Literature Review on Management of Cancer Pain - Essay Example

?Literature Review on Management of Cancer Pain Introduction Pain associated to cancer upsets the lives of huge numbers of patients and their relations. Epidemiologic studies on the occurrence and dominance of cancer, on the prevalence of cancer-linked pain, and on the probability of aggregating the pain intensity on progressing cancer phase shows that cancer pain enhances considerably to the present nationwide problem of cancer. Analysis information for the most part does not differentiate amid diverse etiologist and contrivances of cancer pain. Various randomized controlled experiments assessing analgesic medicines for cancer pain respite is minor, even though growing. It is possible to compare the efficacy between opioids and NSAIDs. The involved experiments do not distinguish the relative effectiveness of these two forms given through many methods to patients with minor, moderate, or severe cancer pain. Experiments to relate the effectiveness of NSAIDs against ‘weak’ opioids, that is the opioids normally recommended for slight to moderate pain, expose no change in analgesic effectiveness amid these two types of agents (Goudas, et. al., 2001). In accordance with the World Health Organization (WHO), the prevalence of cancer is increasing and expected to be >15 million in 2020. A systematic evaluation of the writings that examined the incidence of pain in diverse disease phases and kinds of cancer throughout the period 1966–2005, revealed no change in pain dominance among patients all through anticancer medication and those in an advanced or incurable stage of the disease. Especially, pain commonness was 64% in patients with metastatic cancer, 59% in patients on anticancer medication and 33% in patients after healing treatment. Latest researches carried out in Italy and in Europe established these statistics, displaying that pain was existent in all stages of cancer disease and was not effectively managed in a substantial proportion of patients. Established on these realities it is obvious that lots of cancer patients even now agonize with cancer-related pain. This essay mainly discuss cancer pain, types and its causes, assessment of pain and assessment tools, significance of managing pain, best practice in managing pain and barriers nurses face etc. (Ripamonti, et.al. 2011) Cancer pain The Global Association engaged in the research of pain, states that it is a woeful sensual and emotive feeling in connotation with real or possible tissue injury, or defined in relations to such harm. However, pain is a feeling that hurts and it has bodily and emotive features to consider. Pain can be of two types, acute or chronic: Acute pain normally experienced unexpectedly, can be severe, and frequently causes noticeable physical responses, for example, sweating, high blood pressure, and so on. Usually acute pain is an indication of sudden onset of an injury to the body, and it gets cured once the pain relief medicine is administered or the injury is treated. Pain is well-thought-out to be chronic once it continues further than the usual time anticipated for an injury to heal. Chronic cancer pain can be very tense for the body and the soul, and needs cautious, constant care to be properly treated. Together with enduring cancer pain, occasionally people have severe bursts of pain. Normally, these pains are termed as breakthrough pain, can as well be restricted by medications (Cancer-pain.org, 2002). The intensity of pain people experience due to cancer subject to the type of cancer they have, the phase the ailment is at, and the treatment they get. Around 25% to 50% of people with cancer grumble about pain at the time of diagnosis, and usually up to 75% of people with cancer whine of pain as the stages of cancer gradually progresses. Cancer pain can be further explained as an intricate feeling that reproduces harm to the physique and the physique's reaction to the injury. Even though physicians come to an understanding that controlling cancer pain is urgency, pain isn't each time understood or treated appropriately. The reason for this is that of unwarranted fears about individuals with cancer become habituated to analgesics. Controlling the pain is very vital, not only for individuals suffering from the advanced state of cancer; nonetheless also for those individuals whose ailment may continue steady for years to come (C-health, 2012) Types and causes of cancer pain By way of attack by cancer cells on healthy fleshy tissue, visceral and somatic pain receptors named ‘nociceptors’ sense tissue injury and send messages to the brain, where the individual notices pain. Nociceptor pain might be restricted at the cancer location or referred to a distant region. The sensory impulses notify an individual of tissue damage and start the release of neuromodulators that develop swelling and cause even extra pain. Since nervous tissue is penetrated due to cancer growth or injured by its treatment, neuropathic pain is the outcome, frequently prolonging after the first abuse. In several situations, secondary pain advance confuses the status quo. Even though secondary pain fallouts due to tumor growth, it is not the direct source of pain. For instance, a space-consuming growth in the brain upsurges intracranial stress that causes heavy headaches. Over and above physical pain, individuals having cancer and their relations suffer the psychogenic pain of preemptive anguish, fear, and other adverse sentiments, for example, annoyance and nausea. In the sense, cancer causes nociceptor, neuropathic, secondary, and psychogenic pain. Nociceptor pain is explained as the pain spread over intact visceral and somatic nerve fibers from injured tissue initiated by tumorous incursion of physical tissue, radiation treatment, chemotherapy, and the investigative processes. Nociceptor pain might be piercing and acute, hurting and painful and persistent. Neuropathic pain is pain that is conducted over injured nerve fibers because of the irregular handling of sensual information and is produced by intrusion of nervous tissue by cancer cells, radiation treatment, and chemotherapy. The nature of the neuropathic pain is burning, intense, prickly, and drifting. Secondary pain is the outcome of tumor growth however not essentially the straight effect of the incursion of strong tissue by cancer cells. Psychogenic pain is the result of the emotive reaction individuals’ view to cancer and demise, for instance rage, fear, sorrow, revulsion, disgrace, remorse, and denunciation. The pessimistic sentiments upsurge anxiety and decline the influence of pain-relieving processes. Pain Due to Diagnostic Procedures and Treatment of Cancer The diagnostic measures can be the source of substantial distress and absolute pain. Usually they are carried out on a consistent, precautionary basis, for example, colonoscopies and mammograms, or on the instance of a doubtful indication of cancer. To decide the existence of a malignant lesion, a biopsy need to be done and the cells inspected with the help of a microscope. Even though numerous studies are carried out to discover less aggressive methods to treat cancer, currently the primary treatments done to liberate the body of cancer are chemotherapy, radiation, and surgical procedure. These treatments are possibly hazardous, and there is no assurance of success. These treatment procedures extinguish healthy cells in addition to cancer cells and result in nociceptor, neuropathic, secondary, and psychogenic pain. It is projected that 20% to 25% of cancer pain is straight linked to its treatment (Sweeder, 2002) (Hamilton, 2010). Assessment of Pain and Pain Assessment Tools To offer good pain management, appraisal of pain is important. Observing an example of doctors and nurses, Anderson and his team (Anderson, et.al. 2000) established the absence of pain assessment was the most challenging obstacles in realizing better pain control. It is observed that there are several suggestions and procedures for a satisfactory pain assessment; though, many suggestions appear to be unfeasible in acute care practice. Nurses looking after hospitalized patients with acute pain need to choose the suitable elements of assessment for the existing medical condition. The main aspect of pain appraisal is that it is carried out on a systematic basis using a standard setup. The investigated factors should be clearly guided by hospital strategies and processes (American Pain Society, 1995). To attain the patients’ requirements, pain should be reviewed after each intercession to assess the outcome and decide whether adjustment is required. The revision of timing as well should be guided by hospital or unit strategies and processes. The ‘Clinical Practice Guideline on Acute Pain Management’ published by the Agency for Health Care Policy and Research deals with assessment and controlling of acute pain (Carr, et.al.1992). This recommendation sketches a complete pain appraisal that would be utmost beneficial when attained proceeding to the operating process. From the history of pain, the nurse ascertains the patient’s attitudes, views, level of understanding, and earlier involvements with pain. Outlooks of patient and relatives for pain management after surgery will expose unreasonable beliefs that can be managed in advance before the operation. This complete pain history offers the basis for the planning for pain management subsequent to operation that is accomplished in collaboration with the help of the doctor and nurse, the patient, and patient’s relatives. Several pain intensity measures have been recognized and authenticated. Some tools offer a numeric rating of pain concentration, for instance, visual analogue scale, numeric rating scale etc. Modest tools, for example, the verbal rating scale that categorizes pain as mild, moderate or severe, as well are normally used. For patients with limited reasoning capability, scales with sketches or pictures are obtainable such as the Wong-Baker FACES scale. Patients with long-lasting dementia need behavioral scrutiny to decide the incidence of pain; tools like the PAIN-AD are accessible for such patient group. Choosing the pain assessment tool ought to be a joint decision among patient and health care professionals. Once this is done through the pre-surgical time, it confirms that the patient is conversant with the scale. Suppose, if the nurse chooses the tool, he or she must think the age of the patient; his or her bodily, emotive, and reasoning capability; and liking. The pain tool chosen must be used on a consistent basis to measure pain and the outcome of intercessions. However, it should not, be used as the only measure of pain acuity (Gordon, et.al. 2005). Locality and quality of pain have added evaluation features valuable in picking intercessions to control pain. Subsequently patients might get pain in areas away from the surgical site, site of pain using a body sketch or verbal report offers suitable data. The pain experienced may be chronic or it may be related to the positioning and padding used for the duration of the process. The quality of pain differs subject to the fundamental etiology. Devices like the McGill Pain Questionnaire (Melzack, 1975) (Melzack, 1987) comprise a range of verbal descriptors that assist to differentiate among musculoskeletal and nerve-linked pain. Normally, patients explain deep tissue pain as dismal, aching, and cramping whereas nerve-linked pain inclines to be more sporadic, shooting, or burning (Bouhassira, et.al. 2005) (Wilkie, et.al. 2001). Pain affects with several day-to-day actions, and the aim is to manage acute pain and decrease the consequence of pain on patient’s routine and value of life. The capability to continue action, uphold an optimistic attitude, and sleep are pertinent activities for patients after operation. Evaluation of interference with capability to walk, normal movement, attitude, and sleep during the retrieval period will support in choosing intercessions to improve function and value of life. The pain acuities contain decisive annoying and alleviating features. Annoying issues might be as merely as patient position, a full bladder, or hotness of the room. Alleviating features comprise the intercessions used for example analgesics and rational approaches used to manage pain such as entertainment, positive self-talk and enjoyable descriptions. Patient’s pain record will give understanding into the managing approaches earlier used by the patient and their usefulness with preceding painful incidents. Along with self-reported pain acuities, a complete valuation of pain following surgery comprises both physical responses and behavioral responses to pain. Physiological reactions of sympathetic activation (tachycardia, increased respiratory rate, and hypertension) might point out pain is existing. Behaviors that may indicate pain include splinting, grimacing, moaning or grunting, wrong posture, and unwillingness to move. Although these nonverbal approaches of calculation offer useful data, self-report of pain is the most precise. A lack of physiological responses or an absence of behaviors indicating pain may not mean the patient is not experiencing pain. Adequate pain management requires an interdisciplinary approach. Documentation of pain assessment and the effect of interventions are essential to allow communication among clinicians about the current status of the patient’s pain and responses to the plan of care. The Joint Commission requires documentation of pain to facilitate reassessment and follow up. The American Pain Society suggests that pain be the fifth vital sign as a means of prompting nurses to reassess and document pain whenever vital signs are obtained. Documentation also is important as a means of monitoring the quality of pain management within the institution (Wells, et.al. ND). Significance of Managing Pain Incessant, chronic pain triggers the pituitary-adrenal axis that can weaken the immune system and effect in postoperative contamination and reduced injury healing. Compassionate initiation can have undesirable effects on the heart, stomach, and renal systems, affecting patients to contradictory events such as cardiac ischemia and ileus. Of specific prominence to nursing care, chronic pain decreases patient movement, causing in difficulties, for instance, deep vein thrombosis, respiratory embolus, and pneumonia. Postsurgical problems linked to insufficient pain management adversely affect the patient’s well-being and activities since lengthy stay in the hospital and readmissions can cost more. The incapability to avoid pain may make a feeling of vulnerability and even impossibility that might affect the patient to a more enduring despair. Those patients who had the insufficient pain management might be unwilling to pursue treatment for further health complications. Improper handling of pain might put clinicians at threat for lawful action. The national standards indicated by the Joint Commission, named as Joint Commission on Accreditation of Healthcare Organizations, (Jcaho, 2001) need that pain is quickly handled and accomplished. Because of having such standards of care in place, rises the threat of legal action against clinicians and organizations for the lowly pain management,( Furrow, 2001) and there are cases of law suits filed for lowly pain management by doctors(D’Arcy, 2005). Nurses, being part of the joint team accountable for controlling pain throughout hospitalization, as well might be responsible for legal action. Institutions lose their status in addition to revenue if pain is not managed satisfactorily. Evidence shows that greater levels of pain and despair are connected to reduced gratification with care in ambulatory situations (Bair, 2007). With the beginning of transparency in health care; importance on pain management is going to be one of the indicators for the hospitals credibility (Wells, et.al. ND). Best practice in managing of pain in cancer patients The study led by the Cancer Care Research Centre at the University of Stirling to assess the best practice report on the controlling of pain in patients with cancer, NHS QIS specially made the update of this record. This has been created in partnership with a team of nurses and associated health experts engaged in the management of pain in cancer patients. A group of professional from diverse discipline has advised the team. The significance of patient participation in the formulation of clinical strategies has been emphasized (Schunemann, 2006). The prominence of identifying that pain is complex in nature and unique to the patient is vital in confirming best practice for these patients and is mirrored all through the document. The managing of pain, in co-operation with the patient and multidisciplinary team working are emphasized as being vital basics in realizing satisfactory pain control. The objective of the report is to propose direction to health specialists on the best practice in this area, pointing to offer a reliable methodology of practice to allow incorporated provision of care to be carried among the hospital and the society. This document comprise of mainly four sections: pain management education, pain assessment, and the pharmacological management of pain and the non-pharmacological management of pain (NHS Quality Improvement Scotland, 2009). Palliative care is an extraordinary care intended to expand the value of life of individuals with an incurable ailment. It aims at the needs of the patient along with those of his relatives and clinicians, and it starts the instant the individual is diagnosed. Handling the pain is a vital part of palliative care (Palliative Care Australia, 2006). The World Health Organization (WHO) palliative hierarchy, even as giving relief of cancer pain near to the end of life for several victims globally, might have restrictions related to long-term survival and growing ailment complication. To avoid such complications, it is proposed that additional wide-ranging model of cancer pain management is required, which is to be mechanism-based and multimodal, by means of combination treatments comprising intercessions that is personalized to the requirements of an individual aimed at improving pain relief despite the fact minimizing side effects. The neurophysiology of cancer pain is multifaceted and it includes incendiary, neuropathic, ischemic and compression mechanisms at numerous sites. Understanding of these techniques and the capability to determine the pain is due to nociceptive, neuropathic, and visceral or a mixture of all three can guide to excellent practice in pain management. Radiotherapy, chemotherapy, hormones, bisphosphonates and operation are the treatment of palliate cancers. Linking these treatments with pharmacological and non-pharmacological procedures, pain control can enhance pain respite; nonetheless the limitations of these treatments need as well to be researched and recognized. Opioids continue to be the backbone of cancer pain management; however the long-term consequences of tolerance, addiction, hyperalgesia and the destruction of hypothalamic/pituitary axis must be understood and accomplished in cancer pain, as well as the side effects such as constipation. In the management of intricate cancer pain NSAIDs, antiepileptic medications, tricyclic antidepressants, NMDA antagonists, sodium channel blockers, and the neuraxial course of treatment have their place. Psychosomatic suffering surges with the strength of cancer pain. It is observed that cancer pain is frequently not reported and not well treated because of multifaceted causes, mainly due to several views held by patients, relatives, doctors and nurses. There is evidence that those rational behavioral methods that manages worrying and encourage self-efficacy lead to better pain management. Physiotherapists and Professional Therapists have a significant responsibility in controlling of cancer pain and have precise expertise that empowers them to be both patient-focused and holistic. Psychoanalysts employ policies that target to advance patient wellbeing and eminence of existence, however, the task rests in them to practice in an evidence-based approach. There is enough proof for the efficiency of coeliac plexus neurolysis and intrathecal medication. Care and the controlling of probable problems have to be well-thought-out in the assessment procedure. Wherever applied properly and cautiously at the correct stage, these processes can pay improved pain relief, lessening the medicine use and noticeably better value of life (The British Pain Society, 2010). Barriers Nurses Face There has been a lot of talk about the occurrence of inadequately treated pain and insufficient care of patients at the end of life, and several optimistic proposals for improvement of clinical teaching and clinical practice have been echoed. Suggestions for transforming clinician performances in this aspect of patient care have inclined to emphasis on specific barriers to real pain management and palliative care. The main barriers are: The inability of doctors and nurses to recognize pain relief as importance in patient care; Inadequate awareness amongst doctors and nurses concerning the assessment and controlling of pain; Anxiety of controlling analysis of recommending practices for opioid analgesics; The lack of success of the healthcare system to ensure clinicians responsible for pain relief; The diligence of unreasonable views and unconfirmed worries concerning addiction, tolerance, dependence, and bad side effects of opioid analgesics and so on. Over and above two other barriers are the opposition of patients and their relations to the use of opioid analgesics in the management of pain control and cost restraints and their adverse influence on the use of the latest and most useful opioid analgesics (Rich, 2000). Patient-Nurse Communication One of the initial evidence-based etiquettes was created as a portion of the Conduct and Utilization of Research in Nursing (CURN) project. ‘Pain: Deliberative Nursing Interventions’ explains a strategy to a patient’s grievance of pain that comprises skillful message to regulate the patient’s requirements. Although managing analgesics might be the most suitable method to meet the patient’s requirements, the nurse might expose other issues causative to uneasiness, for example, uncomfortable position, thirst, or the need to urinate (Horsley, et.al., 1982). (McCaffery, 2002) recommended that the time used to chat with patient and caring might go afar in offering patient wellbeing. The subject to chat with the patient may be: Attending to patient anxieties, sharing the wish to support the patient turns into more peaceful and decisive approaches that might attain more comfort. Conclusion Learning relating to harmless pain control will assist to avoid inadequate treatment of pain and the subsequent damaging effects. Wellbeing comprises the use of suitable tools for evaluating pain in cognitively intact grown-ups and cognitively weak adults. Use of analgesics, particularly opioids, is the foundation of treatment for most types of pain. Harmless use of analgesics is encouraged by using a multimodal strategy that is in excess of single form of analgesic to control the person’s pain. Nurse observing the sedation levels after opioids are administered is one method to guarantee wellbeing. Further studies needs to be directed to real policies for altering clinician outlooks and actions that will effect in healthier pain management for patients (Wells, et.al. ND) Search Approach The expressions “Cancer pain,” “pain management,” “Best practice in managing of pain in cancer patients” and “Barriers Nurses Face” were used in this literature review search. The web and journal researched for this literature review is listed in the references. References American Pain Society. (1995) Quality improvement guidelines for the treatment of acute and cancer pain. JAMA. Anderson KO, Mendoza TR, Valeroo N, et al. (2000) Minority cancer patients and their providers: Pain management attitudes and practice. Cancer. Bair MJ, Kroenke K, Sutherland JM, et al. (2007) Effects of depression and pain severity on satisfaction in medical outpatients: analysis of the Medical Outcomes Study. J Rehabil Res Dev;44(2). Bouhassira D, Attal N, Alchaar H., et al. (2005) Comparison of pain syndromes associated with nervous or somatic lesions and development of a new neuropathic pain diagnostic questionnaire (DN4), Pain. Carr DR, Jacox AK, Chapman CR, et al. (1992) Acute pain management: Operative or medical procedures and trauma, No. 1. Rockville, MD: AHCPR Pub. No. 92-0032; Public Health Service; U.S. Dept. of Health and Human Services. Chealth, (2012) Pain Management, Cancer Pain [On line] C-Health Available from: [26 May 2012] Cancer-pain.org, (2002) Understanding Cancer Pain [On line] Available from: [26 May 2012] D’Arcy, Y. (2005) Pain management standards, the law, and you. Nursing. Furrow BR. (2001) Pain management and provider liability: no more excuses. J Law Med Ethics. Gordon DB, Dahl J, Miaskowski C, et al. (2005) American pain society recommendations for improving the quality of acute and cancer pain management. Arch Intern Med. Goudas, L., Carr, D. B., Bloch, R., Balk, E., Ioannidis, J. P. Terrin, N., Gialeli-Goudas, M., Chew, P and Lau, J. (2001) Management of Cancer Pain: Summary [On line] NCBI Available from: [26 May 2012] Hamilton, P. M. (2010) Pain Management: Cancer Pain and Pain at the End of Life, [On line] Available from: < http://www.nursingceu.com/courses/324/index_nceu.html> [26 May 2012] Horsley J, Crane J, Reynolds MA. ( 1982) Pain: Deliberative nursing interventions. New York: Grune & Stratton. Jcaho. (2001) Comprehensive hospital accreditation manual, Oakbrook Terrace, IL. McCaffery M. (2002) What is the role of nondrug methods in the nursing care of patients with acute pain? Pain Manage Nurs. Melzack R. (1975) The McGill Pain Questionnaire: Major properties and scoring methods. Pain. Melzack R. (1987) The short-form McGill Pain Questionnaire, Pain. NHS Quality Improvement Scotland, (2009). The management of pain in patients with cancer [On line] Available from: [26 May 2012] Palliative Care Australia. (2006). Palliative Care [On line] Available from: [26 May 2012] Rich, B. A. (2000) An Ethical Analysis of the Barriers to Effective Pain Management, [On line] Cambridge Quarterly of Healthcare Ethics Available from: [26 May 2012] Ripamonti, et.al. (2011) Management of cancer pain: esmo clinical practice guidelines [On line] Esmo Available from: [26 May 2012] Schunemann, H. J., Fretheim, A., & Oxman, A. D. (2006) “Improving the use of research in guideline development: 10. Integrating values and consumer involvement”, Health Research Policy and Systems,vol. 4, p. 22. Sweeder, J. (2002). Educating clinicians on effective pain management. The Pain Clinic. The British Pain Society, (2010) Cancer Pain Management [On line] Available from: [26 May 2012] Wells, N., Pasero, C., McCaffery, M. (ND) Pain Assessment and Management, [On line] Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Available from: [26 May 2012] Wilkie DJ, Huang H, Reilly N, Cain K. (2001) Nociceptive and neuropathic pain in patients with lung cancer: A comparison of pain quality descriptors. J Pain Symptom Manage. Read More