Healthcare: Chronic Pain After Treatment for Cancer - Essay Example

?Management of Chronic Pain Control in Cancer Contents page Introduction Page Thesis Page 3 Justification Page 4 Method Literature Review Discussion Page 8 Conclusion Page 8 References Page 9 Abstract This document considers the topic of chronic pain, in particular after treatment for cancer, whether the pain experienced is somatic and so associated with such things as swellings in joints, skin and deep tissues, neuropathic and visceral pain from organs among cancer survivors, and the best ways to deal with this, using a multidisciplinary approach, involving a variety of techniques, some newer than others. There is also some consideration of ways to minimise the likelihood of pain becoming a chronic problem, as well as how the pain can be avoided to some extent. Introduction In 2010 the Montreal based “International Pain Summit” declared that “Access to pain management is a fundamental human right’(Johnson, 2012). In one year more than 500 people in 100,000 will be diagnosed with cancer within the United Kingdom (Cancer Research UK, 2012). The same site states that the survival rate for all cancers has now reached 50%, with some types having a very high 5 year survival rate of 95% and with women generally having a higher survival rate than men. Treatment will have included such things as surgery, radiotherapy and chemotherapy, all of which play their part in either removing or destroying cancer cells. Such treatment though has its costs and it is a normal experience to have some pain after cancer surgery. Most of this will fade after time, but in some cases pain can persist for months or years, especially if nerves are damaged. After radiation therapy there may be pain which eventually resolves. In some cases though pain can develop a long way down the line. Chemotherapy can also result in pain and numbness. Some people may also find that they are liable to migraines, low back pain and other types of pain ( Cancer.net, 2012). All of these pains require treatment, but often patients are worried about taking large amounts of analgesics, and may not reveal the extent of their problems. Fullen et al( 2006) point within schools of both medicine and nursing the amount of time spent teaching students about pain relief varies considerably, which will contribute to a patchy service when it comes to pain relief, simply because of inadequate training in some areas. This in turn means that more patients suffer to a greater extent than they need do, and also increase time off work and in hospital, at great cost to themselves and to the country’s health service., Chronic pain has been defined as” having pain on a daily basis for more than six months” (Fullen et al, 2006). Cancer is a term used for more than one hundred diseases in which abnormal cells divide uncontrollably and invade surrounding tissues as well as spreading to other parts of the body through such means as the lymphatic and circulatory systems. It affects both organs and mechanisms. This multiplicity of possibilities requires very individualised treatment at every stage from diagnosis on through treatment and into survivorship. The Alliance for Cervical Cancer Prevention (2004) describes how a diagnosis can mean a person feels isolated, anxious, angry and depressed. It might well be assumed that once a cure has been achieved all this could be put behind them, but persistent pain is a very real issue in many cases, as could be psychological issues. Some will feel exalted that they have survived such a major threat, but others may continue to see themselves as a victim, especially if there are long term physical differences, as for example if there is the need for a permanent colostomy, or a man becomes impotent. Within the United Kingdom in 2012 it was declared that treatment for cancer is becoming ever more successful (Department of Health, 2012). The cure is not always the final end of pain however. The patient and his family have had to deal with the shock of diagnosis, the progress of the disease and then the joy of the all clear, but may well be faced with the prospect of long term and even severe pain as a result of the treatment which has saved him. This can mean that any pain experienced, including what Dickman (2011) describes as ‘breakthrough pain’ after successful treatment, needs not just a ‘one size fits all’ approach, but must utilise a more personalised approach. According to Levy et al ( 2008) such pain is often underreported and underdiagnosed , and so undertreated. Roper et al (1980’s onwards) taught that care based upon a model of living must include a variety of aspects and the same applies in the case of post cancer patients. Chronic pain can interfere to a greater or lesser degree with a person’s ability to cope with everyday activities. Fullen et al ( 2006) , although dealing with pain in general rather than cancer pain , describe what they saw as a need for a definite strategy to deal with chronic pain , so that teaching on the topic is standardised and costs are cut, while at the same time pain clinic resources can be used at their optimal level. This would include such things as the education of patients about their condition and possible options , including the encouragement to be open with medical staff about any problems. This would go a long way towards preventing pain becoming a chronic condition. Similar findings emerged from the English Pain Summit, 2011) Johnson 2012) , which concluded that it was necessary to develop a gold standard with regard to the development of education on the topic. In order to do this it was felt necessary to investigate the present variation in provision. It was felt that chronic pain needs to be treated as a long term condition and that needs in a particular area needs analysis. It was felt that this could best be done by developing standard guidelines from the National Institute for Health and Clinical Excellence (NICE), and that self –management of pain should be considered as part of this. Again the need to cover many aspects of pain was described , what the report described as the “biopsychosocial assessment of pain”. The aim was increase the number of specialist-led services in local communities, so that pain can be dealt with in a minimal number of stages. Thesis, Damage caused by treatment among cancer survivors can be a source of unnecessary suffering. Methods must be sought to overcome these difficulties as part of a holistic care plan. Present provision is patchy. Justification Although pain, even when quite severe, is not life threatening in itself, apart from individual suffering, its presence means that significant costs are incurred including lost employment productivity as well of course as healthcare costs, whether in medications or the time and skills of health care personnel as well as such things as payments for insurance and disability. Method This situation will be investigated using a literature search using terms such as cancer survival, chronic cancer pain, cancer care guidelines, post-cancer pain etc. These texts will then be discussed and analysed in a search for best practice, so that this can be acted upon in future practice when dealing with chronic pain in cancer survivors. Literature Review The MD Anderson Cancer Center (2012) describes how about one third of post-cancer patients experience pain. The type of pain and its severity varies. Levy et al (2008) state that neuropathies associated with the period after various cancer treatments such as radiotherapy, chemotherapy and surgery are the commonest types of pain experienced among cancer survivors. In many parts of the world there are carefully defined strategies in place to deal with these situations, following a pattern first set by Australia (Pain Australia 2010). The National Cancer Institute (2012) describes a number of ways in which these post cancer pains can be dealt with. These include, as well as the more obvious analgesics, such things as the use of antidepressant medications which can relieve pain or numbness caused by injured nerves. Physiotherapists might use massage, heat, cold or exercise as helps. Braces may be suggested in order to limit painful movement of a limb or joint. Acupuncture is described as a proven method that uses needles inserted at pressure points with the aim of reducing pain. Specialists in hypnosis or in meditation and yoga can also provide help. Patients can be taught self-help techniques such as deep relaxation. This works be both reducing pain, but also the stress often involved. Nerve block, a surgical technique, may be used if other methods are not helpful and the pain is limiting normal activity, but this has its possible negative side effects, so needs to be considered very carefully. Dickman, (2011) who works with the Marie Curie Palliative Care centre, describes how pain associated with treatment for cancer has its effects not just physically and psychologically, but also economically. This is about more than just not working, although that is important, but also the fact that someone with chronic pain requires the services of others to do every day activities on their behalf , or to help them to do so for themselves. As in the report from Levy et al ( 2008) an integrated approach which makes better use of treatments available is needed in order to optimise care. She describes the use of Fentanyl preparations, which she describes as being preferred by patients to more usual oral opioids, although Ballantyne (2003) describes opioids as” the most effective analgesics for severe pain and the mainstay of acute and terminal cancer pain treatments.” Denby ( 2009) describes a variety of these Fentynal medications including intranasal sprays, sub lingual tablets, buccal tablets and lozenges. This variety means that treatment can be personalised according to patient pa]references. Fentynal is an immediate release medication and so gets to the source of the pain very quickly, a period of 10 -15 minutes is quoted. Denby cites studies which rate the effect of Fentynal as being more effective as against placebos and also oral morphine. It is pointed out however that the various types of Fentynal are not necessarily interchangeable due to them having a variety of pharmacokinetic profiles. The nasal spray was found to be the quickest to reach maximum concentrations in the plasma. This is just one example of how it is necessary to take patient’s preferences, as well as their need for as much autonomy as possible, into consideration when prescribing treatments. Another consideration is of course the amount and type of pain experienced. If nerves or bones are involved then pain will be severe. On the other hand even large tumours can be removed from organs and result in comparatively little pain. Analgesia must be prescribed and used accordingly. Johnson (2012) describes a number of pathways of care, as described by the British Pain Society. These are assessment, spinal pain, non-inflammatory musculoskeletal pain, pelvic pain (male and female) and neuropathic pain. It is this latter form which most often affects those who have received treatment for cancer. He also states that for some time the problem of chronic pain has been considered important, and that in many parts of the world , including some parts of the United Kingdom , that is Wales and Scotland, definite plans are already in place. Some of this has developed out of a report on the topic from the chief medical officer for England in 2008. The report has many aspects, but does include a section on the topic of “Reducing possible late effects of treatment” and this includes strategies to prevent the pain developing (Department of Health, 2012, page 56). This describes (Department of Health, paragraph 4.2, 2012) how using modern methods, such as Intensity Modulated Radiotherapy, means that there is the capability of reducing damage to normal healthy tissue during cancer treatment. As well as leading to improved rates of cancer cure rates, subsequent side effects, including pain, are reduced, and so there is less need for long term management, including the management of pain, with the subsequent reduction in the need to provide management in the long-term. This woulkd mena that patients would actually require less post –operative care than at present. On the other hand it is pointed out (Department of Health, paragraph 4.3) that very few radiotherapy centres were currently offering this treatment, despite being capable of doing so, and that even then numbers were low. For this reason more funding for radiotherapy is planned for 2013 ( Department of Health, Paragraph 4.4 2012) . This however is in the middle of a recession, and it is impossible to say whether the plans will actually be worked out as planned. There are of course alternatives to radiotherapy as a means of offering pain relief. Fullen et al ( 2006, page 71) describe what they felt were the needs for a successful chronic health clinic. This, the Irish authors feel should be part of a national plan, and the same idea would apply in the United Kingdom. The set-up of such clinics would include having available professionals in health care who can deal with “physical, psychosocial, medical, vocational and social aspects of chronic pain.” These should , they say, include a psychiatrist or a psychologist. They state that there should be one person who ultimately co-ordinates an individual’s care. Record keeping should be therefore be effective, and communications excellent, so that both individual and more general outcomes can be described and analysed in order to arrive at the best practice. They also describe the need for on-going education for the professionals involved. It might be added that patients too require education so that they come to an understanding of what is happening and why and what options are available to them, so that individuals have some say in their own treatment. The NHS has a Cancer Improvement protocol ( 2012). The fact that the site states that, as well as increasing survival rates : It is also about improving patients’ experience of care and the quality of life for cancer survivors and our Strategy also sets out how that will be tackled. Professor Sir Mike Richards, National Cancer Director (Jan 2011) The fact that the information given is divided into a number of sections, such as breast, colorectal and prostate, shows how different types of cancer require different patterns of care. Apart from the physical differences they may also affect a patient differently psychologically. A woman who has a mastectomy or hysterectomy for instance may feel that she is no longer a woman. The accompanying map of the few sites where the matter of cancer survival is being dealt under this scheme, according to the most modern ideas, shows how patchy provision is. It is clear when the web site is investigated that this work is still at a quite early stage, but the Adult Survivorship Pathway (2012), after describing the various stages of the progress of cancer and its treatment, does include such things as self-management programmes, the setting up of peer support groups, the use of complementary therapies, as well as vocational and exercise programmes. Discussion It seems a little late in the day to come up with such extensive plans of long –term care, but in fact much of it has been in place for a long time, and also it is only in fairly recent years that cancer rates were so high, in part simply because people are living longer, for a variety of cancer types, as well as the fact that many diagnostic and treatment options are also fairly recent in origin. The National Cancer Survivor Initiative(2012) describes two million people are presently being cancer survivors in the United kingdom, with an expected increase to three million by 2030. The aims of post cancer care should be about more than pain reduction, and ought to include an attempt to improve physical strength in order to assist in offsetting any limitations resulting from either the cancer itself or its treatment. The person needs to be helped to become as independent as possible, but also to enable them to adjust to the reality of their post-cancer life and its possible limitations. What this involves will depend both upon the type of cancer, and the impact of the treatment used, but also upon the person’s sense of motivation, their particular life style, as well as their psychological mind-set, and so on. The provision of adequate and satisfactory pain relief is part of this post cancer rehabilitation and also lowers the amount of time spent in hospital, decreases the likelihood of more hospitalisations, and increases the possibility of a good nights sleep (Cancer Net 2012). Coward (2006 ) describes how post-cancer patients need to embrace life choices which will improve their physical life , but also their emotional life. Cancer survivors are more susceptible than the average to more cancer, so they require education on this topic as well as to best treatment, in order to manage any complications of their treatment. It may well also be a time in their lives when they want to evaluate priorities, and they should be supported in this. Such things as likely long term survival rates will affect choices made. There is a need not just for pain relief, as important as this may seem, but the person may require help to adjust to what they see as a loss, whether actual, perceived, and potential, caused by either the cancer itself or its treatment. This may require counselling care as described by Cancer.net (2012). The National Cancer Survivorship Initiative ( 2012) mentions such things as a Work Support Route Guide. Staff need to be aware of such initiatives so that they can introduce them to patients in their care. These factors may not be considered as dealing directly with post-cancer pain, but are part of a wider pattern of holistic care. Conclusion Greater comfort for cancer survivors and better function will be optimised if a multidisciplinary and individualised approach is used , a combination of drug treatment using both opioids and a variety of adjuvant medications, but also physical therapies, psychosocial interventions and also using complementary and alternative methods such as nutritional counselling. These need to be accessible to all cancer survivors, rather than only those who live in certain areas. This also means that informed decisions must be made to suit individuals, and that excellent communications must exist between the various disciplines involved, in order that everything helpful will be included in a patient’s care plan, and he receives the optimum care. Care should be taken also to involve patients in decisions requiring the choice of treatments and other possible options such as the choice of place where the treatment can be offered. This is about more than financial concerns. If the treatment centres are to continue as they are, then alternatives need to be considered for at least some of the support, perhaps in local health centres. People simply don’t want to travel many miles just for half an hour of treatment in some distant centre, especially if they are in pain or otherwise feel down or unwell. This means extra training will be required for local health centre staff in order to provide more holistic and readily available care, whatever this involves. 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