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44 august 1 :: vol 26 no 48 :: 2012 NURSING STANDARD / RCN PUBLISHING

Art & science oncology


Abstract
Pain is common in patients with cancer and may be caused by the
disease itself or treatments. Part 1 of this article identied the causes
and types of cancer pain to inform assessment and management of pain,
which will be discussed in this article. Barriers to pain management
and the non-medical prescribing role of the advanced practice nurse in
treating patients with cancer pain will be explored.
Author
Suzanne Chapman
Clinical nurse specialist in pain management, clinical services division,
The Royal Marsden NHS Foundation Trust, London.
Correspondence to: suzanne.chapman@rmh.nhs.UK
Keywords
Breakthrough pain, cancer pain, non-medical prescribing,
pain assessment, pain management
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Cancer pain part 2:
assessment and management
Chapman S (2012) Cancer pain part 2: assessment and management.
Nursing Standard. 26, 48, 44-49. Date of acceptance: April 19 2012.
ADVANCES IN THE treatment of cancer have
led to increased life expectancy for patients. As a
result, cancer is emerging as a chronic and complex
condition (Chapman 2011). Patients with cancer
may experience signicant physical effects,
such as pain from the cancer itself or treatments.
Cancer pain is frequently undertreated despite
the wide range of treatment options available.
Barriers to effective treatment may include poor
assessment, insufcient knowledge of pain
mechanisms and treatment options, and specic
concerns regarding dependence, tolerance,
addiction and drug-related side effects (Fine et al
2004). Individualised assessment and selection
of the most appropriate therapeutic approach
can improve patients function and quality of life
by reducing their pain.
This article focuses on assessment and
management of cancer pain, as well as barriers
to effective treatment of pain. Non-medical
prescribing is also discussed.
Pain assessment
Thorough pain assessment is essential to
dene pain (both its cause and type) and direct
treatment. The aim of assessment is to diagnose
the underlying cause of pain and its effect on the
patient. Pain should be assessed regularly and
systematically with a validated pain assessment
tool. Assessment is not a one-off process; cancer
pain is dynamic and may change in response to
treatment or disease progression. Pain should be
assessed to establish a baseline measure before any
treatment intervention is initiated or changes to
treatment regimens are made, and then reassessed
after the intervention to measure effectiveness. Use
of pain intensity assessment scales enables patients
to quantify a baseline measure of pain, which
is important for monitoring their response to
treatment. Examples of pain intensity assessment
scales include the Numerical Rating Scale (0-10),
Verbal Rating Scale (none, mild, moderate, severe,
very severe), pain thermometer scales (Figure 1)
and Faces Pain Scale (Fink and Gates 2006,
Herr et al 2007).
Multi-dimensional pain tools enable assessment
of other core features of pain, such as affective,
cognitive, social and spiritual dimensions (Table 1).
Pain assessment needs to incorporate factors that
will moderate sensitivity to pain. Pain sensitivity
can be increased when patients are uncomfortable,
not sleeping well, or fatigued, anxious, fearful,
angry, sad, depressed or bored (Dougherty
and Lister 2011). Pain sensitivity is reduced
when symptoms are relieved, patients are well
rested, anxiety is reduced and mood is elevated
(Dougherty and Lister 2011). If patients are
shown empathy and understanding, and offered
companionship and diversional activities,
pain sensitivity can be further reduced. The
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Short-Form McGill Pain Questionnaire and
Brief Pain Inventory (Fink and Gates 2006) are
simple tools that can be used for routine clinical
assessment in patients with cancer.
Other methods of pain assessment include
patients self-reports. These include hand-held
patient records, which may be electronic or paper
to enable assessment and management approaches
to be shared by all healthcare professionals
involved in patients care. Diaries, charts or scales
may be used by patients to record the intensity of
their pain, the analgesics and non-pharmacological
approaches they have tried, and how well these
worked. Carers should be included in the
assessment process as they may need to be
involved in the ongoing monitoring of pain,
and may provide insight about whether the
patient is being stoical.
Personal judgements and experiences may
inuence healthcare professionals assessment of
pain, leading to an over reliance on physiological
signs and behaviours indicating the presence of
pain. These can be misleading and inaccurate,
particularly in patients with chronic pain. The
use of formal pain assessment tools enables
effective assessment and communication between
healthcare professionals and patients, and reduces
error and bias (Carr and Mann 2000a). Pain is
a personal experience and the challenge for nurses
is to enable patients to express their pain.
The presence of breakthrough pain should
be assessed as part of comprehensive cancer
pain assessment. As part of history taking during
initial assessment, patients should be asked
a series of questions to establish whether they
have breakthrough pain, including:
Do you have background pain (a constant pain
experienced on a daily basis)?
Is the background pain adequately controlled?
Do you have transient exacerbations of pain?
If the patient answers yes to all three questions,
breakthrough pain is present (Davies et al 2009).
Management of cancer pain
Flexibility is key to managing cancer pain.
Diagnosis, stage of disease, response to pain and
interventions, and personal preferences will vary
between patients. Box 1 lists principles that should
guide the development of an individualised pain
management plan for patients with cancer.
Management strategies for cancer pain include
pharmacological approaches, in which analgesics
can be given via various routes (oral, buccal,
sublingual, intranasal, rectal, subcutaneous,
intravenous, transdermal) and non-pharmacological
approaches. Box 2 summarises the different
approaches to management of cancer pain following
thorough pain assessment.
Pharmacological approaches
The World Health Organizations (WHO) (1996)
analgesic ladder is used to guide prescribing.
It involves a stepwise approach to the use of
analgesics, including non-opioids (step 1), opioids
for mild to moderate pain (step 2), opioids for
moderate to severe pain (step 3) and adjuvant drugs
that can be used at any step if appropriate (Figure 2).
The WHO (1996) has suggested ve simple
recommendations for maximising effectiveness
of prescribed treatments, including:
Analgesics should be administered orally
whenever possible.
FIGURE 1
Example of a pain thermometer scale
Point to the words that best show how
bad or severe your pain is now
Pain as bad as could be
Extreme pain
Severe pain
Moderate pain
Mild pain
No pain
(Adapted from Herr et al 2007)
TABLE 1
Dimensions of pain
Dimension Example
Physiological Aetiology when the pain started, type of pain
(sharp dull) and relieving or aggravating factors.
Sensory Location, severity of pain.
Affective Emotional responses and feelings.
Cognitive Thought processes.
Behavioural Communication of pain and fatigue.
Sociocultural Culture, family and work roles.
Spiritual Meaning and purpose attributed to pain.
(Silkman 2008)
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Analgesics should be given at regular intervals.
Consider the duration of drug action, prescribe
a dose that should be taken at denite regular
intervals in accordance with the patients
pain level and adjust the dose until the patient
is comfortable.
Analgesics should be prescribed according to pain
intensity as evaluated using a pain intensity scale.
The dose of an analgesic should be adapted to
the individual. There is no standard dose to treat
certain types of pain every patient will respond
differently. The correct dose is one that will
provide adequate pain relief.
Analgesics should be prescribed with
consideration given to prescribing rst and last
doses linked to waking time and bedtime for the
patient, and monitoring for effectiveness and
side effects.
Beginning on step 1 of the WHO (1996) analgesic
ladder may be insufcient for patients with severe
cancer pain or treatment-related pain; these
patients may need to start on step 3 (opioid with
or without adjuvant drugs). There are several
different opioids available for the treatment of
moderate to severe pain. There is no evidence that
one opioid is superior to another for the treatment
of pain, but individuals may have unique opioid
receptor proles and genetic differences that
mean one opioid may work better for them than
another (Hall and Sykes 2004). Other factors may
also affect a patients ability to tolerate opioids,
including (Fallon et al 2006):
How responsive the type of pain is to opioids.
Previous use of opioids.
How quickly the opioid dose was titrated.
Concomitant medication.
Concomitant disease.
Genetic factors (differences between individuals
in opioid response).
Biochemical factors such as renal and hepatic
function.
Opioids are available in many different
preparations depending on their duration of
action (immediate release or modied release),
drug formulation and delivery route (oral tablets
or capsules, transdermal patches, buccal or
sublingual formulations, or administration via
subcutaneous or intravenous routes). The route
of administration that is most suitable for the
patient will guide drug preparation. For example,
transdermal drug delivery via patches may
need to be considered in those with dysphagia
and in patients at the end stages of the disease.
For patients unable to continue taking oral
medications, subcutaneous infusions or bolus
doses can be administered instead. Choice of
drug and preparation should be based on what
is most appropriate for the patient, family and
setting where the person will be cared for. Patients
taking regular doses of opioids will require careful
monitoring for side effects such as constipation,
sedation, nausea and opioid toxicity.
Adjuvant drugs contribute to pain management,
but are not primarily used for pain relief; their
use is indicated on all steps of the WHO (1996)
analgesic ladder. Addition of these drugs to
a patients individual pain management plan
should be based on pain assessment and the
likely cause of pain. Examples of adjuvant
drugs include antispasmodics for acute colic or
spasm, antidepressants and anticonvulsants for
neuropathic pain, and bisphosphonates for bone
pain (Gannon and Davies 2006).
Other pharmacological interventions may
also be considered, for example continuous
BOX 2
Management approaches to cancer pain
Pharmacological approaches:
Non-opioids (paracetemol, non-steroidal anti-inammatory drugs).
Opioids (codeine, dihydrocodeine, tramadol, morphine, oxycodone,
fentanyl, hydromorphone).
Adjuvant drugs (corticosteroids, antidepressants, anti-epileptics,
N-methyl-D-aspartate-receptor antagonists (ketamine)),
antispasmodics, muscle relaxants, bisphosphonates.
Single nerve blocks.
Infusions of drug combinations, for example including local anaesthetics,
opioids and/or adjuvant drugs via the epidural or intrathecal route with
external pumps.
Implantable infusion systems.
Non-pharmacological approaches:
Physiotherapy.
Occupational therapy.
Transcutaneous electrical nerve stimulation.
Acupuncture.
Massage.
Relaxation.
Psychological support.
Pastoral care.
BOX 1
Principles of cancer pain management
Ask the patient about pain regularly.
Use assessment tools (such as pain intensity scales, the Short-Form
McGill Pain Questionnaire and the Brief Pain Inventory).
Ask the patient which symptom is most troublesome this may not
always be the one that is most severe.
Believe patient and family reports of pain and what relieves pain.
Choose pain control options appropriate for the patient, family and
setting.
Deliver interventions in a timely, logical and co-ordinated fashion.
Empower the patient and family. Enable patients to control their
approach to pain management as much as possible.
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infusions of combinations of drugs such as local
anaesthetics, opioids or adjuvant drugs via the
neuraxial route (epidural or intrathecal), targeted
nerve blocks and inhalation therapy (such as
nitrous oxide). Neuraxial route infusions require
monitoring to detect drug-related side effects,
potential infection risks and device-related
problems (Farquhar-Smith and Chapman 2012).
The nurse should be vigilant and know how
to manage these situations appropriately.
Nurses have an important role in medicines
management. This includes ensuring that patients
understand what medication they are taking and
why, and the likely side effects. When administering
analgesics, nurses should also be aware of how to
progress to the next level of stronger analgesia for
breakthrough pain or how to increase doses when
end-of-dose failure occurs.
Non-pharmacological approaches
Optimal pain control is more likely to be
achieved by combining pharmacological and
non-pharmacological approaches. The use of
non-pharmacological approaches should be
based on thorough pain assessment so that
referrals can be made to appropriate healthcare
professionals for review and advice regarding
management strategies.
Physical therapies, such as physiotherapy and
occupational therapy, can help to reduce pain and
improve function and quality of life for patients
(British Pain Society 2010). Interventions include
therapeutic exercises, pacing of daily activity,
graded and purposeful activity, transcutaneous
electrical nerve stimulation and lifestyle
adjustment (British Pain Society 2010). Comfort
measures such as instruction on positioning and
posture may ease pain and prevent exacerbations
(Dougherty and Lister 2011).
Complementary and alternative medicine
refers to treatment modalities that complement
mainstream approaches. Complementary and
alternative medicine may improve the patients
sense of wellbeing and therefore inuence pain
perception and tolerance (British Pain Society 2010).
Psychological interventions can improve
patients pain and sense of pain control by
reducing anxiety, stress and muscle tension.
Distraction techniques can be used to divert
the patients attention from the pain and on to
something else, at least temporarily. Examples
of distraction techniques include reading,
listening to music, counting, doing crossword
puzzles, watching television and interacting with
visitors or carers. Nurses can develop trusting
therapeutic relationships with patients by listening
to and acknowledging the persons experience
of pain, acting as a patient advocate, and
providing physical and emotional support. These
relationships can be instrumental in reducing
anxiety and helping patients cope with pain
(Carr and Mann 2000b).
Information and education can make the
difference between effective and ineffective pain
management. Education enables the patient
to engage in decision making about his or her
pain management plan and can consequently
reduce anxiety. Education should include specic
information about why pain control is important,
expectations about pain relief, how the patient
can participate in pain management and what
the person should do if pain is not controlled
(Dougherty and Lister 2011). Care must be
taken to tailor the level of information to the
individuals needs.
Guided imagery may be used to manage pain
and anxiety associated with procedures such as
venepuncture and cannulation. When guided
imagery is used with relaxation breathing it
can help patients cope with the procedure and
promote a feeling of patient participation. Guided
imagery engages the person by focusing on a
pleasant activity, providing distraction from the
pain or changing the perception of the painful
experience. Guided imagery is used to give the
person the opportunity to imagine being in a more
pleasant situation and involves all of the senses.
For example, when imagining a favourite place the
person is asked to feel the warmth all around, see
the colours, smell the odours and hear the sounds.
FIGURE 2
World Health Organization three-step analgesic ladder
Freedom from cancer pain
1
2
3
Opioid for moderate to severe pain
Non-opioid
Adjuvant
Opioid for mild to moderate pain
Non-opioid
Adjuvant
Pain persisting or increasing
Pain persisting or increasing
Non-opioid
Adjuvant
Pain
(World Health Organization 1996)
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Management of breakthrough pain
Management of breakthrough pain should
be individualised and include treatment of
the underlying cause of pain; avoidance
and/or treatment of any precipitating factors;
modication of the background analgesic
regimen (around the clock medication); use of
rescue medication (breakthrough medication);
use of non-pharmacological methods (rubbing
or massage, heat or cold therapies, distraction
techniques, relaxation techniques); and use of
interventional techniques such as nerve blocks
(Davies et al 2009). The nurse has a key role in
monitoring interventional approaches such as
neuraxial blockade and assisting the patient to
develop appropriate non-pharmacological pain
management strategies.
Patients with breakthrough pain should have
their pain reassessed to determine the efcacy
and tolerability of treatment and any change
in the nature of breakthrough pain (Davies et al
2009). Successful management of background and
breakthrough pain depends on accurate ongoing
reassessment. Cancer pain may change over time
in response to analgesics and other interventions,
chronic pain syndromes following treatment,
tumour progression at the primary site of cancer
or development of metastatic disease.
Barriers to pain management
Pain is a subjective experience and several barriers
have been identied that may lead to inadequate
treatment of cancer pain. Barriers can originate
from patients or healthcare professionals.
Patient barriers can be related to patient anxiety
and the effect this has on the pain experience or
factors that prevent patients from reporting pain.
Anxiety about pain, which may be caused by
specic cancer treatments or interventions, can
inuence the level of pain experienced. Previous
experiences or the experiences of close family
members or friends may further exacerbate these
anxieties (Carr 2007). Patients may be reluctant
to report pain for various reasons. Fears about
opioids, such as addiction and side effects, and the
association of opioids with pain management at
the end of life may prevent patients from adhering
to the pain management plan. Patients may not
report pain because they assume that healthcare
professionals are the experts and may not want
to distract medical staff from treating their cancer.
Patients may also fear that by taking medication
to manage their pain they may mask early
warning symptoms of disease progression,
which may delay consultation for urgent review
(Carr 2007, Christo and Mazloomdoost 2008).
Exploring these issues with the patient and
addressing any concerns about reporting pain
and analgesics can improve adherence to pain
management strategies and therefore reduce
the patients level of pain.
Pain management barriers associated with
healthcare professionals include: misconceptions
about pain, for example that patients should
expect to experience pain (particularly in relation
to certain procedures or types of cancer); patients
in pain always have observable signs (facial
grimacing and body posture, elevated pulse and
blood pressure); patients will always tell staff
when they have pain; one type of intervention, for
example medication, is sufcient to relieve pain;
and addiction and respiratory depression are to
be expected with opioid therapy (Carr and Mann
2000c). These are personal beliefs and healthcare
professionals need to explore their own level of
knowledge and attitudes in relation to pain relief.
Most hospitals provide some education regarding
pain and pain management.
Non-medical prescribing
Non-medical prescribing has evolved as part of
some advanced practice nursing roles and was
developed to:
Improve patient care by promoting access
to medications.
Empower patients by enabling choice
in healthcare.
Enhance exible ways of working in healthcare
teams and use the skills and knowledge of nurses
working at an advanced practice level.
Non-medical prescribing has helped to address
some issues relating to adherence to pain
management strategies, improve patients access
to analgesics, and provide a holistic approach to
the assessment and management of cancer pain.
Lewis-Evans and Jester (2004) identied some of
the benets of non-medical prescribing to patients,
including improved communication, better
continuity of care and increased patient condence
in healthcare professionals.
Patients receiving palliative care are responsive
to and supportive of non-medical prescribing
because the nurse is deemed to have in-depth
knowledge of the patient, a sound knowledge of
analgesics and more time for the consultation
process (Creedon and ORegan 2010). In palliative
care, patients may need to be prescribed opioids.
The nurses role as an independent non-medical
prescriber enables timely management of patients
pain and access to appropriate drugs. Nurses can
also initiate alterations to medications and referral
to other healthcare professionals as appropriate,
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therefore improving the quality of care that
patients with advanced chronic illness receive.
Until recently, prescribing of opioids by
non-medical prescribers for acute and chronic
pain in patients with cancer was limited by
legislation. There were regulations regarding
which opioids could be prescribed for moderate to
severe pain and other indications for prescribing,
the majority of which were for patients receiving
palliative care (dened as care of patients with
advanced, progressive illness). For example, an
independent nurse prescriber would be unable to
treat a patient with chronic pain following surgery
or acute pain following curative radiotherapy
with an opioid such as morphine, oxycodone or
a fentanyl patch, as these drugs could only be
prescribed for palliative care. Following a lengthy
consultation process, these regulations have
recently been changed (Department of Health
2012), and it is hoped that this will enhance patient
access to expert review and analgesics to relieve
pain associated with cancer. This is increasingly
important as the number of people who survive
cancer and live with the chronic effects of
treatment or stable disease increases.
Conclusion
Many patients with cancer will require timely and
effective pain relief. Part 1 of this article identied
the causes and types of cancer pain, which is
necessary to ensure appropriate assessment
and management strategies are adopted.
Comprehensive pain assessment is pivotal to direct
treatment strategies. It also enables patients to
quantify a baseline measure of pain, so that the
effects of any interventions can be monitored.
It is important to assess and reassess patients
pain as this may change over time. Effective
management of cancer pain often combines
pharmacological and non-pharmacological
approaches. Barriers to pain management need
to be addressed to promote effective pain relief.
Nurses have a pivotal role in the management
of cancer pain and should develop therapeutic
relationships with patients to optimise care NS
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