Ch 29 Pain mgmt in Cancer

Question 1

Cancer pain can be relieved in __ of patients.

Answer 1

90%

Question 2

Despite the availability of effective treatments, __ goes unrelieved in a large number of patients.

Answer 2

cancer pain

Question 3

Barriers to pain relief include:

Answer 3

inadequate prescriber training, fears of addiction, and a healthcare system that until recently has put a low priority on pain management.

Question 4

Pain is a personal, subjective experience that encompasses not only the:

Answer 4

sensory perception of pain but also the patient’s emotional and cognitive responses to both the painful sensation and the underlying disease.

Question 5

Pain has two major forms:

Answer 5

nociceptive pain, which results from injury to tissues, and neuropathic pain, which results from injury to peripheral nerves.

Question 6

Management of cancer pain is an ongoing process that involves repeated cycles of (3).

Answer 6

assessment, intervention, and reassessment.

The goal is to create an individualized treatment plan that can meet the changing needs of the patient.

Question 7

The __ is the cornerstone of assessment.

Answer 7

patient self-report

Question 8

__ is a poor substitute for the patient self-report as a method of assessment.

Answer 8

Behavioral observation

Question 9

__ are the principal modality for treating cancer pain.

Answer 9

Analgesic drugs

Question 10

Three groups of analgesics are employed:

Answer 10

nonopioid analgesics (NSAIDs and acetaminophen), opioid analgesics, and adjuvant analgesics.

Question 11

Drug selection is guided by the WHO analgesic ladder: As pain intensity increases, treatment progresses from __.

Answer 11

nonopioid analgesics to opioids of moderate strength (e.g., oxycodone) and then to powerful opioids (e.g., morphine).

Adjuvant analgesics can be used at any time. If pain is already intense, treatment can start with an opioid, rather than trying a nonopioid first.

Question 12

Because nonopioids and opioids relieve pain by different mechanisms, combining an opioid with a nonopioid can be __.

Answer 12

more effective than either drug alone

Question 13

NSAIDs produce their effects by inhibiting __.

Answer 13

cyclooxygenase (COX), an enzyme with two basic forms: COX-1 and COX-2.

Question 14

Most NSAIDs inhibit both:

Answer 14

COX-1 and COX-2. A few NSAIDs are COX-2 selective.

Question 15

Principal adverse effects of the NSAIDs are (3).

Answer 15

GI injury, acute renal failure, and bleeding.

In addition, all NSAIDs except aspirin pose a risk of thrombotic events.

Question 16

The __ cause less GI injury than the nonselective NSAIDs, but they pose a greater risk of thrombotic events.

Answer 16

COX-2 inhibitors

Accordingly, long-term use of COX-2 inhibitors is not recommended.

Question 17

By inhibiting platelet aggregation, __ increase the risk of bruising and bleeding in patients with thrombocytopenia, a common side effect of cancer chemotherapy.

Answer 17

NSAIDs

Question 18

In contrast to opioids, NSAIDs do not cause (3).

Answer 18

tolerance, physical dependence, or psychologic dependence

Question 19

Acetaminophen relieves pain but, unlike the NSAIDs, does not:

Answer 19

suppress inflammation, inhibit platelet aggregation, or promote gastric ulceration or renal failure.

Question 20

Because __ does not affect platelets, the drug is safe for patients with thrombocytopenia.

Answer 20

acetaminophen

Question 21

Combining acetaminophen with alcohol, even in moderate amounts, can result in __.

Answer 21

potentially fatal liver damage.

Question 22

__ are the most effective analgesics available, and

hence are the primary drugs for treating moderate to severe cancer pain.

Answer 22

Opioids

Question 23

Opioids are especially effective against __.

Answer 23

nociceptive pain; efficacy against neuropathic pain is limited.

Question 24

Opioid analgesics relieve pain by mimicking the actions

of __.

Answer 24

endogenous opioid peptides (enkephalins, dynorphins,

endorphins), primarily at mu receptors in the CNS.

Question 25

The opioids fall into two major groups:

Answer 25

pure (full) agonists (e.g., morphine) and

agonist-antagonists (e.g., butorphanol).

Question 26

There is a ceiling to pain relief with the agonist-antagonists, but not with the __.

Answer 26

pure agonists.

Hence, for patients with cancer, pure agonists are generally preferred.

Question 27

For most patients, opioids should be given __.

Answer 27

on a fixed schedule ATC, with additional doses provided for breakthrough pain.

PRN dosing should be limited to patients with intermittent pain.

Question 28

__ is preferred for most patients.

Answer 28

Oral administration

Transdermal administration is a good alternative.

Question 29

__ are painful and should be avoided.

Answer 29

Intramuscular opioids

Question 30

__ is a desirable method of opioid delivery because it gives patients more control over their treatment.

Answer 30

PCA

Question 31

An __ can facilitate dosage selection when switching from one opioid to another or from one route to another.

Answer 31

equianalgesia table

Question 32

Over time, opioids cause tolerance, a state in which a specific dose __.

Answer 32

produces a smaller effect than it could when treatment began.

Question 33

Tolerance develops to (4).

Answer 33

analgesia, euphoria, respiratory depression, and sedation, but not to constipation or miosis.

Question 34

Over time, opioids produce physical dependence, a state in which __.

Answer 34

an abstinence syndrome will occur if the drug is abruptly withdrawn.

Note: Physical dependence is NOT the same as addiction!

Question 35

Addiction is a behavior pattern characterized by __.

Answer 35

continued use of a psychoactive substance despite physical, psychologic, or social harm.

Note: Addiction is NOT the same as physical dependence!

Question 36

__ to opioids is very rare in people taking these drugs to relieve pain.

Answer 36

Addiction

Question 37

Misconceptions about opioid addiction are a major cause for __.

Answer 37

undertreatment of cancer pain.

Accordingly, we must correct these misconceptions by teaching physicians, nurses, patients, and family members that (1) addiction is not the same as physical dependence, and (2) addiction is very rare in therapeutic settings.

Question 38

__ is the most dangerous side effect of the opioids.

Answer 38

Respiratory depression

Fortunately, significant respiratory depression is rare.

Question 39

__ is increased by other drugs with CNS-depressant actions (e.g., alcohol, barbiturates, benzodiazepines). Accordingly, combining these agents with opioids should be avoided.

Answer 39

Respiratory depression

Question 40

Severe respiratory depression can be reversed with __.

Answer 40

naloxone [Narcan], an opioid antagonist.

However, because excessive naloxone will reverse opioid analgesia and precipitate withdrawal, dosage must be titrated carefully.

Question 41

Opioids cause __ in most patients. No tolerance

develops.

Answer 41

constipation

Constipation can be minimized by increasing
dietary fiber and fluids, and by taking one or more appropriate drugs (stool softener, stimulant laxative, osmotic laxative, peripherally acting opioid antagonist).

Question 42

Use of meperidine (a pure opioid agonist) should be avoided because __.

Answer 42

a toxic metabolite can accumulate

Question 43

Agonist-antagonist opioids must not be given to patients

taking __.

Answer 43

pure opioid agonists because doing so could reduce analgesia and precipitate withdrawal.

Question 44

Adjuvant analgesics can (3).

Answer 44

enhance analgesia from opioids,
help manage concurrent symptoms that exacerbate pain,
and treat side effects caused by opioids.

In addition, several adjuvants are effective against neuropathic pain.

Question 45

__ are given to complement the effects of opioids.

Answer 45

Adjuvant analgesics

Accordingly, these drugs are employed in
combination with opioids—not as substitutes.

Question 46

__ are the last resort for relieving intractable pain. All other options should be exhausted before these are tried.

Answer 46

Invasive therapies (nerve blocks, neurosurgical procedures)

Question 47

Physical interventions (e.g., heat, cold, massage, acupuncture, TENS) and psychosocial interventions (e.g., relaxation, imagery, cognitive distraction, peer support groups) can help __.

Answer 47

reduce pain, but the degree of relief is limited.

Accordingly, these interventions should be used only in conjunction with drug therapy—not as substitutes

Question 48

Older adults are more sensitive to drugs than are younger adults. The principal reason is __.

Answer 48

drug accumulation secondary to a decline in hepatic metabolism and renal excretion.

Question 49

Undertreatment of pain is especially common in __.

Answer 49

older adults.

Undertreatment is inexcusable and must not be allowed.

Question 50

__ are at risk of increased side effects and adverse drug interactions. Careful drug selection and monitoring can minimize risk.

Answer 50

Older adults

Question 51

Management of cancer pain in children is much like management in adults, except that __.

Answer 51

assessment is more difficult.

Question 52

For children who can verbalize and are older than 4 years, __ is the most reliable way to assess pain.

Answer 52

self-reporting

The self-report can be supplemented with behavioral observation to enhance accuracy.

Question 53

___ cannot self-report pain, and a less reliable assessment method must be used. The principal option is behavioral observation, a method that carries a significant risk of underassessment.

Answer 53

Preverbal and nonverbal children

Question 54

When opioid abusers get cancer, they __.

Answer 54

feel pain and need relief like anyone else.

If their pain is sufficient to justify opioids, then opioids should be used—nonopioids should not be substituted for opioids out of concern for addiction.

Question 55

Pain management standards from TJC are designed to make pain relief an institutional priority, and hence should greatly reduce the incidence of __.

Answer 55

pain undertreatment