provides a reliable and constant route of
administration that is safe to use in unsupervised
settings (Barnett, 2000). However, setting up a driver can
be complicated and driver-specific as well as patientspecific. Local skin irritation at the infusion site,
mechanical problems and difficulties in mixing drugs are
all widely recognized (Mitten, 2001).
Over 5 000 articles describing syringe drivers have been
published globally in the last decade (Costello, 2008),
yet many community nurses still lack confidence in how
to set up a syringe driver. Local hospices, primary care
teams or hospital pain and palliative care teams are a
good place to turn to for advice and/ or training. A good
reference book, such as Dickman, Schneider and Varga’s
The Syringe Driver, continuous subcutaneous infusions in
palliative care, can be a valuable resource for all
healthcare professionals who are involved in the set-up
and management of syringe drivers.
impairment, community nurses will find that the observations of family members or caregivers, alongside visual
(e.g. facial grimacing) and physical signs of pain (e.g. tense
muscles), can provide useful information.
In the community, nurses can ask patients to keep a diary
of their pain, recording the intensity and location of the pain
on a daily basis alongside their sleeping, eating and activity
patterns. In this diary, patients should also record their mood
and any other factors that may influence their pain.
Pharmacological methods
of pain management
Since pain is multifaceted it is best managed with a multidisciplinary approach that uses a combination of pharmacological and non-pharmacological treatments (Twycross, 1994).
Pharmacological therapies are the cornerstone of pain
management, and work by various mechanisms to alter
the transmission of pain pathways. The World Health
Organization (WHO) guidelines on the relief of cancer
pain are widely accepted as the international standard by
which treatment should be governed (WHO, 1996). These
guidelines can be built upon to account for more recent
advances in pain management.
WHO recommendations
1. Analgesics should be given orally unless administration
by mouth is not feasible. When the oral route is not possible, alternative routes, such as intramuscular or subcutaneous, should be considered (Box 4). An exception to
this is the transdermal route. This is now being used more
frequently as an alternative to the oral route, particularly if
patient compliance is a problem or the patient feels they
have too many tablets to take.
2. Analgesics should be given at fixed intervals of time
British Journal of Community Nursing Vol ?, No
TOPIC HEADER
(WHO, 1996). Ideally, each dose should be administered
before the effect of the previous one wears off, to provide
continuous pain relief.
3. A three-step analgesic ladder based on whether the pain
is mild, moderate or severe is recommended (Figure 2).
Analgesic treatment should begin at an appropriate step of
the WHO analgesic ladder and move up a step when needed.
It is important to remember that the analgesic ladder is not
a rigid clinical path that must be adhered to in the care of
every patient. The clinical judgement of an experienced and
knowledgeable clinician in determining appropriate pain
medication is important (von Gunten and Ferris, 1999).
Step one of the WHO
analgesic ladder
Step one of the ladder represents non-opioids, such as
paracetamol and/or non-steroidal anti-inflammatory drugs
(NSAIDS). Used by themselves, non-opioids are generally
used to treat mild to moderate pain. However, they can also
be used in combination with opioids to treat moderate to
severe pain. Paracetamol can be given in conjunction with
stronger analgesics; for example morphine and regular paracetamol for the treatment of severe cancer pain. NSAIDs,
including ibuprofen and diclofenac, are useful for managing
pain related to cancer and may be useful to treat musculoskeletal pain, especially pain due to bone metastases. It is
particularly important that community nurses are aware of
the specific side effects of NSAIDs, especially gastric irritation, and monitor patients for these. Step one non-opioids
can also be supplemented by adjuvants (Box 2, Table 1).
Both adjuvants and non-opioids can also be used at any
step of the ladder, either by themselves (step one, nonopioids alone or with adjuvants) or in combination with
weak or strong opioids (steps two and three). For example,
adjuvant drugs, such as antidepressants and anticonvulsants,
have an important role in the management of neuropathic
pain. These drugs dampen down the abnormal nerve activity caused by tumour damage to nerves. For nurses working
in the community this means that patients who describe
their pain as ‘burning’, ‘shooting’ or ‘pins and needles’ in
nature are likely to get pain relief from antidepressants or
anticonvulsant drugs.
Steps two and three
of the WHO analgesic ladder
Steps two and three of the WHO analgesic ladder represent
weak and strong opioids, respectively. Opioids are effective
for treating a variety of pains including nociceptive and
neuropathic pain (Quigley, 2005) (Eisenberg et al, 2006).
Originally it was thought that neuropathic pain was unresponsive to opioids, but it is now believed that there is a
gradation of response. Opioids do have a role in its treatment, in conjunction with adjuvants including anticonvulsants and antidepressants. Step two represents weak opioids,
such as codeine, dihydrocodeine and tramadol. Weak
opioids are normally used to treat mild to moderate pain
and are often administered in combination with non-opioids, especially paracetamol. Codeine and dihydrocodeine
British Journal of Community Nursing Vol ?, No are nearly always used
‘Some patients may not
in this way, as they
respond to morphine or
are not as effective by
themselves (Moore
experience unacceptable
et al, 1997) (SIGN,
side effects, such as sickness,
2000). The choice of
which weak opioid to
hallucinations or drowsiness’
use depends upon a
number of factors, including mechanism of action, potency,
potential side effects, contraindications and even the availability of the drug. Again, community nurses have an
important role in evaluating the effectiveness of these drugs
while monitoring and preventing side effects.The most significant side effect with codeine based drugs is constipation
and therefore patients should be co-prescribed laxatives.
Tramadol, however, is less constipating, but can cause sickness and drowsiness.
Step three of the ladder represents strong opioids, such as
morphine, oxycodone or fentanyl. Morphine is often the
first choice of strong opioid. As with other opioids, it should
be titrated for each individual patient – the dose being
gradually increased in a stepwise manner until pain control is achieved or dose-limiting side effects occur (Walsh,
2000). Often, the process of titration may take several days
and requires team work. While GPs have responsibility for
prescribing and titrating opioid analgesics, the community
nurse is often in the best position to regularly review the
dose and provide ongoing monitoring of the patient.
Some patients may not respond to morphine or experience unacceptable side effects, such as sickness, hallucinations or drowsiness. It is important that these are monitored
by community nurses so that, if necessary, another strong
opioid on the same step of the ladder can be substituted
(if the pain is opioid sensitive). This is known as ‘opioid
switching’ or ‘opioid rotation’. Alternatively, the route of
administration may be changed. In general, opioid switching/rotation or changes in the route of administration
should be managed in conjunction with hospital or hospice
teams who have knowledge of equivalent drug doses. For
example, transdermal fentanyl can be difficult to switch to
without experience, as each patch is equivalent to a range
of morphine dosages. Community nurses often have close
working relationships with hospice teams and are well
placed to make use of the specialist skills and experience
of these teams when managing pain in the community. In
addition, if the route of administration is changed to subcutaneous delivery using a syringe driver, specialist input
is often needed to determine correct drug dosages for
subcutaneous use. Syringe drivers are used when a patient
is unable to absorb, tolerate or take oral analgesics. This can
be due to persistent vomiting or malabsorbtion, difficulty
swallowing due to tumour obstruction, severe weakness or
if the patient is in a semi/or unconscious state (Box 4).
Non-pharmacological
methods of management
A large proportion of patients, possibly up to 30%, will not
have their pain adequately controlled with conventional
TOPIC HEADER
pharmacological therapy alone (WHO, 1996). Analgesic
drugs should be used in conjunction with other treatments, such as physical and psychological techniques.
Non-pharmacological therapies complement pain medication, targeting some of the different components that
contribute to an individual’s sensation of pain.
Physical interventions should ideally be introduced
early in the care of the patient, enabling these therapies
to become an established part of the overall management
strategy. There are a wide variety of physical approaches
that can be employed, and individual patients may derive
benefit from different combinations of these. Referral to
a physiotherapist may be necessary. The physiotherapist
can assess the patient’s physical needs and decide upon
a strategy of exercise and rest best suited to the patient,
following their own assessment. They can also advise
on counter stimulation using Transcutaneous Electrical
Nerve Stimulation (TENS). TENS devices send a weak
electrical current through the skin to stimulate sensory
nerve endings. Patients can be shown how to operate
TENS machines and told to expect a comfortable prickly
or buzzing sensation upon use. Machines may be hired or
purchased from health shops and may also be available on
short-term loan from the National Health Service. Other
physical therapies that can be explored alongside pharmacological therapy include acupuncture, massage or the
application of superficial heat or cold to the affected area.
Some of these approaches have been slow to gain clinical approval because of limited evidence-base. However,
many have now been shown to be beneficial (Carr and
Mann, 2000) (Vickers and Cassileth, 2001). Patients can
often access these services via their local oncology centre
or hospice, if they have been referred to one.
Psychological interventions can also be valuable in controlling pain and offer the patient a sense of self-control.
Such interventions can be explored through visiting a psychologist and can encompass both cognitive and behavioural
techniques. Cognitive techniques focus on perception and
thought and are designed to influence how patients interpret events or bodily sensations. Behavioural techniques are
directed at helping patients develop skills to cope with pain
and modify their reactions to it. Such interventions include
hypnotherapy, relaxation and distraction techniques or music
and art therapy. Emotional, religious or spiritual support also
play a part in psychological well-being, as does having good
communication and a trusting relationship between the
healthcare professional and patient. Psychological interventions do not eliminate a patient’s pain, but can help them
adapt and cope with it.
Patient education
Patients should know how their pain is being managed,
what to expect and should be involved in decisions about
treatment. Community nurses therefore find themselves
educating patients and their families about pain management. Education is important for many reasons, particularly
because it can help patients and their families take control
of their pain and improve its overall management.
Free educational CD ROM
The information in this article has been adapted from
extracts taken from the Breaking Barriers: management of cancer-related pain CD ROM. This educational resource has been developed by the Interactive
Education Unit at The Institute of Cancer Research, in
collaboration with The Royal Marsden NHS Foundation
Trust.
The CD ROM is freely available for the education of
healthcare professionals working in the field of cancer
pain. To order a copy call: 0560 1422921
See www.ieu.icr.ac.uk for more details
Conclusion
Nurses are well placed to have a direct impact on the
quality of pain control provided to cancer patients in the
community. Keeping up-to-date with advances in the field
can lead to increased confidence in how to approach the
complex and multifaceted experience of pain. Armed with
a good awareness of the barriers to its management and
a good knowledge of pain pathways and dimensions, the
community nurse will be well equipped to take a thorough
pain assessment and advise on an optimal and multidisciplinary management strategy.
BJCN
Azevedo São Leão Ferreira K, Kimura M, Jacobsen Teixeira M (2006) The WHO
analgesic ladder for cancer pain control, twenty years of use. How much pain
relief does one get from using it? Support Care Cancer 14(11): 1086–93
Barnett M (2001) Alternative opioids to morphine in palliative care: a review of
current practice and evidence. Postgrad Med J 77(908): 371–8
Brescia F (1993) Pain management issues as part of the comprehensive care of
the cancer patient. Semin Oncol 20 (Suppl 1): 48–52
Carr E, Mann E (2000) Pain – Creative Approaches to Effective Management.
Palgrave Macmillan, Hampshire
Cleeland C (1991) The Brief Pain Inventory. Pain Research Group, Department of
Neurology, University of Wisconsin, Madison
Cleeland C, Ryan K (1994) Pain assessment: global use of the Brief Pain
Inventory. Ann Acad Med Singapore 23(2): 129–38
Costello J, Nyatanga B, Mula C, Hull J (2008) The benefits and drawbacks of
syringe drivers in palliative care. Int J Palliat Nurs 14(3): 139–44
Davis M, Walsh D (2004) Cancer pain : how to measure the fifth vital sign. Cleve
Clin J Med 71(8): 625–32
Dickman A, Schneider J,Varger J (2005) The Syringe Driver, Continuous subcutaneous infusions in palliative care. Oxford University Press, Oxford
Dows K, Booth K, Beaver K (1998) Managing cancer pain at home: the WHO
guidelines in perspective. Br J Community Nurs 3(6): 283–8
Eisenberg E, McNicol E, Carr D (2006) Opioids for neuropathic pain.
Cochrane Database Syst Rev 2006, Issue 3. Art. No.: CD006146. DOI:
10.1002/14651858.CD006146. Available at: www.cochrane.org/reviews/en/
ab006146.html
Fulfaro F, Casuccio A, Ticozzi C, Ripamonti C (1998) The role of bisphosphonates in the treatment of painful metastatic bone disease: a review of phase
III trials. Pain 78(3): 157–69
Gebhart G (2004) Descending modulation of pain. Neurosci Biobehav Rev 27(8):
729–37
Glajchen M (2001) Chronic pain: treatment barriers and strategies for clinical
practice. J Am Board Fam Pract 14(3): 211–8
Godfrey H (2005) Understanding pain, part 1: physiology of pain. Br J Nurs
14(16): 846–52
Gunnarsdottir S, Donovan H, Ward S (2003) Interventions to overcome clinican- and patient-related barriers to pain management. Nurs Clin North Am
38(3): 419–34
Hall E, Sykes N (2004) Analgesia for patients with advanced disease: II. Postgrad
Med J 80(941): 190–5
British Journal of Community Nursing Vol ?, No
TOPIC HEADER
Hanks G (1995) Problem areas in pain and symptom management in advanced
cancer patients. Eur J Cancer 31A(6): 869–70
Jacobsen R, Siøgren P, Modlrup C, Christrup L (2007) Physician-related barriers to cancer pain management with opioid analgesics: a systematic review. J
Opioid Manag 3(4): 207–14
Kennedy C (2005) District nursing support for patients with cancer requiring
palliative care. Br J Community Nurs 10(12): 566–74
Melzack R, Wall P (1965) Pain mechanisms: a new theory. Science 150(3699):
971–9
Melzack R (1983) The McGill Pain Questionnaire: from description to measurement. Anesthesiology 104(3): 597–608
Mitten T (2001) Subcutaneous drug infusions. Int J Palliat Nurs 7(2): 75–85
Moore A, Collins S, Carroll D, McQuay H (1997) Paracetamol with and without codeine in acute pain: a quantitative systematic review. Pain 70(2-3):
193–201
Oldham J, Bacon P (2001) Nursing Times Essential Guide to Pain Assessment.
EMAP Healthcare, London
Pargeon K, Hailey B (1999) Barriers to Effective Cancer Pain Management: A
Review of the Literature. J Pain Symptom Manage 18(5): 358–68
Quigley C (2005) The role of opioids in cancer pain. BMJ 331(7520): 825–9
Rao A, Cohen H (2004) Symptom Management in the Elderly Cancer Patient:
Fatigue, Pain and Depression. J Natl Cancer Inst Monogr 32: 150–7
Scottish Intercollegiate Guidelines Network (2000) Control of pain in patients
with cancer. SIGN 44. Available at: www.sign.ac.uk/guidelines/fulltext/44/
index.html
Thomason TE, McCune JS, Bernard SA, Winer EP, Tremont S, Lindley CM
(1998) Cancer Pain Survey: Patient-Centred Issues in Control. J Pain Symptom
Manage 15(5): 275–84
Twycross R (1994) Pain relief in advanced cancer. Churchill Livingstone,
Edinburgh
Von Gunten C, Ferris F (1999) Pharmacological management of pain. Available
at www.galter.northwestern.edu/geriatrics/chapters/pharmacological_management_pain.cfm
Vickers A, Cassileth B (2001) Unconventional therapies for cancer and cancerrelated symptoms. Lancet Oncol 2(4): 226–32
Walsh D (2000) Pharmacological management of cancer pain. Semin Oncol 27:
British Journal of Community Nursing Vol ?, No 45–63
Ward G (2000) Pain in cancer. Journal of Community Nursing 4(9): Available
at: www.jcn.co.uk/journal.asp?MonthNum=09&YearNum=2000&Type=ba
ckissue&ArticleID=271
White S (2004) Assessment of chronic neuropathic pain and the use of pain tools.
Br J Nurs 13(7): 372–8
Wong R, Wiffen P (2002) Bisphosphonates for the relief of pain secondary to
bone metastases. Cochrane Database Syst Rev (2002) 2: CD002068. DOI:
10.1002/14651858.CD002068. Available at: www.cochrane.org/reviews/en/
ab002068.html
World Health Organization (1996) Cancer pain relief and palliative care: Report of a
WHO Expert Committee (Technical Reports No. 804). WHO, Geneva
World Health Organization (1996) Cancer pain relief: with a guide to opioid availability, 2nd ed. WHO, Geneva
World Health Organization (2008) Palliative care. Available at: www.who.int/cancer/palliative/en/
Key points
wOnly half of cancer patients experience adequate pain
relief.
wMost cancer pain can be relieved with good
management.
wA number of ‘barriers’ exist to effective pain
management.
wPain is subjective and multidimensional.
wA combination of pharmacological and nonpharmacological treatments should be used for
optimal pain management.