Time for the Cancerous Tumours - Case Study Example

 Optimal pain management in cancer Cancer is a debilitating disease in itself, but when it afflicts the elderly, it poses an even greater risk because of the difficulties arising out of coping with the pain. A large percentage of the population in the West in the current day is elderly and the incidence of cancer in the elderly is higher. The reason is firstly, there is more time for the cancerous tumours to develop and for mutations to occur and secondly, older tissues may be much more susceptible to carcinogens in the atmosphere (www.cancer.gov). In the case of elderly patients, it may also be more difficult to ascertain the extent of paint they are suffering and clinicians may tend to under-treat such patients for pain because they may assume that elderly patients have a higher sensitivity and pain threshold than they actually have. With advancing age, elderly patients may also be on other courses of medication which can interfere with the drug treatments that are set aside for cancer. Moreover, since older patients may suffer from vision or hearing losses, it may actually be necessary to have more frequent monitoring in order to assess whether and to what extent these patients are suffering pain. Problems such as constipation, headaches and other kinds of toxicity are more likely to occur in older patients. Before any kind of medical intervention can be planned and administered, the critical aspect to be noted would be pain assessment.(Fink, 2000). Several different studies have shown that about 30 to 40% of patients who are at the diagnosis stage experience pain, while 70 to 80% of patients who are going through therapy or who are at the end stages of their life experience pain( Cleenan et al, 1994; Van Ronenn et al, 1993). In the study by Van Roennen et al (1993), 897 physician survey responses in Wisconsin were assessed in order to determine physician perception of pain management in cancer patients. In relation to the use of analgesics in pain management, 86% of respondents felt that that cancer patients were under-medicated and the overall consensus was that adjuvants and prophylactic side effect management should be used more effectively and frequently in devising a treatment plan for cancer patients, in order to help them cope with their pain. The significant aspect about this study was the finding that most physicians rated poor assessment of pain as the single largest barrier in effective pain management in cancer patients. On this basis, Fink (2000) argues that an accurate assessment of the pain being experienced by the patient is the cornerstone to optimal pain management, and the quality and efficacy of nay assessment tools will depend largely upon the ability of the clinician to focus on the patient. Fink (2000) recommends the WILDA approach to pain management, whereby five key components are integrated into the pain assessment process, so that it is an ongoing, individualized and documented process (see WILDA chart in the Appendix). The first step is the use of Words, i.e., the physician can help the patient to describe the specific nature of the pain by providing a selection of words. For example, burning or shooting pains indicate neuropathic pain, achy, throbbing and dull pain indicate somatic pain, squeezing and cramping kind of pain is visceral. In the first case, the pain is caused by nerve disorders, hence antidepressants and benzodiazepenes may be useful. Somatic pain is largely localized, hence muscle relaxants or optimally, non steroidal, anti-inflammatory drugs would be indicated. In the case of visceral pain, opoids would be the treatment of choice. The next aspect that is important is the Intensity of the pain, which must be quantified if appropriate doses of the indicated drugs are to be administered. Asking patients to rate their pain on a scale of 1 to 10 with 1 being no pain and 10 being unimaginable pain, both before and after an intervention as well as over a period of time, would be helpful to patients in assessing how effective treatment is. The third important aspect to determine is the Location of the pain, because patients may have pain in more than one place, which can provide added specificity in pain assessment. Fourthly, the Duration of the pain is also important to determine, because it can help to distinguish between temporary acute pain and chronic pain, each of which needs to be treated differently. Lastly, the Aggravating factors that cause the pain must also be determined, for example does physical activity contribute to the pain or mental anguish? Enquiring about side effect symptoms such as nausea, vomiting, headaches, sleepiness, urinary retention and similar factors would also be very helpful to the clinician in arriving at an accurate assessment of pain. As Fink(2000) points out, accurately determining the exact nature of the pain the patient is suffering would be very useful in determine the appropriate course of treatment, its duration and nature. In a study carried out by Sawe et al (1981) on the management of long term pain associated with cancer, fourteen patients who were suffering from severe pain received a dose of 10gms of methadone, with the intervals between doses being determined by the patients themselves on the basis of the severity of the pain they were experiencing. As Fink (2000) has pointed out, while pain is an unpleasant sensory experience that may arise out of actual damage to the tissue or other organs in the body, there is also a highly subjective element involved in it. Thus, allowing the patients to determine when medicine is to be administered might be a good approach to take because it is difficult for a clinician to determine exactly when the patient is in pain if the patient chooses not to disclose it. In the study by Sawe et al (1981) with the trial of methodone, the objective of the exercise was to enable patients to experience rapid relief of the pain they were suffering but at the same time, to also ensure that the levels of methodone in the blood did not reach a level where they could become toxic. In single doses, the drug methadone has been found to be very effective in providing relief from pain, but administering methadone in the case of chronic pain may pose problems because repeat doses every six to eight hours may lead to an accumulation of methadone with the development of toxicity, thereby posing as threat to life. The study by Sawe et al (1981) found that a patient controlled dosage regimen of oral methodone could be a safe alternative, because the administration of doses would not be so frequent, being determined by the patient’s pain needs and incorporating adjustments for variations in pain intensity. As Quigley (2005) points out, while pain is not synonymous with cancer, it does occur in almost two thirds of the patients and she reiterates Fink’s assertion that pain is a largely subjective experience that is influenced by social, physical, psychological and spiritual factors. Pain is one of the most feared symptoms in patients who are diagnosed with cancer. In the management of pain based upon her own clinical experience, Quigley (2005) who is a specialist in palliative medicine working in a hospital team, has examined the efficacy of opoids in the treatment of cancer. Cancer treatments are generally based upon the WHO analgesic ladder, a “framework of principles” which “allows flexibility in the choice of analgesics”. (Quigley, 2005:825). She points out that morphine has generally been accepted to be the drug of choice in managing moderate and severe cancer pain, although the primary position occupied by morphine is being challenged recently by the introduction of other drugs, i.e., opoids. Some of the opoids being used include hydromorphone and oxycodone, as well as trans dermal opoids such as fentanyl and byprenorphine, although the last two work better in the case of patients who have stable opoid requirements. Barriers to the use of opoids: Where the administration of opoids for pain relief in the elderly is concerned, there are some potential complications which must be taken into consideration. For instance, some of the side effects of opoids are constipation, drowsiness, confusion and cognitive impairment, but in the elderly who already suffer from these symptoms, using opoids may aggravate the symptoms to the point where they pose a serious health hazard. The efficacy of application of the WHO analgesic ladder was assessed in Quigley’s study, which found that in 71 to 100% of the patients, the WHO analgesic ladder is used appropriately. (Quigley, 2005). But in the elderly, opoids may still pose a significant health risk. The European Pain in Cancer survey was carried out using 5000 patients from more than 16 countries and this study showed that the pain was long lasting, widespread and inadequately controlled, with breakthrough pain being a significant problem.(Hawksley, No Date). 46% and 37% of this particular sample were on strong and weak opoids. While the patients in the sample initially reported that opoids were useful in managing their pain, but when they were prompted, revealed that the medication was not adequate in some instances. About half of the patients reported the incidence of breakthrough pain. (Hawksley, No Date). Hence, one of the barriers in treatment with opoids is that they may be inadequate, especially in older patients. As a result, these patients may need to supplement opoids with other medication, which can cause their own side effects. One of the side effects of opoids is constipation, because the opoids act upon the μ-opioid receptors present in the gastrointestinal tract which tend to hinder rectal sensitivity and reduce peristalsis. Constipation can cause abdominal bloating and discomfort, nausea and related symptoms; constipation can reduce the benefits derived from opoid therapy by as much as 30%. For patients who do not suffer from constipation, the incidence of patient visits to the doctor may still rise, together with absences from work. Other barriers to the use of opoids could be (a) reluctance by patients to report their pain, especially older patients (b) patients not taking their medications due to concerns about side effects or concerns about addiction (c) patients being misinformed about pain management, thereby necessitating a more comprehensive discussion by their physicians (d) the low priority in the health care system for pain management (Piro et al: 636). Additionally, pharmacists could also pose barriers themselves because they may not maintain adequate supplies of opoids, may not be fully aware of their benefits and need for use and thereby counsel patients and their inadequately about their use. The inherent resistance of patients to the use of opoids could pose another barrier. Religious and cultural beliefs may affect use of opoids; for instance the belief that pain is inevitable and must not be stopped or that opoids must be used only as a last resort could also function as barriers (www.pain.com). Other patients may see opoids as possessing addictive properties and resist taking the medication; thus it may be seen that patient beliefs could play a significant role in determining use of opoids. Conclusions: On the basis of the above, it may be seen that the overall finding suggests that pain management in cancer patients may be inadequate, especially in elderly cancer patients. As the literature review above suggests, physicians are of the view that patients are under-medicated and one of the most important reasons for this is the fear of side effects. It may be noted that aide effects may pose an even greater risk in elderly patients, because some of the side effects such as constipation, dizziness and cognitive impairment are already experienced by elderly patients and exacerbating these symptoms through the administration of additional drugs which heighten such symptoms could have more damaging effects. In such an instance, it would pose a greater risk to the patient’s health rather than not administering the drug at all. It is the elderly patients however, who may be at a greater risk for pain because they are not able to adequately articulate their pain and physicians may assume a lower sensitivity to pain than what may actually exist. Moreover, elderly patients may already be on other drugs to treat various other medical conditions that are associated with age; as a result, administering more drugs poses the risk of serious side effects arising out of clashing drugs. Thus, there is a contradiction posed – on the one hand, elderly patients are in greater levels of pain because their body are less elastic and recover more slowly as compared to younger people; hence may need greater doses of medication, yet their inability to adequately express their pain and their already high levels of other kinds of medication may contraindicate the administration of such drugs. As the literature review also suggests, arriving at an assessment of the pain that elderly patients is perhaps the most difficult part, because pain is largely a subjective experience. Applying the WILDA approach as suggested by Fink(2000) may help clinicians to more accurately determine the kind of pain the patient is suffering, its intensity, duration and location as well as the associated symptoms, which would considerably improve the administration of pain relief and enhance its efficacy. In general, morphine has been viewed as one of the best drugs that can be administered in the case of pain, but various opoids have also been found to be effective in pain management. Determining the exact nature of the pain through the use of the WILDA analysis however, may be most effective in determining treatment, because neuropathic pain may require anti-depressants and similar drugs, while localized somatic pain would respond to analgesics and visceral pain is likely to be well managed through the administration of opoids. In the case of elderly patients, active interaction with the patient, and clinician sensitivity to arrive at an accurate assessment of pain through strong communication is vital. Accurate administration of medication is even more important in the case of elderly patients because any clashes with other drugs must also be taken into consideration before an optimal treatment plan can be devised which would be effective in dealing with cancer and providing for treatment for pain associated with it. References: “Cancer risk and ageing”, retrieved May 27, 2010 from: http://www.cancer.gov/cancertopics/understandingcancer/cancer/Slide38 Cleeland CS, Gonin R, Hatfield AK, Edmonson JH, Blum RH, Stewart JA and Pandya KJ, 1994.”Pain and its treatment in outpatients with metastatic cancer”, New England Journal of Medicine, 330(9): 592-6 DePiro, Joseph T, 2003. “Encyclopedia of clinical pharmacy”, Informa Healthcare Fink, Regina, 2000. “Pain assessment; the cornerstone to optimal pain management”, Proc (Baylor University Medical Center), 13(3):236-239 Hawksley, heather, No date. “Pain management in cancer care: Overcoming barriers to improve the management of chronic pain”, European Oncology Nursing Society, Retrieved June 3, 2010 from: http://www.cancernurse.eu/documents/EONSSupplementPainManagement.pdf Sawe, J, Hansen, J, Ginman, C, Hartvig, P, Jakobsson, P.A., Nilsson, M.I., Rane, A and Anggard, E, 1981. “Patient controlled dose regimen of methadone for chronic cancer pain”, British Medical Journal (Clinical research Edition), 282 (6266):771-773. “Update on the pharmacologic management of cancer pain”, Retrieved June 3, 2010 from: http://www.pain.com/go/default/practitioner/medical-library/archives/monographs/ Von Roenn JH, Cleeland CS, Gonin R, Hatfield AK and Pandya KJ, 1993. “Physician attitudes and practice in cancer pain management: A survey from the Eastern Cooperative Oncology Group”, Annals of Internal Medicine,119(2): 121-6 Appendix (Source: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1317046/figure/F1/) Read More