Cancer Pain Management - Case Study Example

Cancer Pain Management Name Institution Pain Management Pain is a common occurrence among people with cancer. At least fifty percent of patients with cancer have reported that they experienced pain (Fisch et al. 2012, p.1). This pain is prevalent among cancer patients. Literature also shows that there is no significant difference in the prevalence of pain in patients that are in the terminal phase of cancer and those undergoing anti-cancer treatment. The prevalence of pain in patients with metastatic or terminal phase is 64 percent while the pain prevalence in patients undergoing anti-cancer treatment is 59 percent. Thirty-three percent of patients that receive curative treatment also complain of pain (Ripamonti, Bandieri & Riola 2011). Overall, advanced cancer patients experience at least two forms of cancer-related pain. Sixty-nine percent of the patients rate the worst pain at the level where their function is impaired (Stevens, Mendoza & Cleeland 2012). Patient History The case history is a 65-year-old female patient with breast carcinoma. The patient was admitted for chronic pain. The patient has advanced breast carcinoma with skeletal metastases. The patient had a regular heart rate but said that she had difficulty breathing. The verbal rating scale was initially used to diagnose the intensity of the pain. However, the oncology nurse observed that the patient had limited communicative skills to make self-reports about the level of pain. Since the nurse could not make clinical diagnosis using the verbal rating scale, observation was an ideal alternative strategy for diagnosing the patient’s pain. The nurse observed the patient’s facial expression, change in interpersonal interactions with family and body movements. The nurse rated the patient’s pain using the visual analogue scale rather than the verbal rating scale. The rating was worst pain. This translates to moderate to severe on the verbal rating scale. The nurse administered paracetamol to reduce the discomfort as further tests were carried out such as physical and biochemical investigations. The day following the admission, the patient showed signs of severe discomfort and inability to perform functions such as walking. Biophysical Factors that may Influence the Patient’s Current Pain Breast carcinoma is a malignant disease. This type of cancer is associated with malignant tumor that spreads to the bone. Studies show that seventy percent of patients with prostate carcinoma or breast carcinoma at an advanced stage have skeletal metastases (Clohisy & Mantyh 2003). This pain is intermittent but can progress to continuous pain. Occurrences of breakthrough pain exacerbate this continuous pain. After chronic pain has been observed, the patient’s condition could deteriorate once mechanical allodynia occurs. Mechanical allodynia is argued to occur when a patient perceives an activity that was previously non-painful as painful such as turning in bed as a painful activity (Clohisy & Mantyh, 2003). Pain Experienced by the Patient in Relation to Underlying Disease Pathology The oncology nurse diagnosed the patient’s pain as moderate to severe. Language barrier and the patient’s inability to communicate prevented the nurse from using the verbal rating scale to determine the degree of pain. Although the patient did not have cognitive impairments, the limited communication skills made it difficult to make a self-report of the pain. Observations of pain-related discomfort and behaviors provide an alternative for determining the level of pain (Ripamonti, Bandieri & Riola 2011). This moderate to severe pain is prevalent in patients with metastatic solid tumors. Assessing the quality of pain is important. This is because it influences the choice of treatment or therapy. Pain Management Strategies Prior to being admitted to the oncology department, the patient’s relative said that the patient had been taking oral analgesics for pain management. However, the relative brought her to hospital when the patient complained of continuous chronic pain. Upon arrival to the hospital, the emergency department nurse administered an oral analgesic. Analgesics are used for chronic pain (Stevens, Mendoza & Cleeland 2012). Physicians prescribe analgesics on a regular basis because the therapy can be easily administered and managed. Oral analgesics are advocated as first treatment for treating breakthrough pain. Breakthrough pain is moderate to severe in intensity, lasts for about 30 minutes and has rapid onset. Although the patient had been given 600mg paracetamol four times a day, she showed signs of discomfort and inability to perform normal functions such as shift in her bed or walk. This confirmed that the patient was still in pain. The recommendations from World Health Organization (WHO) on opioids shows that step II drugs can be administered to patients with moderate or mild pain or who do not feel any relief from paracetamol (Caraceni et al. 2012, p.e59). The current best practice for first-time treatment of moderate cancer pain is the use of tramadol and codeine. A combination of paracetamol and codeine produces an effective analgesic effect for patients that have moderate pain or do not feel relief from paracetamol use. A study confirmed that combining 600mg of paracetamol and 60mg of codeine four times daily was effective and is as safe as using 150 mg of codeine alone. This combination has fewer adverse effects compared to tramadol, morphine or hydrocodone. Limited evidence shows that low doses of oral morphine provide relief. Recommended guidelines from the World Health Organization (WHO) are the use of codeine, tramadol, morphine, hydromorphone and hydrocodone as step II drugs. These drugs can be administered alone or combined with paracetamol for an analgesic effect (Caraceni et al. 2012, p.e59). Another best practice is the administration of oral morphine. This drug has been arguably the first drug of choice for 25 years due to its availability, cost effectiveness and familiarity. Systematic reviews have supported the prescribing of oral morphine for treating cancer pain. The outcome of these reviews have influenced the use of morphine, hydromorphone and oxycodone as first-choice step three drugs for treating moderate-to-severe pain (Caraceni et al. 2012, p.e59). Patient assessment and re-assessment is a recommended practice guideline. According to Ripamonti, Bandieri & Riola (2011), the best practice guidelines for making correct assessments of cancer pain involve assessment and re-assessment of the patient’s pain. Firstly, a clinician should assess the cause of the pain. Factors such as the intensity, duration, site, onset, type and the temporal patterns of pain should be assessed. In addition, the trigger factors and symptoms of the patient should be recorded. Information on the tolerability, use and efficacy of analgesics also needs to be assessed. Secondly, the patient’s status should be assessed. This assessment could include physical examination, biochemical or radiological examination, interference with daily activities and functioning, impact of the pain on social or psychological condition, the patient’s awareness of the cancer, the social environment, spiritual health and psychological status (such as anxiety, depression or suicide ideation) (Ripamonti, Bandieri & Riola 2011). Lastly, the clinician needs to re-asses his or her communication with the patient. A nurse, for instance, should take time to interact with their patients and their families to understand their concerns, needs and expectations. Adjunct Strategies that Were or Could Have Been used to Complement Patient’s Pain Management Plan Paracetamol was prescribed because it is a non opioid analgesics used to treat mild pain. Nevertheless, parecetamol and non-steroidal anti-inflammatory drugs are universally adopted as cancer pain treatment at any intensity level. An alternative would have been to use non-steroidal anti-inflammatory drug. The concern with this option that the nurse would need to monitor the long-term use of the drugs to prevent the effects of toxicity associated with long-term prescribing such as renal failure or gastrointestinal bleeding (Ripamonti, Bandieri & Riola 2011). An adjunct strategy would have been to use step II or step III opioids depending on the outcome of the patient’s assessment and re-assessment. Since the patient’s level of pain in the case scenario is moderate-to-severe, pain relief can be achieved by opioid analgesics such as morphine, oxycodone, fentanyl, oxymorphone, buprenorphine and methadone (Bell, Eccleston & Kalso 2012). These drugs are commonly used in Europe for analgesic therapy. Opioid analgesics are common analgesic therapy used to control mild to moderate-to-sever pain. These analgesics can be administered in combination with non-opioid analgesics such as non-steroidal anti-inflammatory drugs, acetaminophen and paracetamol (Ripamonti, Bandieri & Riola 2011). Newer opioid analgesics such as a combination of naloxone and oxycodone are also being increasingly adopted due to their effectiveness and fewer adverse effects in clinical settings. The administration of oral morphine would be an ideal first treatment for patients that complain of moderate to severe pain. Oral morphine is popularly used to manage chronic cancer pain because has increased tolerance, easy to administer, inexpensive and is effective in pain relief (Ripamonti, Bandieri & Riola 2011). The oral route is advocated when the degree of cancer pain is moderate. When the patient reports severe pain, urgent relief is recommended through intravenous or subcutaneous route. The parenteral opioids are administered through either of the two routes and the dose should be one-third of the oral morphine medication. The oral dose is divided by three to obtain an equivalent analgesic effect when using parenteral morphine. Once this has been done, the nurse can adjust the dose downward or upward depending on the patient’s status. Alternatives to oral morphine are oxycodone, hydromorphone, transdermal buprenorphine and transdermal fentanyl (Stevens, Mendoza & Cleeland 2012). The last two alternatives are most suitable for patients with stable opioid requirements. These treatments are preferable for patients that complain of difficulty swallowing, poor tolerance to morphine or poor compliance. In the case of renal impairment, buprenorphine is an effective analgesic therapy since it does not require drug reduction. These alternatives are preferable because the administration of morphine is not based on evidence-based research such as controlled clinical trials. Caraceni et al. (2012) agree that morphine administration is based on its pharmacokinetic profile rather than clinical trials. This profile makes it easy to individualize the dose by starting with a low dose then titrating upwards until the expected effect is achieved. Practice guidelines recommend the use of immediate-release opioids and then switching to modified-release preparations, which are more flexible for patients where pain has not been controlled effectively. Another alternative is the use of physical therapy such as transcutaneous electrical nerve stimulation (TENS) and other forms of electrical stimulation (Hurlow et al., 2012). TENS is non-invasive treatment used to manage chronic and acute pain. This therapy has been adopted in different clinical settings and is popular among health professionals and patients because of its ease of use, portability, fewer adverse effects and user autonomy over pain management. Low-frequency high-intensity TENS works by stimulating the A-beta afferent fibers to lower the perception of pain. It also stimulates C-fibers and A-delta fibers to descend the pain suppression system (Hurlow et al. 2012). In conclusion, the patient could benefit from switching treatment from a non-opioid therapy to opioids. This switch is recommended when the initial treatment does not produce the required analgesic effect, has severe side effects or is unmanageable. Patient assessment and re-assessment is recommended prior to, during and after administering step II or step III opioids. References Bell, R, Eccleston, C & Kalso, EA 2012, ‘Ketamine as an adjuvant to opioids for cancer pain (Review), Cochrane Database of Systematic Review, No. 11, pp.1-23. Clohisy, D & Mantyh, PW 2003, ‘Bone cancer pain’, Cancer, Vol. 97, No. S3, pp.866-873. Fisch, M, Lee, W, Weiss, M, Wagner L, Chang, V, Cella, D, Manola, J, Minasian, L, McCaskill- Hurlow, A, Bennett, M, Robb, K, Johnson, M, Simpson, K & Oxberry, S 2012, ‘Transcutaneous electric nerve stimulation (TENS) for cancer pain in adults (Review)’, Cochrane Database of Systematic Reviews, No. 3, pp. 1-27. Stevens, W, Mendoza, T & Cleeland, CS 2012, ‘Prospective, observational study of pain and analgesic prescribing on medical oncology outpatients with breast, colorectal, lung or prostate cancer’, Journal of Oncology, Vol. 30, pp.1-12. Ripamonti, C, Bandieri, E & Riola, F 2011, ‘Management of cancer pain: ESMO clinical practice guidelines’, Annals of Oncology, Vol. 22, No.6, pp.vi69-vi77. Read More