1. Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Chapter 29 Pain Management in Patients with Cancer

2. 2Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Pain Management in Patients with Cancer  Pathophysiology of pain  Management strategy  Assessment and ongoing evaluation  Drug therapy  Nondrug therapy  Pain management in special populations  Patient education  The Joint Commission (TJC) pain management standards

3. 3Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Pathophysiology of Pain  What is pain?  Unpleasant sensory and emotional experience associated with actual or potential tissue damage  The most reliable method of assessing pain is to have the patient describe his or her experience.

4. 4Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Pathophysiology of Pain  Neurophysiologic basis of painful sensations  Nociceptive pain vs. neuropathic pain  Nociceptive pain Results from injury to tissues Results from injury to tissues Two forms: somatic and visceral pain Two forms: somatic and visceral pain  Neuropathic pain Results from injury to peripheral nerves Results from injury to peripheral nerves Responds poorly to opioids Responds poorly to opioids  Pain in cancer patients

5. 5Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Management Strategy  ASK about pain regularly.  Assess pain systematically.  BELIEVE the patient and family in their reports of pain and what relieves it.  CHOOSE pain control options appropriate for the patient, family, and setting.  DELIVER interventions in a timely, logical, coordinated fashion.  EMPOWER patients and their families.  Enable patients to control their treatment to the greatest extent possible.

6. 6Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Assessment and Ongoing Evaluation  Comprehensive initial assessment  Intensity and character of pain  Physical and neurologic examination  Diagnostic tests  Psychosocial assessment  Pain intensity scales  Ongoing evaluation  Barriers to assessment

7. 7Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Comprehensive Initial Assessment  The primary objective: to characterize the pain and identify its cause  Assessment of pain intensity and character: the patient’s self-report  Onset and temporal pattern  Location  Quality  Intensity  Modulating factors  Previous treatment  Impact

8. 8Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Fig. 29 – 1. Flow chart for pain management in patients with cancer.

9. 9Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Comprehensive Initial Assessment  Physical and neurologic examinations  Diagnostic tests  Psychosocial assessment  Directed at both patient and family  Pain intensity scales

10. 10Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Fig. 29–2. Linear pain intensity scales. *If used as a graphic rating scale, a 10-cm baseline is recommended.

11. 11Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Fig. 29–3. Wong-Baker FACES pain rating scale. Explain to the patient that the first face represents a person who feels happy because he or she has no pain, and that the other faces represent people who feel sad because they have pain, ranging from a little to a lot. Explain that face 10 represents a person who hurts as much as you can imagine, but that you don’t have to be crying to feel this bad. Ask the patient to choose the face that best reflects how he or she is feeling. The numbers below the faces correspond to the values in the numeric pain scale shown in Figure 29–2.

12. 12Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Ongoing Evaluation  Reassess frequently  Evaluate after sufficient time has elapsed  Be alert for the development of new pain

13. 13Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Barriers to Assessment  Inaccurate reporting by patient  Under-reporting by patient  Language and cultural barriers

14. 14Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Drug Therapy  Nonopioid analgesics  Opioid analgesics  Adjuvant analgesics

15. 15Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Drug Therapy  WHO analgesic ladder  Step 1: mild to moderate pain Nonopioid analgesic Nonopioid analgesic NSAIDs and acetaminophen NSAIDs and acetaminophen  Step 2: more severe pain Add opioid analgesic, oxycodone, hydrocodone Add opioid analgesic, oxycodone, hydrocodone  Step 3: severe pain Substitute powerful opioid—morphine, fentanyl Substitute powerful opioid—morphine, fentanyl WHO = World Health Organization.

16. 16Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Fig. 29–4. The World Health Organization (WHO) analgesic ladder for cancer pain management. Note that steps represent pain intensity. Accordingly, if a patient has intense pain at the outset, then treatment can be initiated with an opioid (step 2), rather than trying a nonopioid first (step 1).

17. 17Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Nonopioid Analgesics  Nonsteroidal anti-inflammatory drugs  NSAIDs (aspirin, ibuprofen)  Acetaminophen  Acetaminophen (Tylenol, others)

18. 18Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Opioid Analgesics  Mechanism of action and classification  Tolerance and physical dependence  Addiction  Drug selection  Preferred opioids  Opioid rotation  Opioids to use with special caution  Dosage

19. 19Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Drug Selection  Pure opioid agonists are preferred for all cancer patients  Opioid rotation  Dosage should be individualized  Use with caution  Methadone (Dolophine), levorphanol (Levo- Dromoran), codeine  Avoid  Meperidine (Demerol)

20. 20Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Routes of Administration  Oral  Rectal  Transdermal  Intravenous and subcutaneous  Intramuscular  Intraspinal  Intraventricular  Patient-controlled analgesia

21. 21Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Managing Breakthrough Pain  Patients may experience transient episodes of moderate to severe breakthrough pain  Access to rescue medication  Strong opioid with rapid onset and short duration

22. 22Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Managing Side Effects  Respiratory depression  Constipation  Sedation  Nausea and vomiting  Other side effects

23. 23Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Adjuvant Analgesics  Used to complement the effects of opioids— not used as substitutes  Tricyclic antidepressants  Amitriptyline (Elavil)  Antiseizure drugs  Local anesthetics/antidysrhythmics

24. 24Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Adjuvant Analgesics  CNS stimulants  Antihistamines  Hydroxyzine (Vistaril)  Glucocorticoids  Bisphosphonates

25. 25Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Invasive Procedures  Neurolytic nerve block  Neurosurgery  Tumor surgery  Radiation therapy

26. 26Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Physical and Psychosocial Interventions  Physical interventions  Heat  Cold  Massage  Exercise  Acupuncture and transcutaneous electrical nerve stimulation

27. 27Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Physical and Psychosocial Interventions  Psychosocial interventions  Relaxation and imagery  Cognitive distraction  Peer support groups

28. 28Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Pain Management in Special Populations  Older adults  Young children  Opioid abusers

29. 29Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Older Adults  Heightened drug sensitivity  Undertreatment of pain  Misconceptions Belief that elderly patients are insensitive to pain Belief that elderly patients are insensitive to pain Belief that elderly patients can tolerate pain well Belief that elderly patients can tolerate pain well Belief that elderly patients are highly sensitive to opioid side effects Belief that elderly patients are highly sensitive to opioid side effects  Increased risks of side effects and adverse interactions

30. 30Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Young Children  Assessment  Verbal children  Preverbal and nonverbal children  Treatment

31. 31Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Opioid Abusers  Two primary obligations  Try to relieve the pain  Avoid giving opioids simply because the patient wants to get high

32. 32Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Patient Education  General issues  Nature and causes of pain  Assessment/importance of honest self-reporting  Plans for drug and nondrug therapy  Drug therapy  Tolerance  Physical dependence and addiction  Fear of severe side effects  Nondrug therapy  Focuses on psychosocial interventions

33. 33Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. The Joint Commission Pain Management Standards  Purpose is to make assessment and management of pain a priority in healthcare  Compliance is mandatory