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Cancer Pain Chapter 13.

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Presentation on theme: "Cancer Pain Chapter 13."— Presentation transcript:

1 Cancer Pain Chapter 13

2 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

3 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.

4 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

5 Pain Definition Difficult to describe b/c it is such a multi-dimensional 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”

6 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”

7 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

8 Total Pain Seven “P’s”: Physical Pain Intellectual Pain Emotional pain
Interpersonal pain Spiritual Pain Financial Pain Bureaucratic Pain Pain does not occur in isolation. There are multiple dimensions that can cause or worsen the experience of pain and the pain experience can impact on other dimensions to increase overall suffering. Some of these include; Physical Pain – actual physical pain from any source Intellectual Pain- knowledge, memory, self-control, looking ahead Emotional pain- feelings such as anguish, anger, lonliness Interpersonal pain- strain among family members or others Spiritual Pain- facing death, after-life, meaning, faith Financial Pain- disability, loss of work, actual cost of care Bureaucratic Pain- frustrations of forms, people, visits, departments, rules Other factors- Age, Gender, Expectations & placebo effect

9 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 Transduction – noxious stimuli (can be chemical, mechanical) causes cell damage which results in the release of sensitizing substances Transmission – pain impulse travels to spinal cord and brain Modulation – inhibition of pain impulse through release of substances such as serotonin, norepinephrine, and endogenous opioids ( e.g.endorphins & enkephalens). Perception – the conscious perception of pain

10 Pathophysiology of Pain

11 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

12 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

13 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 % Related to cancer or debility (i.e. muscle spasms, constipation) % Related to treatment (i.e. mucositis, incisional pain) % Concurrent disorder (i.e. arthritis) % This category includes neuropathic, deep visceral and bone pain. Each type of pain is best managed with strategies specific to it. Pain can be completely relieved in 80-90% of clients and an acceptable level of relief can be achieved in most of the rest.

14 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

15 Pain: Pain - is a perceptual interpretation of nerve activity that reaches consciousness.

16 Pain can be classified according to pathophysiologic mechanism:
Nociceptive pain: pain that arises directly from chemical, thermal or physical stimulation of normal nerve endings. 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. Nociceptors are specialized cells that respond to noxious stimuli. Nociceptive pain: it is the result of tissue damage, and the “pain message” travels from pain receptors (nociceptors) in peripheral tissue along intact neurons. Nociceptive pain comprises somatic and visceral pain

17 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) Pain can be classified according to the pathological process and clinical characteristics of the pain Nociceptive pain is a result of an injury or insult to non-neurologic structures and occurs in the presence of an intact nervous system. Nociceptive pain can be further classified into visceral, bone, soft tissue, and muscle pain.

18 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 Somatic or superficial pain originates in the skin, bone, joints and connective tissues It is usually localized and non-radiating Often described as sharp, deep, dull, aching or throbbing Constant and intermittent Often worse with movement Palpation of area elicits pain NSAIDs should be considered in any patient wi bone pain; often in combination with opioids.

19 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 Bowel obstruction e.g. Visceral or deep pain originates in the cardiac, lung, GI and GU tract tissues It is more diffuse over the viscera involved It is often described as cramping, gnawing, colicky pain that is associated with obstruction of hollow viscus Often referred to cutaneous sites Other visceral tissues, pain described as aching, stabbing, throbbing, spasms, cramping, pressure

20 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 Neuropathiic pain occurs as a result of neural injury and abnormal or pathologic transmission, processing and integration e.g. phantom limb pain

21 Pain relief can be accomplished by:
Preventing activation of nociceptive receptors in the periphery Preventing transmission of electrical signal along a pathway Preventing transfer of the signal from one neuron to another NSAIDS act at the peripheral level whereas opioids act centrally. NSAIDS are drugs that inhibit prostaglandin synthesis involved in the production of pain and inflammation. Opioids prevent the release of substance P.

22 Methods for Pain Control
Nonopioid analgesics Opioid analgesics Adjuvant drug therpy Radiation therapy Chemotherapy Hormonal therapy Anesthetic procedures Neurosurgical procedures Psychosocial interventions

23 Radiation Good to excellent relief in: Painful bone metastases
Acute spinal cord compression Chest pain 2ndary to bronchial carcinoma Dysphagia due to esophageal cancer

24 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

25 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

26 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

27 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

28 Physical/non-pharmaceutical Methods
Local heat Local cold applications Massage TENS Vibration therapy Acupuncture Exercise Local heat: joint stiffness, muscle spasms - wrap hot packs in towels to prevent burning -do not apply to areas exposed to radiation Local Cold application: may relieve burning or muscle spasm when heat is ineffective -wrap in towel to prevent skin irritation Massage: comfort measure; - terminally ill clients generally do not tolerate deep or vigorous rubsso light message with baby oil TENS: mild to moderate pain due to nerve compression, neuralgia, bone pain from mets Vibration therapy: not understood – indicated for pain in nerves or muscles -works best at frequency around 100 Hz - apply distal to painful site Acupuncture –may be helpful for painful; muscle spasms, bladder spasms Exercise – to maintain muscle strength, joint mobility, coordination and balance. (active then passive if possible)

29 Psychosocial Interventions
The goal of most psychosocial interventions is to help the client regain a sense of control that has been under-mined 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..)

30 Psychosocial Interventions Con’t
Relaxation techniques (focused breathing, meditation) Guided imagery Hypnosis Music Humor Therapeutic touch Music, humor are thought to stimulate the release of endogenous opioids, Therapeutic touch realigns a person’s energy field to return it to normal.

31 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

32 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

33 Pain Assessment “Tell me about your pain”
Why is it important to pay attention to the words the patient uses to describe the pain

34 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?

35 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?

36 Pain Assessment What investigations have been done? X-rays CT scan
Bone scan Blood work

37 Pain Assessment Tools

38 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 VAS is particularly useful for children, elderly and the cognitively impaired.

39 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. The tool was photographed at the Children's Hospital of Michigan, Detroit.

40 What if your client is cognitively impaired?
Unable to communicte verbally?

41 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 Ascertain if the patient has a condition that might cause pain. Determine whether the patient has been treated for pain before, and if so, which treatment regimen was most effective. Attempt to obtain nonverbal feedback from the patient to signal the presence of pain (such as head nodding or eye movements). Ascertain the behaviors the patient usually exhibits when in pain. (This information may need to be obtained from family, friends, or other health care providers.) If there are signs of acute pain or reasons to suspect its presence, treat with analgesics, nonpharmacologic interventions, or both. Continue any pharmacologic and nonpharmacologic interventions that appear to result in pain relief. If a behavioral cue persists or intensifies, rule out other causes (such as delirium, adverse effects of treatment, or accumulation of drug metabolites) and focus treatment on the known or suspected cause. Assess family members' and primary caregivers' interpretations of the patient's behavior. If they believe the patient is still in pain, ask why.

42 WHO General Principles of Pain Management
By mouth By clock By the ladder For the individual Use of adjuvants Attention to details By mouth Spares the client painful injections Gives clients more control over the situation Fixed dose around the clock Clients hesitate to use meds on a PRN basis “I’ll wait a little longer” Scheduled dosing ensures that the next dose is given before the last dose wears off. When pain is allowed to reemerge before next dose, the client experiences needless suffering and tolerance is more likely requiring escalating doses. Use of Adjuvants To enhance analgesic effects (I.e. coticosteroids, anticonvulsants) To control adverse effects of opioids (antiemetics & laxatives) To manage symptoms that contribute to client's pain (anxiety, depression, insomnia) Best Practice!

43 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. know

44 WHO Ladder: outlines pain management principles.
The WHO ladder outlines pain management principles. The following guidelines for pain management in palliative care can help nurses understand how to put these principles into practice.[10] Perform a basic assessment of the patient's pain and evaluate its effects on the patient's quality of life. Titrate analgesics according to goals of care, pain severity, need for supplemental analgesics, severity of adverse side effects, measurements of functional abilities (such as interaction with others, mobility, and sleep), emotional state, and effects of pain on quality of life. Use sustained-release formulations and around-the-clock dosing for continuous pain. Treat breakthrough pain with immediate-release formulations. Monitor the patient's status frequently, especially during dose titration. Anticipate adverse effects and prevent or treat them as necessary. Be aware of possible drug-drug and drug-disease interactions. Reassess pain regularly. Determine what level of pain is acceptable to the patient. If pain is not relieved adequately, don't give up. Consult resources outside your institution, including nursing colleagues and experts in related disciplines.

45 A Stepped Approach Step Three Severe pain (6-10 / 10)
Morphine, hydromorphone, methadone, fentanyl, oxycodone ± adjuvants ± nonopioid analgesics Step Two Moderate pain (3-5 / 10) Acetaminophen with codeine, acetaminophen or ASA with oxycodone ± adjuvants ± nonopioid analgesics Step One Mild pain (1-2 / 10) Acetaminophen, NSAIDs ± adjuvants

46 Nonopioid Analgesics – Acetaminophen
Effective for mild pain No anti-inflammatory effect Usual adult dose mg po q4h (maximum 4000 mg daily) Often combined with opioids

47 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

48 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

49 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

50 A word about meperidine!
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. Gradner, A. (2002). Merperidine: Time for a change. The Distillate, 27(4) PS!

51 Sphincter of Oddi: is sensitive to narcotics
PS! 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.

52 Equianalgesic Doses and Half-Lives of Selected Morphine-Like Agonists

53 Equianalgesic Conversion Table
Source: Texas Children's Cancer Center. (n.d.). Equianalgesic conversion guide. Available at: and Global (n.d). Narcotic analgesic dosage conversion chart. Available at:

54 For the Individual Requirements vary deeply
The average person will require 60 to mg 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 For the individual Requirements vary tremendously depending on the individual The dosage must be titrated against the particular client’s pain Factors Influencing effectiveness of analgesics: Relative analgesic potency Duration of action Oral potency

55 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) See page 492 for more discussion

56 So where do we start? Aim for graded relief
Start with a specific drug for a specific pain Choose an appropriate route of administration Titrate the dosage of opioids Provide for rescue doses Anticipate and treat side effects Initial goal is a pain free night’s sleep to break the cycle of pain = insomnia=exhaustion=increased pain. Next step would be relief of pain at rest, then during weight bearing and movement. E.g. Aches = acetaminophen; neuropathic pain=opioid + dexamthasone or opioid + amitriptyline Need to look at potency of delivery route For opioid-naïve clients: - 1st day give immediate-release morphine 7.5mg q4h - 2nd day add total dose taken during previous 24 hours, divide by two to arrive at bid doe of controlled release. 5. Rescue dose may be 5-15% of 24 hour amt. Of 24 hour dose of morphine, usually Q1h 6. Side effects include constipation (bowel protocol). Nausea/vomiting, etiology is the effect of opioids on CTZ in the medulla, increased vestibular sensitivity, and delayed gastric emptying. Sedation, generally subsides 2-3 days. Confusion & hallucinations, are the most temporary (ARE THERE OTHER CAUSES? Renal failure?) Active metabolites of morphine can cause confusion in clients with impaired renal function. Prutitus caused by histamine result. Treat with haldol or antihistamine. Respiratory depression: “arousable factor” is a satisfactory guide. Naloxone (Narcan) is an opiate antagonist.

57 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

58 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 sustained-release product

59 Side Effects of Opioids
Common Less Frequent Rare Constipation Nausea GI Upset Sedation Dry Mouth Urinary retention Pruritus Severe myoclonus Confusion Hallucinations, nightmares Postural hypotension Vertigo Respiratory depression Allergy

60 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)

61 Ongoing Assessment Important!
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) In a study of 1000 persons with advanced cancer – only 5% required an average daily dosage increase of more 10% of previous dose.

62 Factors Affecting Pain
Situational factors Sociocultural factors Age Gender Meaning of pain Anxiety Past experience with pain Expectations & placebo effect Page 476 of med/surg text.

63 Barriers to Effective Pain Management

64 Who is at risk for inadequate pain management?

65 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) Cultural differences include language barriers, variations in the expression and tolerance of pain. Studies demonstrate that: Clients from minority groups may mistrust the health care system b/c of previous traumatic experiences Physicians had negative stereotypes about African Americans and people of low socioeconomic status. Intelligence, likelihood of risk-taking behaviors, ability to comply with medical advice was based on race. SES was associated with perception about personality, abilities and behavior. Females are more likely to experience inadequate pain management due to 1) perception that women complain more 2) inaccurately report pain 3) are able to better tolerate pain 4)have better coping skills than men. Religion: increased sense of well being and support; “God is punishing me”

66 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

67 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

68 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

69 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

70 Next Class Read Chapter 17 End-of-Life Care

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