Management of Cancer Pain - Literature review Example

? MANAGEMENT OF CANCER PAIN Written by Presented to [mentor’s In partial fulfillment of the requirements of [program ] ABSTRACT Management of cancer pain remains a challenge mainly due to the numerous types that it contains along with the lack of proper research regarding the best techniques of managing it. Currently there are many pharmacological as well as non pharmacological treatment options available. Not one can be considered as the best option. This is because the types of pain and their severity are the key determinants in the selection of pain treatment. The nurses need to understand how to apply their clinical knowledge in the management of pain by identifying the type of pain patient presents with, along with the right medication or treatment strategy to manage it. MANAGEMENT OF CANCER PAIN Pain is one of the most common features of cancer, but it can present itself at any stage and can be both acute and chronic in type. Around 90% of the patients with cancer are likely to experience certain type of pain. This severity is likely to increase should proper medication is not given at the right time (Cancer Pain Overview, 2011). Defined as a physiological identification of a series of electrical and chemical events, pain can take many shapes and levels of severity. Not only the cancer itself but also other clinical situations may cause pain, which may or may not be related to the disease. These may include surgery, use of certain medications and the effects of radiation therapy (Cancer Pain Overview, 2011). Nurses come across the management of pain very regularly, not only in cancer, but also in other care aspects as well. However, cancer pain management is much more challenging due to the constantly changing dynamics of health of the cancer patients. Many reports reveal that although pain is the most common complaint one presents with, it often is not managed properly, with the result that patients do not find complete relief from their ailment (Pain Management, nd). Nurses therefore, have been working on this area of research and creating ways to identify best practices of controlling and eliminating pain, with ease to both the staff and the patient (Zepettella, 2009). The intensity of pain can be of many types and durations, and based on these two factors, the treatment therapy and approach is determined. Patients may have varying types and intensities of pain within the same day, therefore, it is important to analyze and identify they type of pain they are experiencing. At one moment the pain may be regular pain that is a feature of the normal body. At the other moment, the pain may be of breakthrough kind (Zepettella, 2009). Still other type of pain may be taking place due to pressure on the surrounding structures. Therefore, the key need by nursing professionals will be to correctly analyze the type, severity, duration and cause of pain. There are many concerns that nurses may have regarding provision of pain medication. Nurses are concerned that providing high doses of medication can lead to substance abuse among patients. They also believe that pain should be treated when it occurs and unnecessary medication before the onset of pain is unnecessary. Nurses believe that pain should be physically expressed in order to receive the medication, and that patients may exaggerate their level of pain, which may lead to overdose. These and other such reasons may make nurses hesitate in providing pain medication or high doses of pain medication to their patients (Pain Management, nd). The pain in cancer can be of many types, and the chief determinant is the location where the tumor is expanding along with the regional structures that may be affected by it. Types of pain in cancer from can include nerve and bone pain, soft tissue pain, phantom pain and referred pain respectively (Zepettella, 2009). Some of the common reasons that can trigger such pain include blocked blood vessels in the tumor region, leading to poor circulation of blood, fracture of bones mostly due to metastasis, infection and inflammation, the side effects of the treatments that take place during treatment, and finally tumor exerting pressure on a nerve (Zepettella, 2009). A very common type of pain in cancer is known as the break through pain. As the name suggests, it is a flare up of severe pain that can occur at any time during the treatment. This type of pain is very much common, with almost 24% to 95% of the patients demonstrating it (Zepettella, 2009). as the cancer progresses, so does the frequency and intensity of breakthrough pains. In order to manage it effectively, its characteristics should be known. Breakthrough pain has a fast onset with severe intensity which peaks within a few minutes. Breakthrough pains can then be classified as either incident pain or spontaneous pain. The different types of pain have a very deep impact in almost all aspects of the patient’s as well as the patient’s family life. The economic burden reflects itself in the increased number of pain medications and duration of visits to the emergency as well as outpatient wards (Zepettella, 2009). The physical impact reflects in the reduction of the health of the patient, mainly due to lack of rest and side effects from the drugs that are being given for the cancer (Zepettella, 2009). Patients also suffer from deep psychological issues, and may feel helpless, sad, angry, frustrated or tired. This may affect their social life, which may lead to feelings of isolation (Zepettella, 2009). Sadly, even with the identification of the different types of cancer pains, there is still very little material available for the management of it. It was only the guidelines that were put forward by the European Association for Palliative Care in 2002 that gave some initial guidelines about the management of pain (Zepettella, 2009). The first and foremost requirement therefore, is the collection of guidelines that inform about the correct management of all types of cancer pains, including breakthrough pains. The recommendations must be easily applicable in all health care settings, which can then ensure that the patient can access it anywhere according to his or her convenience (Zepettella, 2009). The non pharmacological management of pain is a very important adjuvant to the treatment of cancer pain. This includes the use of physical therapies, to help improve functioning, and mobilityof the patients, as well as help in recovery (Zepettella, 2009, Simpson and Budd, 2001)). Other commonly used non pharmacological methods include nerve blocks, radiotherapy and acupuncture respectively (Simpson and Budd, 2001). Diathermy and cryotherapy are another new series of treatments that have been found to provide relief in pain. The pharmacological methods include the around the clock medications, which are a set of prescriptions that patients need to take every day to manage their pain state. The second type of medication is the rescue medications that are given when pain is not relieved from the regular prescription doses (Zepettella, 2009). Since chronic pain affects the psychological health of the patients, such patients must also receive psychotherapy (Meyers, 1997). It has become an integral part of the multisystem therapy of the patients. Among the various therapies are included relaxation therapy, cognitive behavioral therapy, biofeedback, and hypnosis respectively (Meyers, 1997). The route of administration is perhaps the key determinant of the type of pain management carried out in a patient (Simpson and Budd, 2001). Other factors that determine the type of drug used and its method of delivery include the class or formulation of the drug, the route of administration, dosage, patient setting, that is, whether the patient is in a hospital or at home, and the type of pain, that is acute or chronic. The medication provided must be able to provide immediate relief according to the severity of pain, through a route that is appropriate for the kind of response needed. The route can be of two types, parenteral or non parenteral, and it is the decision of the clinical staff to decide which option is better to carry out (Cancer Pain Overview, 2011). Methods of medication are many in the case of cancer pain management. The oral route of administration of drugs is a very common method, especially of morphine. Patients are given a prescription about the dosage of the drug, and how many times a day the patient needs to take them. The use of oral opioids is effective for half and hour pain management on average. While it may be an effective method for management of chronic pain; the acute pains require something that is more potent and faster. This kind of medication is usually appropriate for every day chronic pain management. In situations where the normal prescribed dosage may not suffice, a rescue dose and be given to the patient. Opioid medications chiefly work through this principle, where there is a baseline background opioid dosage, which can be topped up with a rescue dose should there be a need (Simpson and Budd, 2001). This form of dosage is mainly decided on the individual response, therefore, careful evaluation through observation is needed and medical records must be clear on the amount of the dose that is tolerable for the patient. A commonly used drug to manage pain when other opioid analgesics fail includes ketamine. This drug has been found to prevent or reduce the number of adverse effects of use of morphine (McQueen and Baroletti, 2002). A somewhat recent and novel approach in the management of cancer pain involves infusion technique both in hospitals as well as at homes. The administration of epidural opioids is one of the drugs that can be given to the patients, in order to manage the pain better (Boersma et al, 1992). Another method to reduce pain includes intrathecal administration of medication to reduce pain. This method has been advocated for spinal and back pains that take place due to propagation of cancer (Patel et al, 2009). This method has been found effective in acute forms of pain, and has not been able to exert significant improvements in the management of chronic pain (Simpson and Budd, 2001). Present use however, is mostly to reduce pain due to non cancer reasons (Patel et al, 2009). METHODOLOGY The purpose of the research is to identify which method of delivery is the best for optimal management of cancer pain. The methodology and research therefore, were first directed to identifying the different methods of cancer pain management. Literature reviews, books, studies, researches and thesis were located with the help of online search engines such as Google, MEDLINE, Cancerlit and Cochrane Controlled Trials Registry data bases. The results showed a large number of entries about cancer pain management. Among these the initial selection was carried out by filtering those researches and literature that was published within five years. Therefore, the researches included in the study are those from the year 2009 onwards. The second selection criteria were the identification of source of publication. The emphasis was placed on the selection of international medical and oncology journals, with peer reviews and high impact factors. The studies were then looked up for their relevance to the topic of discussion and the final read up of these was carried out. Based on this the different methods of pain management were identified, their advantages and disadvantages were noticed. Next studies were located to assess the efficacy of these methods. Based on the information, the final conclusions and deductions were made. RESULTS The study is essentially a qualitative study looking over texts, studies and publications related to the best method of cancer pain management. The study aimed to identify those methods which make significant improvement in the management of different kinds of cancer pain. Based on the type of pain and its severity, the following methods were found to be most effective. Results show that NSAIDS are used more commonly than opioids. Alongside, the series of studies have shown that palliative methods such as use of chemotherapy, bisphosphonates or calcitonin can benefit from the course of nonpharmacological cytotocxic and cytostatic therapies. These methods may be helpful in improving pain management. The method of delivery for the management of cancer pain is largely influenced by the current condition of the patient. The chronic pain cases are usually managed through oral administration of drugs. Patients who are admitted in hospital however, may be given medication through both the routes. Therefore, the technique of pain management essentially depends upon the case of the patient and severity. DISCUSSION Cancer pain management is a very complex series of evaluation and inspection due to ever changing dynamics of pain within the same patient (Simpson and Budd, 2001). Therefore, the optimal management of pain can only take place when the patient is given accurate dosage of medicine with the accurate time frame, which is able to reduce the severity of the condition and improve the quality of life for him. The present study is limited in many ways due to its qualitative nature. There is presently very little research available about the correct management of cancer pain, with each school of thought having its own approach towards the problem. In this regard, the key lies in creating guidelines and methods that are incorporated in the nursing academics and clinical practice. This is to ensure that nurses are able to handle all kinds of cancer pains with correct clinical approach and decision making power. Nurses face the cases of pain management the most. Proper management of pain is both an obligation as a nurse along with an ethical and moral concern. patients with cancer pain suffer from various intensities of pain and complying with their request for proper relief should be the key priority. In order to understand the level of pain, nurses should learn clinical protocols and evaluation guidelines that help make clinical judgment about cancer pain and thereby provide the necessary treatment. Nurses need to develop a deep understanding of the different aspects of pain (Pain Management, nd). They should know when and how to identify it through the symptoms presented by the patient. They need to learn how to correctly differentiate acute from chronic pain (Pain Management, nd). They must be aware of the different medications that are used in the management of pain, their indications and their dosages. Finally, the nurses must be cognizant of the side effects of various drugs in order to prevent and treat them accordingly (Pain Management, nd). These are the core competencies that nurses must learn in order to manage the patients successfully. CONCLUSION Limited numbers of studies have been carried out in the management of cancer pain. Most of the studies are the traditional methods of treating pain; therefore, there is presently conflict in the dosage and methods of administration according to the type of cancer pain presented. In order to gain proficiency in this area, more research is needed to manage different forms of cancer pains. REFERENCE Boersma FP, Bosma ES, Giezen LM and Theuvenet PJ, 1992. Cancer Pain Control by Infusion Technques in the Home Situation in the Northern Netherlands: An Innovative Project on the Use of Medical Technology in the Home Situation. Journal of Pain and Symptom Management Vol 7, Issue 3, pp 155-159. Cancer Pain Overview, 2011. Site last accessed on March 10th, 2011 from http://www.oncologychannel.com/pain/index.shtml Meyers CA, 1997. Current Pain and Headache Reports Vol1, No. 2, pp 126-129. McQueen A and Baroletti SA, 2002. Adjuvant Ketamine Analgesia for the Management of Cancer Pain. Annals of Pharmacotherapy Vol 36, No 10, pp 1614-1619. Pain Management Nursing Role/Core Competency A Guide of Nursing, nd. Site last accessed on March 21st, 2011 from http://www.painpolicy.wisc.edu/domestic/states/MD/nursing.pdf Patel VA, Manchikanti L, Singh V, Schultz DM, Hayek SM and Smith HS, 2009.Systematic Review of Intrathecal Infusion Systems for Long Term Management of Chronic Non Cancer Pain. Pain Physician 12:345-360 Simpson K and Budd K, 2001. Cancer Pain Management A Comprehensive Approach. Oxford Universtiy Press. Zepettella G, 2009. Breakthrough Pain Should be Distinguished from Background Pain. Guidelines in Practice March 2009, Vol 12 (3), pp 1-5. Read More