Ch. 29: Pain Management with Cancer

Question 1

Patient Concerns

Answer 1

• not being a “good” patient
• reluctance to take pain medication
• fear of addiction or being thought an addict
• worries about unmanageable side effects
• concern about becoming tolerant to pain med
• inability to pay for treatment

Question 2

Healthcare System Barriers

Answer 2

• low priority given to cancer pain
• inadequate reimbursement
• restrictive reguation of controlled substances
• treatment is unavailable or access is limited

Question 3

Healthcare Professionals

Answer 3

• inadequate knowledge of pain management
• poor assessment of pain
• fear of patient addiction
• concern about side effects and tolerance
• resistance to report pain
• fear of distracting HCP from treating cancer
• fear the pain means the cancer is worse

Question 4

Pathophysiology of Pain: What is Pain

Answer 4

• unpleasent sensory and emotional experience associated with actual or potential tissue damage
• most reliable method of assessing pain is to have patient describe his or her experience
• pain is inherently personal and subjective

Question 5

Nociceptive Pain vs. Neuropathic Pain

Answer 5

• results from injury to tissues; 2 forms: somatic and visceral pain
• results from injury to peripheral nerves; responds poorly to opioids

Question 6

Pain in Cancer Patients

Answer 6

• direct invasion of surrounding tissues: nerves, muscles, and visceral organs
• metastatic invasion at distinct sites
• therapeutic interventions:
  chemotherapy
  radiation
  surgery (phantom limb)

Question 7

Management Strategy

Answer 7

• ASK about pain regularly
• BELIEVE patient and family
• CHOOSEpain control options appropriate
• DELIVER interventions in timely, logical, coordinated fashion
• EMPOWER patients and families

Question 8

Assessment and Ongoing Evaluation

Answer 8

• comprehensive initial assessment:intensity, physical and neurological examination, diagnostic tests, psychosocial assessment, pain intensity scales
• ongoing evaluation
• barriers to assessment

Question 9

Comprehensive Initial Assessment

Answer 9

• primary objective is to characterize the pain and identify its cause
• assessment of pain intensity and character
• PQRST

Question 10

Ongoing Evaluation

Answer 10

• reassess frequently
• evaluate after sufficent time has elapsed
• be alert for the development of new pain

Question 11

Barreirs to Assessment

Answer 11

• inaccurate reporting by patient
• underreporting by patient
• language and cultural barriers

Question 12

Drug Therapy

Answer 12

Nonopiod analgesics: NSAIDS and acetaminophen

• opiod analgesics: oxycodone, fentanyl, and morphine
• adjuvant analgesics:

Question 13

WHO Analgesic Ladder

Answer 13

step 1: mild to moderate pain (NSAIDS and acetaminophen; nonopioid analgesics)
step 2: more severe pain (add an opioid analgesic, oxycodone, or hydrocodone)
step 3: severe pain (substitute a powerful opioid such as morphine or fentanyl

Question 14

NSAIDS Principles

Answer 14

• aspirin and ibuprofen
• pain relief, supression of inflammation, and reduction of fever
• adverse effects: gastric ulceration, acute renal failure, and bleeding
• all except aspirin increase the risk of thrombotic events
• do not cause tolerance, physical dependence, or psychological dependence

Question 15

NSAIDS

Answer 15

• inhibit COX-1 and COX-2
• greater risk of thrombotic events
• Thrombocytopenia

Question 16

Acetaminophen

Answer 16

• inhibit COX in CNS but not periphery
• combine with an opioid can produce greater analgesic than either drug alone
• lacks anti-flammatory actions
• does not inhibit platelet actions or promote gastric ulceration, renal failure, or thrombotic events
• drug interactions: Alcohol= fatal liver damage and Warfarin= increase risk of bleeding

Question 17

Drug Selection

Answer 17

• pure opioid agonists are preferred for all cancer patients
• opioid rotation
• dosage should be individualized
• use with caution: methadone, and codeine
• avoid meperidine

Question 18

Routes of Admin

Answer 18

• oral (preferred)

Question 19

Managing Breakthrough Pain

Answer 19

• may experience transient episodes of moderate to severe breakthrough pain
• access to resuce medication:
  strong opioid with rapid onset and short duration, immediate release oral morphine, transmucosal fentanyl, fentanyl nasal spray

Question 20

Managing Side Effects

Answer 20

• resp. depression: Naloxone
• constipation: stool softeners, laxatives, methylnaltrexone
• sedation: CNS stimulant (caffeine, methylphenidate)
• nausea and vomiting: antiemetic or serotonin antagonist
• itching: antihistamine

Question 21

Adjuvant Analgesics

Answer 21

• used to complement the effects of opiods; not used as substitutes
• enhance analgesia caused by opioids
• help manage concurrent symptoms that exacerbate pain
• treat side effects caused by opioids

Question 22

Adjuvant Analgesics Ex.

Answer 22

• tricyclic antidepressants
• antiseizure drugs
• local anesthetics/antidysrhythmics
• CNS stimulants
• antihistamines
• glucocorticoids
• bisphosphonates

Question 23

Invasive Procedures

Answer 23

• Neurolytic nerve block
• neurosurgery
• tumor surgery
• radiation therapy

Question 24

Physical Interventions

Answer 24

• heat, cold
• massage, exercise
• acupunture and transcutaneous electrical nerve stimulation

Question 25

Psychosocial Interventions

Answer 25

• relaxation and imagery
• cognitive distraction
• peer support groups

Question 26

Pain Management in Special Populations: older adults

Answer 26

• heightened drug sensitivity
• undertreatment of pain
• misconceptions: insensitive to pain, can tolerate pain well, highly sensitive to opioid side effects
• increased risk of side effects and adverse interactions

Question 27

Pain Management in Special Populations: Young Children

Answer 27

• experience more pain from chemotherapy and other interventions from cancer itself

Question 28

Pain Management in Special Populations: Opioid Abusers

Answer 28

• HCP must try to relieve the pain and avoid opioids simply because the patient wants to get high