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Cancer Pain
Chapter 13
Last Class:
• Discuss the goals of chemotherapy.
• Describe the agents used in
chemotherapy, including classification,
methods of administration and side
effects.
• Describe the nursing management of side
effects of chemotherapy
Today’s Objectives:
• Describe radiation as a modality for cancer
treatment, and the uses of radiotherapy
• Identify factors affecting cell response to
radiotherapy.
• Discuss the principles of radiation protection
• Describe the types of radiation therapy and
related nursing care.
• Discuss side-effects of radiation therapy and
nursing care.
Today’s Class:
Define pain
Outline the pathophysiology of pain
Discuss the concept of “total pain”
Compare and contrast acute and chronic pain
Discuss the different classifications of pain and
common descriptors.
Describe the WHO analgesic ladder
Describe common assessments and
interventions for pain
Read Chapter 13 Text
Pain Definition
Difficult to describe b/c it is such a multidimensional phenomenon. According to
International Association for the Study of
Pain:
“An unpleasant sensory and emotional experience
associated with actual or potential tissue
damage, or described in terms of such damage”
Pain Definition
McCaffrey’s
definition addresses
the subjectivity of
pain ….
“whatever the
experiencing
person says it is
and existing
whenever the
person says it is”
Facts About Pain:
Pain is always subjective.
The severity of pain is not in linear relation
to the amount of tissue damage
Many factors influence a person’s
perception of pain, including:
Fatigue
Depression
Anger
Fear & anxiety (including past experience with pain)
Feelings of helplessness and hopelessness.
Pain tolerance
Total Pain
Seven “P’s”:
Physical Pain
Intellectual Pain
Emotional pain
Interpersonal pain
Spiritual Pain
Financial Pain
Bureaucratic Pain
Pathophysiology of Pain
Transduction – initial pain stimulus
triggers action potential
Transmission – action potential travels
from the site of damage to spinal cord and
brain
Perception – the conscious perception of
pain
Modulation – inhibition of pain impulse
Pathophysiology of Pain
http://www.bayareapainmedical.com/nerva
nim.html
Types of Pain
May be Acute or Chronic
Acute Pain
– Short duration (<6 mths)
– Immediate, identifiable onset
(surgery)
– Limited & often predictable duration
– Often described as “sharp”,
stabbing”, “shooting”
Sharp
Stabbing
Shooting
Chronic Pain
Three types:
chronic non-malignant (low back pain),
chronic intermittent (migraine headaches),
chronic malignant (cancer-related pain)
Characteristics of chronic pain:
– Lasts long periods of time(months to years)
– Is not readily treatable
– Pain that is constant, continuous, &
moderate is described as “difficult to bear”
– Often associated with withdrawal &
depression
Cancer-Related Pain
Malignant pain has characteristics of both acute &
chronic pain.
Moderate to severe pain occurs in 30% of clients
receiving treatment and in 60-90% in clients with
advanced disease
Sources of pain in persons with cancer:
– The cancer itself
46-92%
– Related to cancer or debility (i.e. muscle spasms,
constipation)
12-29%
– Related to treatment (i.e. mucositis, incisional
pain) 5-20%
– Concurrent disorder (i.e. arthritis)
8-22%
Remember that…..
A receptor is any functional macromolecule in a
cell to which a drug binds to produce an effect
The term affinity to a receptor means the
strength of attraction between receptor and drug
Pain:
Pain - is a perceptual interpretation of nerve
activity that reaches consciousness.
Pain can be classified according to
pathophysiologic mechanism:
Nociceptive pain: pain that
arises directly from chemical,
thermal or physical stimulation
of normal nerve endings.
http://www.youtube.com/watc
h?v=PMZdkac4YLk
Neuropathic pain: results from
injury to a nerve or from
abnormal nerve function at
any point along the line of
neuronal transmission from
the most peripheral tissues to
the CNS.
Nociceptive Pain
Types:
– Somatic (superficial)
– Visceral (deep)
Somatic pain originates in skin, bone,
joints, muscles, or connective tissue.
Visceral (deep) originates in the organs
(lungs, GI, GU tract)
Somatic Pain
Originates in bones, joints, muscles, skin or
connective tissue
Usually localized & non-radiating
Often described as sharp, deep, dull, aching, throbbing
Constant or intermittent
Often worse with movement
Palpation of area usually elicits pain
NSAIDs should be considered in any patient with bone
pain. Often combined with opioids
Examples bee sting, sunburn
Visceral pain
Originates in cardiac, lung, GI or GU tract
tissues
Is more diffuse over the viscera involved
Cramping, gnawing or colicky pain associated with
obstruction of hollow viscus
Often referred to cutaneous sites
Other visceral tissues, pain described as aching,
stabbing, or throbbing, spasm, cramping, pressure.
Ex. Acute appendicitis, cholecystitis, bowel
obstruction
Neuropathic Pain
Results from abnormal sensory processing which occurs
after damage to a nerve, the spinal cord or brain
Burning, deeply aching that may be accompanied by sudden,
sharp, lancinating pain
Often distributed along a dermatome or peripheral nerve
Numbness or tingling over the skin
Hyperesthesia over an area of the skin
Severe pain from the slightest pressure or touch
Ex. Phantom limb pain
http://www.youtube.com/watch?v=qq5VsVf3CzA
Pain relief can be accomplished by:
1. Preventing activation of
nociceptive receptors in
the periphery
2. Preventing
transmission of
electrical signal along a
pathway
3. Preventing transfer of
the signal from one
neuron to another
Methods for Pain Control
Nonopioid analgesics
Opioid analgesics
Adjuvant drug therpy
Radiation therapy
Chemotherapy
Hormonal therapy
Anesthetic procedures
Neurosurgical procedures
Psychosocial interventions
Radiation
Good to excellent relief in:
– Painful bone metastases
– Acute spinal cord
compression
– Chest pain 2ndary to
bronchial carcinoma
– Dysphagia due to
esophageal cancer
Chemotherapy
May provide excellent pain relief in
responsive tumors
Usually administered in oral formulations
when possible
Single agents with lowest toxicity are used
Administered in short courses
Hormonal therapy
Is used primarily for cancers arising in
cells that have an endocrine function
(breast, endometrium, prostate)
Hormonal therapy to relieve pain is most
likely to be effective in carcinoma of the
prostrate.
Bilateral orchidectomy brings relief of bone
pain in 60-80% of clients within hours of
surgery & may last up to 2 years
Palliative surgery
Indicated for:
Stabilization of long bone
with mets to prevent a
pathological fracture
Decompression of the
spinal canal to prevent
impending paralysis
Relief of bowel obstruction
in selected patients
Anesthetic & Neurosurgical
Procedures
Anesthetic procedures are most helpful
in treating well-localized somatic or
visceral pain.
Procedures include injections, inhalation
of nitrous oxide, epidural infusion with
opioids or local anesthetics.
Neuroablation involves interruption of
specific nerve tracts
Physical/non-pharmaceutical
Methods
Local heat
Local cold
applications
Massage
TENS
Vibration therapy
Acupuncture
Exercise
Psychosocial Interventions
The goal of most psychosocial
interventions is to help the client regain a
sense of control that has been undermined by illness and pain. These
include:
– Education and accurate information
about pain, pain control, & common
misconceptions about the use of
opioids (fear of addiction, side
effects..)
Psychosocial Interventions Con’t
Relaxation
techniques (focused
breathing, meditation)
Guided imagery
Hypnosis
Music
Humor
Therapeutic touch
ABCDE’s of Pain
A- Ask about the pain regularly. Assess pain
systematically
B- Believe the patient and family in their reports of
pain and what relieves it.
C- Choose pain control options appropriate for the
patient and family, and setting.
D- Deliver interventions in a timely, logical , and
coordinated fashion
E- Empower patients and their families. Enable
them to control their course as much as possible
Pay Attention to Detail:
Take nothing for granted
Be precise in history taking
Explore the client’s “total pain”
Determine what the person knows about
the situation, what s/he believes and fears
about pain and the things that can relieve
it
Make sure instructions are precise and
written down
Pain Assessment
“Tell me about your pain”
Why is it important to pay attention to the
words the patient uses to describe the
pain
Pain Assessment
How intense is your pain?
Use a pain scale
Where is your pain?
How long does it last?
What makes it better or worse?
How does the pain affect your sleep,
appetite, energy, mood, relationships,
daily activities?
Pain Assessment
Are you having any other symptoms?
What do you think is causing the pain?
What medications are you taking for the
pain?
Do have any concerns about medications?
What are you doing to try to relieve the
pain?
Do you have support from family and
friends?
Pain Assessment
What investigations have been done?
X-rays
CT scan
Bone scan
Blood work
Pain Assessment Tools
Subjective tools such as the
Visual Analog Scale (VAS)
and the Faces Scale are
used to assess pain.
The VAS is a straight
horizontal 100 mm line
anchored with "no pain" on
the left end and "worst
possible pain" or "pain as
bad as it could possibly be"
on the right. Clients are
asked to choose a position
on the line that represents
their pain.
The Faces Scale depicts
facial expression on a scale
of 0-6, with 0=smile, and
6=crying grimace. Clients
should choose a face that
represents how the pain
makes them feel.
The African-American
version of the Oucher
was developed and
copyrighted by Mary J.
Denyes, PhD, RN,
Wayne State
University School of
Nursing, and Antonia
M. Villarruel, PhD, RN,
currently of the
University of
Pennsylvania.
Behavioral Cues
Non-verbal cues include:
– Decreased activity or restlessness
– Furrowed brow
– Grimacing
– Crying, moaning
– Withdrawal from interacting with each other
– Guarded or stiffened posture
– irritability
Physical signs include increased BP, rapid
pulse
WHO General Principles of Pain
Management
By mouth
By clock
By the ladder
For the individual
Use of adjuvants
Attention to
details
WHO 3-step Analgesic Ladder
The WHO has developed a three-step
analgesic ladder to guide the use of
drugs in treating cancer pain
First step: non-opioid drug with/without
adjuvant drug as required
Second step: add a weak opioid for
mild to moderate pain, with adjuvant
drugs as required
Third step: a strong opioid should be
substituted for the weak.
WHO Ladder:
outlines pain management principles.
A Stepped Approach
Step One
Mild pain
(1-2 / 10)
Acetaminophe
n, NSAIDs ±
adjuvants
Step Two
Moderate pain
(3-5 / 10)
Acetaminophen with
codeine,
acetaminophen or ASA
with oxycodone ±
adjuvants ± nonopioid
analgesics
Step Three
Severe pain
(6-10 / 10)
Morphine, hydromorphone,
methadone, fentanyl,
oxycodone ± adjuvants ±
nonopioid analgesics
Nonopioid Analgesics –
Acetaminophen
Effective for mild pain
No anti-inflammatory effect
Usual adult dose 325-1000 mg po q4h
(maximum 4000 mg daily)
Often combined with opioids
Nonopioid Analgesics – NSAIDs
Act by inhibiting prostaglandins
Analgesia and anti-inflammatory action
Appropriate for mild to moderate pain
Effective adjuvants for bone pain
Side effect profiles vary between agents within the
class
Gastroprotectants may be necessary
Use cautiously in patients with renal insufficiency
Due to ↓ platelet aggregation, NSAIDs should be
avoided in patients at risk of thrombocytopenia
Opoid Analgesics
Act primarily by stimulation of receptors in the
brain
Are the mainstay of cancer pain management of
moderate to severe intensity
Use the oral route whenever possible
Use the SC or IV route for rapid pain relief or if
the patient is not able to take medications orally
All parenteral opioids can be given SC
IM injections not recommended
Opioid Analgesics – Choice of
Agent
Start with morphine (unless contraindicated) as
most patients will achieve pain control and it is
easily available in multiple doses and dosage
routes
Hydromorphone and fentanyl may be preferred
in the elderly
Oxycodone, fentanyl and methadone may be
safer in patients with renal failure
Avoid meperidine/Demerol
Useful for short term acute care.
Has a long half-life
The metabolite of meperidine is associated with
many adverse effects and may reach toxic
levels, leading to CNS excitation or even
seizures.
Sphincter of Oddi is sensitive to all narcotics.
Sphincter of Oddi:
is sensitive to narcotics
The sphincter of Oddi is a
muscular valve that
controls the flow of
digestive juices (bile and
pancreatic juice) through
the ampulla of Vater into
the first part of the small
intestine (duodenum).
Narcotics cause spasms
of the spinchter of oddi.
The spasms cause a
back-up of these digestive
juices the result being
episodes of severe
abdominal pain.
Equianalgesic Doses and Half-Lives of
Selected Morphine-Like Agonists
Equianalgesic Conversion Table
For the Individual
Requirements vary deeply
The average person will require 60 to
120mg of oral morphine per day
Some will require less opioid
A small % may require very high doses
(>2000mg/day)
The dose of analgesic must be titrated
against the particular patient pain
Use of Adjuvants
Enhances the analgesic effect (steriods,
anticonvulsants)
Controls the adverse effects of opiods
(e.g. antiemetics, laxatives)
To manage symptoms that are
contributing to the client’s pain (anxiety,
depression, insomnia)
1. Aim for graded relief
2. Start with a specific drug for a
3.
4.
5.
6.
specific pain
Choose an appropriate route of
administration
Titrate the dosage of opioids
Provide for rescue doses
Anticipate and treat side effects
Attention to Detail
Take nothing for granted
Be precise in history taking
Explore the client’s “total pain”
Determine what the person knows about
the situation, what s/he believes and fears
about pain and the things that can relieve
it
Make sure instructions are precise and
written down
Initiating An Opioid
Assess the level of pain
Start with an immediate-release preparation,
q4h around the clock
Follow a titration schedule to establish pain
control
Breakthrough doses of the same opioid
(immediate-release only) should be provided
When pain is controlled, convert to a sustainedrelease product
Side Effects of Opioids
Common
Less Frequent
Urinary retention
Pruritus
Constipation
Severe myoclonus
Nausea
Confusion
GI Upset
Hallucinations,
nightmares
Sedation
Postural hypotension
Dry Mouth
Vertigo
Respiratory depression
Rare
Allergy
Use of Adjuvants
Enhances the analgesic effect (steriods,
anticonvulsants)
Controls the adverse effects of opiods
(e.g. antiemetics, laxatives)
To manage symptoms that are
contributing to the client’s pain (anxiety,
depression, insomnia)
Ongoing Assessment
Pain is a dynamic process and may
change from hour to hour!
New pains, disease progression, a
treatable acute problem may arise.Pain
assessment must be documented
Assess for tolerance:the need to increase
dosage of a drug over time to maintain a
given level of analgesia. (rare)
Factors Affecting Pain
Situational factors
Sociocultural factors
Age
Gender
Meaning of pain
Anxiety
Past experience with pain
Expectations & placebo effect
Barriers to Effective Pain
Management
Who is at risk for inadequate pain
management?
Rural clients (access)
Elderly (natural part of aging? Difficulty
describing pain?
Cultural differences
Ethnic minorities, lower income brackets
Gender - women
Religious beliefs (positive & negative
impact)
Barriers to Pain Management
HCPs & Families
Lack of education about pain management from
health professionals.
Poor communication (subjectivity)
Personal Barriers
Stigma associated with use of narcotics
Fear of addiction
Side effects
Need to be “good patient”
Fear it will impede progress
Fear of injections
Barriers to Pain Management
Health Care System Factors
Pain not recognized as a major
management priority in past
Lack of prescription drug coverage for
many people
Restrictions on prescriptions for narcotics
Health Care Professionals
Lack of education
Fear of regulatory scrutiny
Concerns about addiction and respiratory
depression from opioids
Poor pain assessment skills
Concerns about people seeking drugs for
illicit use
Patients and Family
Fears about the meaning of the pain
Strong views on the use of opioids
The belief that pain is a “normal” part of the
illness
Past experiences with pain
Cultural, or religious beliefs
Denial of disease or disease progression
Fears about constipation, addiction, sedation,
cognitive changes
Next Class
Read Chapter 17
End-of-Life Care