44 august 1 :: vol 26 no 48 :: 2012 NURSING STANDARD / RCN PUBLISHING
Art & science oncology
Abstract Pain is common in patients with cancer and may be caused by the disease itself or treatments. Part 1 of this article identied the causes and types of cancer pain to inform assessment and management of pain, which will be discussed in this article. Barriers to pain management and the non-medical prescribing role of the advanced practice nurse in treating patients with cancer pain will be explored. Author Suzanne Chapman Clinical nurse specialist in pain management, clinical services division, The Royal Marsden NHS Foundation Trust, London. Correspondence to: suzanne.chapman@rmh.nhs.UK Keywords Breakthrough pain, cancer pain, non-medical prescribing, pain assessment, pain management Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software. Online Guidelines on writing for publication are available at www.nursing-standard.co.uk. For related articles visit the archive and search using the keywords above. Cancer pain part 2: assessment and management Chapman S (2012) Cancer pain part 2: assessment and management. Nursing Standard. 26, 48, 44-49. Date of acceptance: April 19 2012. ADVANCES IN THE treatment of cancer have led to increased life expectancy for patients. As a result, cancer is emerging as a chronic and complex condition (Chapman 2011). Patients with cancer may experience signicant physical effects, such as pain from the cancer itself or treatments. Cancer pain is frequently undertreated despite the wide range of treatment options available. Barriers to effective treatment may include poor assessment, insufcient knowledge of pain mechanisms and treatment options, and specic concerns regarding dependence, tolerance, addiction and drug-related side effects (Fine et al 2004). Individualised assessment and selection of the most appropriate therapeutic approach can improve patients function and quality of life by reducing their pain. This article focuses on assessment and management of cancer pain, as well as barriers to effective treatment of pain. Non-medical prescribing is also discussed. Pain assessment Thorough pain assessment is essential to dene pain (both its cause and type) and direct treatment. The aim of assessment is to diagnose the underlying cause of pain and its effect on the patient. Pain should be assessed regularly and systematically with a validated pain assessment tool. Assessment is not a one-off process; cancer pain is dynamic and may change in response to treatment or disease progression. Pain should be assessed to establish a baseline measure before any treatment intervention is initiated or changes to treatment regimens are made, and then reassessed after the intervention to measure effectiveness. Use of pain intensity assessment scales enables patients to quantify a baseline measure of pain, which is important for monitoring their response to treatment. Examples of pain intensity assessment scales include the Numerical Rating Scale (0-10), Verbal Rating Scale (none, mild, moderate, severe, very severe), pain thermometer scales (Figure 1) and Faces Pain Scale (Fink and Gates 2006, Herr et al 2007). Multi-dimensional pain tools enable assessment of other core features of pain, such as affective, cognitive, social and spiritual dimensions (Table 1). Pain assessment needs to incorporate factors that will moderate sensitivity to pain. Pain sensitivity can be increased when patients are uncomfortable, not sleeping well, or fatigued, anxious, fearful, angry, sad, depressed or bored (Dougherty and Lister 2011). Pain sensitivity is reduced when symptoms are relieved, patients are well rested, anxiety is reduced and mood is elevated (Dougherty and Lister 2011). If patients are shown empathy and understanding, and offered companionship and diversional activities, pain sensitivity can be further reduced. The p44-49w48.indd 44 27/07/2012 12:08 NURSING STANDARD / RCN PUBLISHING august 1 :: vol 26 no 48 :: 2012 45 Short-Form McGill Pain Questionnaire and Brief Pain Inventory (Fink and Gates 2006) are simple tools that can be used for routine clinical assessment in patients with cancer. Other methods of pain assessment include patients self-reports. These include hand-held patient records, which may be electronic or paper to enable assessment and management approaches to be shared by all healthcare professionals involved in patients care. Diaries, charts or scales may be used by patients to record the intensity of their pain, the analgesics and non-pharmacological approaches they have tried, and how well these worked. Carers should be included in the assessment process as they may need to be involved in the ongoing monitoring of pain, and may provide insight about whether the patient is being stoical. Personal judgements and experiences may inuence healthcare professionals assessment of pain, leading to an over reliance on physiological signs and behaviours indicating the presence of pain. These can be misleading and inaccurate, particularly in patients with chronic pain. The use of formal pain assessment tools enables effective assessment and communication between healthcare professionals and patients, and reduces error and bias (Carr and Mann 2000a). Pain is a personal experience and the challenge for nurses is to enable patients to express their pain. The presence of breakthrough pain should be assessed as part of comprehensive cancer pain assessment. As part of history taking during initial assessment, patients should be asked a series of questions to establish whether they have breakthrough pain, including: Do you have background pain (a constant pain experienced on a daily basis)? Is the background pain adequately controlled? Do you have transient exacerbations of pain? If the patient answers yes to all three questions, breakthrough pain is present (Davies et al 2009). Management of cancer pain Flexibility is key to managing cancer pain. Diagnosis, stage of disease, response to pain and interventions, and personal preferences will vary between patients. Box 1 lists principles that should guide the development of an individualised pain management plan for patients with cancer. Management strategies for cancer pain include pharmacological approaches, in which analgesics can be given via various routes (oral, buccal, sublingual, intranasal, rectal, subcutaneous, intravenous, transdermal) and non-pharmacological approaches. Box 2 summarises the different approaches to management of cancer pain following thorough pain assessment. Pharmacological approaches The World Health Organizations (WHO) (1996) analgesic ladder is used to guide prescribing. It involves a stepwise approach to the use of analgesics, including non-opioids (step 1), opioids for mild to moderate pain (step 2), opioids for moderate to severe pain (step 3) and adjuvant drugs that can be used at any step if appropriate (Figure 2). The WHO (1996) has suggested ve simple recommendations for maximising effectiveness of prescribed treatments, including: Analgesics should be administered orally whenever possible. FIGURE 1 Example of a pain thermometer scale Point to the words that best show how bad or severe your pain is now Pain as bad as could be Extreme pain Severe pain Moderate pain Mild pain No pain (Adapted from Herr et al 2007) TABLE 1 Dimensions of pain Dimension Example Physiological Aetiology when the pain started, type of pain (sharp dull) and relieving or aggravating factors. Sensory Location, severity of pain. Affective Emotional responses and feelings. Cognitive Thought processes. Behavioural Communication of pain and fatigue. Sociocultural Culture, family and work roles. Spiritual Meaning and purpose attributed to pain. (Silkman 2008) p44-49w48.indd 45 27/07/2012 12:08 Art & science oncology 46 august 1 :: vol 26 no 48 :: 2012 NURSING STANDARD / RCN PUBLISHING Analgesics should be given at regular intervals. Consider the duration of drug action, prescribe a dose that should be taken at denite regular intervals in accordance with the patients pain level and adjust the dose until the patient is comfortable. Analgesics should be prescribed according to pain intensity as evaluated using a pain intensity scale. The dose of an analgesic should be adapted to the individual. There is no standard dose to treat certain types of pain every patient will respond differently. The correct dose is one that will provide adequate pain relief. Analgesics should be prescribed with consideration given to prescribing rst and last doses linked to waking time and bedtime for the patient, and monitoring for effectiveness and side effects. Beginning on step 1 of the WHO (1996) analgesic ladder may be insufcient for patients with severe cancer pain or treatment-related pain; these patients may need to start on step 3 (opioid with or without adjuvant drugs). There are several different opioids available for the treatment of moderate to severe pain. There is no evidence that one opioid is superior to another for the treatment of pain, but individuals may have unique opioid receptor proles and genetic differences that mean one opioid may work better for them than another (Hall and Sykes 2004). Other factors may also affect a patients ability to tolerate opioids, including (Fallon et al 2006): How responsive the type of pain is to opioids. Previous use of opioids. How quickly the opioid dose was titrated. Concomitant medication. Concomitant disease. Genetic factors (differences between individuals in opioid response). Biochemical factors such as renal and hepatic function. Opioids are available in many different preparations depending on their duration of action (immediate release or modied release), drug formulation and delivery route (oral tablets or capsules, transdermal patches, buccal or sublingual formulations, or administration via subcutaneous or intravenous routes). The route of administration that is most suitable for the patient will guide drug preparation. For example, transdermal drug delivery via patches may need to be considered in those with dysphagia and in patients at the end stages of the disease. For patients unable to continue taking oral medications, subcutaneous infusions or bolus doses can be administered instead. Choice of drug and preparation should be based on what is most appropriate for the patient, family and setting where the person will be cared for. Patients taking regular doses of opioids will require careful monitoring for side effects such as constipation, sedation, nausea and opioid toxicity. Adjuvant drugs contribute to pain management, but are not primarily used for pain relief; their use is indicated on all steps of the WHO (1996) analgesic ladder. Addition of these drugs to a patients individual pain management plan should be based on pain assessment and the likely cause of pain. Examples of adjuvant drugs include antispasmodics for acute colic or spasm, antidepressants and anticonvulsants for neuropathic pain, and bisphosphonates for bone pain (Gannon and Davies 2006). Other pharmacological interventions may also be considered, for example continuous BOX 2 Management approaches to cancer pain Pharmacological approaches: Non-opioids (paracetemol, non-steroidal anti-inammatory drugs). Opioids (codeine, dihydrocodeine, tramadol, morphine, oxycodone, fentanyl, hydromorphone). Adjuvant drugs (corticosteroids, antidepressants, anti-epileptics, N-methyl-D-aspartate-receptor antagonists (ketamine)), antispasmodics, muscle relaxants, bisphosphonates. Single nerve blocks. Infusions of drug combinations, for example including local anaesthetics, opioids and/or adjuvant drugs via the epidural or intrathecal route with external pumps. Implantable infusion systems. Non-pharmacological approaches: Physiotherapy. Occupational therapy. Transcutaneous electrical nerve stimulation. Acupuncture. Massage. Relaxation. Psychological support. Pastoral care. BOX 1 Principles of cancer pain management Ask the patient about pain regularly. Use assessment tools (such as pain intensity scales, the Short-Form McGill Pain Questionnaire and the Brief Pain Inventory). Ask the patient which symptom is most troublesome this may not always be the one that is most severe. Believe patient and family reports of pain and what relieves pain. Choose pain control options appropriate for the patient, family and setting. Deliver interventions in a timely, logical and co-ordinated fashion. Empower the patient and family. Enable patients to control their approach to pain management as much as possible. p44-49w48.indd 46 27/07/2012 12:08 NURSING STANDARD / RCN PUBLISHING august 1 :: vol 26 no 48 :: 2012 47 infusions of combinations of drugs such as local anaesthetics, opioids or adjuvant drugs via the neuraxial route (epidural or intrathecal), targeted nerve blocks and inhalation therapy (such as nitrous oxide). Neuraxial route infusions require monitoring to detect drug-related side effects, potential infection risks and device-related problems (Farquhar-Smith and Chapman 2012). The nurse should be vigilant and know how to manage these situations appropriately. Nurses have an important role in medicines management. This includes ensuring that patients understand what medication they are taking and why, and the likely side effects. When administering analgesics, nurses should also be aware of how to progress to the next level of stronger analgesia for breakthrough pain or how to increase doses when end-of-dose failure occurs. Non-pharmacological approaches Optimal pain control is more likely to be achieved by combining pharmacological and non-pharmacological approaches. The use of non-pharmacological approaches should be based on thorough pain assessment so that referrals can be made to appropriate healthcare professionals for review and advice regarding management strategies. Physical therapies, such as physiotherapy and occupational therapy, can help to reduce pain and improve function and quality of life for patients (British Pain Society 2010). Interventions include therapeutic exercises, pacing of daily activity, graded and purposeful activity, transcutaneous electrical nerve stimulation and lifestyle adjustment (British Pain Society 2010). Comfort measures such as instruction on positioning and posture may ease pain and prevent exacerbations (Dougherty and Lister 2011). Complementary and alternative medicine refers to treatment modalities that complement mainstream approaches. Complementary and alternative medicine may improve the patients sense of wellbeing and therefore inuence pain perception and tolerance (British Pain Society 2010). Psychological interventions can improve patients pain and sense of pain control by reducing anxiety, stress and muscle tension. Distraction techniques can be used to divert the patients attention from the pain and on to something else, at least temporarily. Examples of distraction techniques include reading, listening to music, counting, doing crossword puzzles, watching television and interacting with visitors or carers. Nurses can develop trusting therapeutic relationships with patients by listening to and acknowledging the persons experience of pain, acting as a patient advocate, and providing physical and emotional support. These relationships can be instrumental in reducing anxiety and helping patients cope with pain (Carr and Mann 2000b). Information and education can make the difference between effective and ineffective pain management. Education enables the patient to engage in decision making about his or her pain management plan and can consequently reduce anxiety. Education should include specic information about why pain control is important, expectations about pain relief, how the patient can participate in pain management and what the person should do if pain is not controlled (Dougherty and Lister 2011). Care must be taken to tailor the level of information to the individuals needs. Guided imagery may be used to manage pain and anxiety associated with procedures such as venepuncture and cannulation. When guided imagery is used with relaxation breathing it can help patients cope with the procedure and promote a feeling of patient participation. Guided imagery engages the person by focusing on a pleasant activity, providing distraction from the pain or changing the perception of the painful experience. Guided imagery is used to give the person the opportunity to imagine being in a more pleasant situation and involves all of the senses. For example, when imagining a favourite place the person is asked to feel the warmth all around, see the colours, smell the odours and hear the sounds. FIGURE 2 World Health Organization three-step analgesic ladder Freedom from cancer pain 1 2 3 Opioid for moderate to severe pain Non-opioid Adjuvant Opioid for mild to moderate pain Non-opioid Adjuvant Pain persisting or increasing Pain persisting or increasing Non-opioid Adjuvant Pain (World Health Organization 1996) p44-49w48.indd 47 27/07/2012 12:08 Art & science oncology 48 august 1 :: vol 26 no 48 :: 2012 NURSING STANDARD / RCN PUBLISHING Management of breakthrough pain Management of breakthrough pain should be individualised and include treatment of the underlying cause of pain; avoidance and/or treatment of any precipitating factors; modication of the background analgesic regimen (around the clock medication); use of rescue medication (breakthrough medication); use of non-pharmacological methods (rubbing or massage, heat or cold therapies, distraction techniques, relaxation techniques); and use of interventional techniques such as nerve blocks (Davies et al 2009). The nurse has a key role in monitoring interventional approaches such as neuraxial blockade and assisting the patient to develop appropriate non-pharmacological pain management strategies. Patients with breakthrough pain should have their pain reassessed to determine the efcacy and tolerability of treatment and any change in the nature of breakthrough pain (Davies et al 2009). Successful management of background and breakthrough pain depends on accurate ongoing reassessment. Cancer pain may change over time in response to analgesics and other interventions, chronic pain syndromes following treatment, tumour progression at the primary site of cancer or development of metastatic disease. Barriers to pain management Pain is a subjective experience and several barriers have been identied that may lead to inadequate treatment of cancer pain. Barriers can originate from patients or healthcare professionals. Patient barriers can be related to patient anxiety and the effect this has on the pain experience or factors that prevent patients from reporting pain. Anxiety about pain, which may be caused by specic cancer treatments or interventions, can inuence the level of pain experienced. Previous experiences or the experiences of close family members or friends may further exacerbate these anxieties (Carr 2007). Patients may be reluctant to report pain for various reasons. Fears about opioids, such as addiction and side effects, and the association of opioids with pain management at the end of life may prevent patients from adhering to the pain management plan. Patients may not report pain because they assume that healthcare professionals are the experts and may not want to distract medical staff from treating their cancer. Patients may also fear that by taking medication to manage their pain they may mask early warning symptoms of disease progression, which may delay consultation for urgent review (Carr 2007, Christo and Mazloomdoost 2008). Exploring these issues with the patient and addressing any concerns about reporting pain and analgesics can improve adherence to pain management strategies and therefore reduce the patients level of pain. Pain management barriers associated with healthcare professionals include: misconceptions about pain, for example that patients should expect to experience pain (particularly in relation to certain procedures or types of cancer); patients in pain always have observable signs (facial grimacing and body posture, elevated pulse and blood pressure); patients will always tell staff when they have pain; one type of intervention, for example medication, is sufcient to relieve pain; and addiction and respiratory depression are to be expected with opioid therapy (Carr and Mann 2000c). These are personal beliefs and healthcare professionals need to explore their own level of knowledge and attitudes in relation to pain relief. Most hospitals provide some education regarding pain and pain management. Non-medical prescribing Non-medical prescribing has evolved as part of some advanced practice nursing roles and was developed to: Improve patient care by promoting access to medications. Empower patients by enabling choice in healthcare. Enhance exible ways of working in healthcare teams and use the skills and knowledge of nurses working at an advanced practice level. Non-medical prescribing has helped to address some issues relating to adherence to pain management strategies, improve patients access to analgesics, and provide a holistic approach to the assessment and management of cancer pain. Lewis-Evans and Jester (2004) identied some of the benets of non-medical prescribing to patients, including improved communication, better continuity of care and increased patient condence in healthcare professionals. Patients receiving palliative care are responsive to and supportive of non-medical prescribing because the nurse is deemed to have in-depth knowledge of the patient, a sound knowledge of analgesics and more time for the consultation process (Creedon and ORegan 2010). In palliative care, patients may need to be prescribed opioids. The nurses role as an independent non-medical prescriber enables timely management of patients pain and access to appropriate drugs. Nurses can also initiate alterations to medications and referral to other healthcare professionals as appropriate, p44-49w48.indd 48 27/07/2012 12:08 NURSING STANDARD / RCN PUBLISHING august 1 :: vol 26 no 48 :: 2012 49 therefore improving the quality of care that patients with advanced chronic illness receive. Until recently, prescribing of opioids by non-medical prescribers for acute and chronic pain in patients with cancer was limited by legislation. There were regulations regarding which opioids could be prescribed for moderate to severe pain and other indications for prescribing, the majority of which were for patients receiving palliative care (dened as care of patients with advanced, progressive illness). For example, an independent nurse prescriber would be unable to treat a patient with chronic pain following surgery or acute pain following curative radiotherapy with an opioid such as morphine, oxycodone or a fentanyl patch, as these drugs could only be prescribed for palliative care. Following a lengthy consultation process, these regulations have recently been changed (Department of Health 2012), and it is hoped that this will enhance patient access to expert review and analgesics to relieve pain associated with cancer. This is increasingly important as the number of people who survive cancer and live with the chronic effects of treatment or stable disease increases. Conclusion Many patients with cancer will require timely and effective pain relief. Part 1 of this article identied the causes and types of cancer pain, which is necessary to ensure appropriate assessment and management strategies are adopted. Comprehensive pain assessment is pivotal to direct treatment strategies. It also enables patients to quantify a baseline measure of pain, so that the effects of any interventions can be monitored. It is important to assess and reassess patients pain as this may change over time. Effective management of cancer pain often combines pharmacological and non-pharmacological approaches. Barriers to pain management need to be addressed to promote effective pain relief. Nurses have a pivotal role in the management of cancer pain and should develop therapeutic relationships with patients to optimise care NS References British Pain Society (2010) Cancer Pain Management. www.britishpainsociety.org/ book_cancer_pain.pdf (Last accessed: July 11 2012.) Carr E (2007) Barriers to effective pain management. Journal of Peri- operative Practice. 17, 5, 200-208. Carr ECJ, Mann EM (2000a) Assessing pain. In Carr ECJ, Mann EM (Eds) Pain Creative Approaches to Effective Management. Palgrave Macmillan, Basingstoke. 30-50. Carr ECJ, Mann EM (2000b) Managing chronic pain. In Carr ECJ, Mann EM (Eds) Pain Creative Approaches to Effective Management. Palgrave Macmillan, Basingstoke. 81-108. Carr ECJ, Mann EM (2000c) Recognising the barriers to effective pain relief. In Carr ECJ, Mann EM (Eds) Pain Creative Approaches to Effective Management. Palgrave Macmillan, Basingstoke. 109-129. Chapman S (2011) Assessment and management of patients with cancer pain. Cancer Nursing Practice. 10, 10, 28-36. Christo PJ, Mazloomdoost D (2008) Cancer pain and analgesia. Annals of the New York Academy of Sciences. 1138, 278-298. Creedon R, ORegan P (2010) Palliative care, pain control and nurse prescribing. Nurse Prescribing. 8, 6, 257-264. Davies AN, Dickman A, Reid C, Stevens A-M, Zeppetella G (2009) The management of cancer-related breakthrough pain: recommendations of a task group of the Science Committee of the Association for Palliative Medicine of Great Britain and Ireland. European Journal of Pain. 13, 4, 331-338. Department of Health (2012) The Misuse of Drugs (Amendment No. 2) ( England, Wales, and Scotland) Regulations (2012) www.legislation. gov.uk/uksi/2012/973/made (Last accessed: July 11 2012.) Dougherty L, Lister S (2011) Patient comfort. In Dougherty L, Lister S (Eds) The Royal Marsden Hospital Manual of Clinical Nursing Procedures. Eighth edition. Wiley-Blackwell, Chichester. 462-538. Fallon M, Hanks G, Cherny N (2006) Principles of control of cancer pain. British Medical Journal. 332, 7548, 1022-1024. Farquhar-Smith P, Chapman S (2012) Neuraxial (epidural and intrathecal) opioids for intractable pain. British Journal of Pain. 6, 1, 25-35. Fine PG, Miaskowski C, Paice JA (2004) Meeting the challenges in cancer pain management. Journal of Supportive Oncology. 2, Suppl 4, 5-22. Fink RM, Gates RA (2006) Pain assessment. In Ferrell BR, Coyle N (Eds) Oxford Textbook of Palliative Nursing. Third edition. Oxford University Press, Oxford. 137-160. Gannon C, Davies A (2006) Non-opioid drugs. In Davies A (Ed) Cancer-related Breakthrough Pain. Oxford University Press, Oxford. 83-96. Hall EJ, Sykes NP (2004) Analgesia for patients with advanced disease: I. Postgraduate Medical Journal. 80, 941, 148-154. Herr K, Spratt KF, Garand L, Li L (2007) Evaluation of the Iowa pain thermometer and other selected pain intensity scales in younger and older adult cohorts using controlled clinical pain: a preliminary study. Pain Medicine. 8, 7, 585-600. Lewis-Evans A, Jester R (2004) Nurse prescribers experiences of prescribing. Journal of Clinical Nursing. 13, 7, 796-805. Silkman C (2008) Assessing the seven dimensions of pain. American Nurse Today. 3, 2, 13-15. World Health Organization (1996) Cancer Pain Relief. Second edition. tiny.cc/WHO_cancer_pain (Last accessed: July 11 2012.) p44-49w48.indd 49 27/07/2012 12:08 Copyright of Nursing Standard is the property of RCN Publishing Company and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.