Pain Management in Cancer Patients - Essay Example

MSc & Diploma in Pain Management OF ASSIGNMENT Do psychological interventions have a positive impact on pain management in the cancer patients?MODULE TITLE The Psychological Aspects of Pain (Module 3) NAME OF MODULE LEADER Professor Michael Wang STATE OF THE ASSIGNMENT (Essay) STUDENT NUMBER 9037 12 (Full Time Study) WORD COUNT 2,811 Words SUBMISSION DATE Introduction (497 words) The over-all success of cancer treatment relies not only on the chemotherapeutic techniques used to get rid of malignant cells but also on the choice of approach to manage cancer-associated pain.6 Although cancer by itself is a painful disease, pain is mostly worsened by medical procedures such as lumbar punctures (LP), bone marrow aspiration (BMA), laser therapy, tumor surgery, and chemotherapeutic drug administration.7, 24,37 Recent reports for instance, indicated that the anti-neoplastic drug Paclitex, upregulates the expression of pro-inflammatory cytokines like tumor necrosis factor-alpha, which is implicated as one of the causative agents of painful peripheral neuropathies. Moreover, cancer patients treated with Paclitex were documented to experience burning and tingling sensations in both hands and feet, which sometimes become a chronic problem.32 Since as much as 50-90% of cancer patients experience pain during and after the course of cancer treatment, pain management has become an integral component of cancer therapy.1,33 In fact, most hospitals have established pain management protocols that seek to reduce and tolerate, if not to totally eliminate pain, during and after the treatment.45,10 Prevailing cancer-related pain management usually involves administration of drugs that act by blocking inflammatory mediators, pain receptors and secondary messengers; making ion-channels less responsive to stimulus; or destroy the integrity of the pain-related neurotransmitters.42,29 Morphine, opiodes and ibuprofen for instance, are among the most common bedside anti-pains that have been used to relieve discomfort and distress brought about by cancer treatment.48 Even though, several studies show that these painkillers are not always reliable.46 In fact, patients tend to develop drug dependence and depress immune function.9 A comprehensive review conducted by Telch and Telch (1985) on the various approaches that help cancer patients cope up, revealed that intensity of pain accompanying cancer therapy is also influenced by emotional distress, anxiety, and other psychological disturbances.42,48 Also, according to Reinville et al (2005), positive emotions like satisfaction and anticipation of relief tend to decrease the perception of pain.35 Studies like these and several others reinforce and recognize the fact that pain also has a cognitive and psychological element, aside from its pharmacological dimension, which can be targeted to create interventions to supplement the current protocols and strategies of achieving pain relief.15, 22, 30, 54 For more than thirty years, psychologists have improved and refined psychological interventions to mitigate persistent pain.22 Turk et al (1983) and Turner et al (1988) have suggested that cognitive-behavioural models of pain could be easily applied to patients having disease-related pain.52, 53 One of the most commonly used psychological interventions cognitive to help reduce the symptom limitations like distress and pain in patients with cancer is cognitive-behavioural therapy (CBT),3 a problem-based intervention was designed to assist patients recognize, evaluate, and correct maladaptive conceptualizations and dysfunctional beliefs about themselves and their current situation. This essay focuses on the importance of CBT in reducing cancer-related pain in cancer patients. Specifically, this essay seeks to present some evidences on the effectiveness of this intervention in providing positive effects on patients experiencing cancer-induced pain. Literature review (497 words) Cognitive behavioural therapy (CBT) is “a short-term, problem-focused psychosocial intervention.”57 This method is a combination of cognitive therapy and behavioural intervention, whereby patients are taught to positively manipulate their interpretation of unpleasant situations and subsequently put these positive thoughts into action.12,26,43 Specifically, the cognitive part of CBT attempts to modify beliefs, expectations and coping abilities in order to create a more positive outlook, which is mostly achieved through counselling sessions and application of cognitive pain control methods like guided imagery, hypnosis and attention/distraction.12 Meanwhile, in the behavioural psychosocial procedure, behaviour modifications are encouraged like relaxation, changes in lifestyle, and diet to prevent occurrence and recurrence of traumatic episodes.26 According to Chapman and Turner (1982), when CBT is applied to control pain-related issues, the strategy involves increasing the patient’s understanding of the nature of his current affliction in order to increase his awareness of the events that may trigger and enhance pain.12 In this way, the patient will develop a better chance to avoid certain pain-enhancing occurrences. In addition to the “awareness-driven counselling”, pain control strategies like relaxation and imagery, among others, are taught to patients to help them tolerate higher intensities of pain.12, 56 Research has proven that cognitive behavioural approaches indeed offer relief to pain-troubled cancer patients.43,44 Many studies advocated the use of CBT in conjunction with conventional painkillers to lessen pain.7,11 Liossi et al (2009) performed a controlled clinical trial on the effects of brief hypnosis intervention on venipuncture-related pain in paediatric cancer patients.60 A total of 45 cancer patients (age 6-16) were randomly assigned to one of the three groups: (1) local anaesthetic plus attention (2) local anaesthetic plus hypnosis; and (3) anaesthetic only. Liossi and her team found that anaesthetic administration, coupled with hypnosis session caused a decrease in anticipatory anxiety and venepuncture-induced pain.60 This result agrees with that of Syrjala et al (1995), who performed another controlled clinical trial on the psychological treatment of cancer-related pain in 94 cancer patients.42 In the study, patients were randomized in 1 of the 4 experimental treatments: group (1) receive no intervention and was considered as the control group; (2) received therapy support (TS); (3) was subjected to imagery and relaxation training; and (4) was given cognitive behavioural training including relaxation and imagery.42 Results obtained confirmed the hypothesis of the researchers that those patients receiving relaxation and imagery training (group3) and those exposed to CBT with relaxation and imagery (group 4) experienced significantly less pain.43 In addition, some controlled trials have even suggested that cognitive behaviour approaches may reduce the risk of relapse in main depressive disorders.19 Evidences based on several controlled trials have shown that CBT is also an effective approach to control depression, panic disorder, generalised anxiety, hoarding and obsessive-compulsive disorder.57 Recent systematic reviews and meta-analyses have provided a strong evidence for the effectiveness of CBT for patients who suffer from chronic and relentless headache pain, arthritis pain, temporomandibular pain, persistent low back pain, mixed chronic pain syndrome, and sickle cell disease pain.51, 55 Critical analysis (1000 words) Although several theories have been formulated to explain the mechanism of pain perception, the Neuromatirx Theory is perhaps the only one that explicitly integrates psychological factors to the process of pain experience.50 According to this theory, the brain has a neural system which incorporates information from several sources to produce the sensation of pain. The key contributors into this system are not only composed of sensory-related information, but also “phasic” and “tonic” inputs from brain area, which are responsible for cognition and emotion.27 Taking this into account, it is not surprising then that the CBT works effectively in reducing pain intensity and improving the over-all well-being of a patient undergoing a painful therapeutic procedure. Kavanagh and Mueser (2001) supports the assumption that the effectiveness of CBT lies on the fact that cognitions like expectations and beliefs an individual upholds during certain unpleasant situations can determine his emotional and behavioural reactions.28 Since many existing literatures provide evidences to support the idea that cognitive ( e.g. anticipation of pain, distraction, mind-relaxation) and emotion-related variables (e.g. self-esteem and anxiety) influence pain perception, it is the logical to argue that manipulating cognitive factors will alter pain experience.23, 38, 58 Reeb and Bush (1996) proposed that the psychological mechanism of CBT is based on two theories: Self-efficacy and bioinformational theory.36 According to the self-efficacy theory, cognitive and behavioural interventions can decrease fear by virtue of increased personal mastery. Meanwhile, the bioinformational theory states that cognitive and behavioural interventions can correct negative reactions when an individual is repeatedly to stressful occurances.36 Many of the CBT techniques employed in the management of cancer-related pain involve distraction and relaxation techniques (e.g. breathing exercise, watching TV, relaxing the face and jaw muscles), cognitive coping (telling oneself about positive things or thinking about solutions to the pain), and activity reduction (i.e. decreasing an individual’s activity when pain increases).2, 16, 43 Anderson et al.3 conducted a clinical trial to assess the benefits of distraction, relaxation, and positive mood interventions in cancer patients. In this study, 57 patients with cancer-related pain caused by opioid treatments were divided into four groups: distraction, relaxation, positive mood, and waiting list control. Results showed that for most patients, cognitive-behavioural treatments produced passing declines in pain intensity. This result further reinforces the idea that CBT techniques like relaxation can relieve pain experience. In addition, Tatrow and Montgomery 46 published a meta-analysis study on the effectiveness of using CBT techniques such as activity pacing, autogenic training, behavioural activation, goal-setting imagery, and meditation in the relief of breast cancer distress and pain. The meta-analysis study involved literatures published from 1974-1994 in Medline, Caberlit, and CINAHL. Sixty-one (61) literatures were chosen, and careful evaluation of these studies brought Tatrow and Montgomery to conclude that CBT techniques help majority of the cancer patients to control their pain compared to the control groups.46 Although this meta-analysis focused only on breast cancer, the findings are consistent with previous report of Turk et al (1991) that CBT in general positively affects cancer patients, whatever type of cancer they have.51 However, the decision on whether to use CBT alone or in combination with medicines seems to be determined by the nature of the patient’s disease and the intensity of pain experience.4,14,34 For problems like aggression management and compulsive hoarding, several studies showed the possibility of using CBT alone.41,49 Borkovec and Ruscio (2001) reviewed 13 research studies on the use of CBT in the treatment of Generalized Anxiety Disorder (GAD), which made use cognitive training and relaxation treatments. 13 Borkovec and Ruscio (2001) found out that within group analysis, CBT was effective in decreasing anxiety symptoms.13 Yet, careful inspection of existing pain-related CBT studies seems to suggest that this type of intervention, if administered with pharmacotherapy, may yield better results.5 Although several studies presented evidence that using CBT alone significantly relieves pain, a considerable amount of evidence also supports the idea that CBT works effectively when used together with other approaches, such as pain-killer medications, rather than when used alone in treating cancer pain. A comprehensive literature survey conducted by Foa et al (2002) presented a strong evidence in favour of combining CBT with the conventional pharmacology-based management in the control of anxiety disorders.20 The literature review included 29 randomized control trial (RCT) studies focusing on CBT-pharmacology combination, drug medication, or CBT alone for anxiety disorder treatment. The review included the study of Power et al (1990) on the treatment of generalized anxiety disorder (GAD).34 In the study, Power and his colleagues randomized 113 GAD patients to one of the five groups: Diazepam only, CBT only, placebo only, Diazepam plus CBT, and Diazepam plus placebo. Results indicated that on week 10 (week after the treatment), combining Diazepam with CBT yielded better results to using Diazepam alone. Interestingly, there was no significant difference with the results of Diazepam-CBT combination with that of CBT alone. 34 Six months follow-up on the anxiety levels of the participants showed that both CBT-Diazepam and CBT alone caused 71% reduction in anxiety levels.34 However, in a literature review conducted by Ellis and Spanos (1994) on the various cognitive-behavioural interventions applied during bone marrow aspirations and lumbar punctures, it was found that CBT is sometimes as effective or even more effective when used alone.18 In one of the cases reviewed by Ellis and Spanos (1994) whereby 83 children with cancer aged 3 ½ to 12 years were randomly assigned to either a CBT or Diazepam plus CBT intervention.18 Although according to study, both groups experienced a significant reduction in the intensity of pain felt, it was found that the Diazepam plus CBT group experienced only one-third of the reduction in comparison to the children treated with CBT alone.18 The researchers suggested that this may have been a result of Diazepam’s ability to interfere with learning cognitive behavioural strategies. Although this result deviates from the results of Power et al (1990), who documented the synergistic effect of CBT and pharmacology, still it cannot be denied that CBT is effective in reducing procedural, cancer-related pain. Conclusion (452 words) Cognitive behavioural therapy is a psychological intervention that aims to correct an individual’s thoughts and beliefs, and modify his behaviour in order lessen distress and other psychological disturbance.59 Although CBT is usually applied to manage depression, anxiety, stress, and other psychological trauma, it can also be used to manage pain associated with diseases such as cancer.15,54,55,22,30 In fact, meta-analysis studies have shown that CBT can efficiently reduce chronic and relentless headache pain, arthritis pain, temporomandibular pain, persistent low back pain, and mixed chronic pain syndrome, among others.55 The theory behind the use of CBT in reducing cancer-related pain comes from the fact that anxiety, fear, and distress influence how a patient experiences pain.58, 23, 38 Studies have clearly shown that pain is indeed elevated when the patient’s anxiety and distress is increased.42,48 The use of CBT techniques in pain management intends to appeal at the subjective part of pain experience, which can be more defined by the patients’ mood condition, thought, beliefs about pain and following behaviours.40 According to Reeb and Bush (1996), the mechanism by which CBT works is based on self-efficacy and bioinformational theory, which are both associated with fear reduction.36 Cognitive behavioural therapy makes use of cognitive training, imagery techniques, distraction activity, mind restructuring, relaxation, hypnosis, activity reduction, and others in order to lessen pain.2,16,43 In managing cancer-associated pain, mostly, CBT involves cognitive training in combination with imagery techniques, breathing exercises, and relaxation or hypnosis. Many literatures provide evidence that CBT can effectively reduce pain during procedures such as lumbar punctures (LP), venipunctures, intramuscular injections, and bone marrow aspirations (BMA).18 There are cases when CBT is used alone in alleviating procedural pain related to cancer treatment. Some studies, however, combine CBT with conventional pharmacological pain treatments like administration of Diazepam and analgesics.20 There are also reports indicating that CBT is sometimes as effective as anaesthesia, in reducing the experience of pain.21 Whether in combination or administered alone, CBT is still effective in pain management. Nevertheless, one limitation that is seen in the use of CBT in cancer-related pain management is the fact that CBT protocols involve several number of intervention techniques (imagery in combination with relaxation, or hypnosis in combination with relaxation, or making use of imagery, distraction, hypnosis, cognitive coping skills all in one) in decreasing pain perception.12,13 The use of multiple techniques makes it difficult to pinpoint which among these techniques are actually responsible for the observed reduction in pain perception. Taking into consideration the randomized control trials and literature review presented in the body of this paper, it can be concluded that CBT provides positive influence in the management of cancer-associated pain. Information gathered from different sources indicates that CBT is effective in reducing cancer-related pain. Future Work (365 words) Although cognitive behavioural therapy is helpful in the management of cancer-associated pain, there are still areas pertaining to the study of CBT that require improvements. First, studies involving CBT made use of multiple techniques like deep breathing, muscle relaxation, and psychoeducation, among others in order to achieve its purpose.7 The problem with this kind of strategy is that it is difficult to determine which among the techniques are really responsible for the effect. It is therefore important to explore the use of only one technique at a time in order to determine the efficiency of one technique over the other. Brown and Kuppenheimer (2002) proposed to breakdown complex studies and try to focus on finding out the effect of one technique.7 Second, the social background of patients (e.g. level of education, family support) and severity of cancer (e.g. if the cancer is stage 1,2, or 3) are usually not taken into consideration during the conduct of CBT studies.31.61 Mostly, age, type of cancer, and gender are the only factors that limit the selection of patients for the studies presented in this paper. In the study conducted by Palermo et al (2010) on the importance of psychological therapies for chronic pain management in children, the authors explicitly recommended to include a comparison between clinic-attendees and non-clinic-attendees.31 It might be more informative to also compare patients with stage 1 cancer to those with stage 3, for instance, to determine if the effectiveness of CBT is affected by the severity of the cancer. Moreover, the effect of psychosocial support from immediate family and friends in the effectiveness of CBT in reducing cancer pain has not been given great attention.18 Conducting a thorough research on the extent of how psychosocial support affects CBT results is necessary. Third, the sample sizes involved in many of the studies are relatively small.61,62 For example, in a study conducted by Hunter et al (2002) about the process of medical and psychological treatment of pain, only 24 women were selected to participate in the CBT group and 21 in the fluoxetine group. Palermo et al suggested that psychological studies like CBT should include a large sample size in order to increase treatment efficiency. 31 References 1. Abernthy AP, Samsa GP, Matchar DB. A clinical decision and economic analysis model of a cancer pain management. Am J Manag Care 2003; 9: 651- 64 2. Anderson et al. Brief cognitive-behavioural audiotape interventions for cancer-related pain. Cancer. 2006; 107:207-214 3. 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