1. What additional assessment data should the nurse collect?

Therapeutic communication is needed on the case of the patient to gain trust and to
have a good nurse-patient relationship. The patient denied the real situation where denial
is the most common defense mechanism used. To address this, the nurse must present
reality pointing alterations of daily living and importance of compliance on the medical
regimen. The nurse must emphasize what his daughter reported regarding severe pain, not
taking his prescribed medications and he doesnt want to die addict to open conversation.
Through these the nurse can assess and verify the condition of the patient. The additional
assessment should be focused on pain. It should be routinely performed on every patient
and should be thought as the 5
th
vital sign. The nurse should ask the patient, Where is
your pain? When a precise pain etiology cannot be defined, the nurse should not assume
that pain is absent or less severe. Pain is subjective; the nurse responsibility is to
acknowledge and respect the patients word. Next, the nurse may use a rating scale to
describe pain severity. The rating scale is easily and quickly understood by the patient and
is simple for the nurse administer. The patient is asked to rate scale is easily and quickly
understood by the patient and is simple for the nurse administer. The patient is asked to
rate his pain on a 0-10 numeric scale, with 0 representing no pain and 10 indicating the
worse pain the patient has ever experienced. The rationale of this is to provide baseline
for assessing changes in pain level and evaluation of interventions. Onset, duration,
aggravating, and alleviating factors of pain must be added on the assessment. The common
pain assessment questions that the nurse could use are the following:
o On a diagram of the body, shade the areas where you feel pain. Put an X on the area
that hurts you most.
o When does the pain start?
o Is it worse or better at certain times of the day?
o What makes the pain better or worse? (e.g., body position, certain activities,
eating, bowel movements)
o Have you tried anything in particular to relieve pain, e.g., medicines, heat, cold,
position changes, rest?
o How do others know when you have pain? Do you talk about it, or do you sometimes
try to hide it?
o How does pain affect your ability to do your normal activities? (e.g., work, sleep,
eat, bathe, cook, have sexual relations)
o Does the pain make you feel nervous, sad, angry, irritable, or worried?
o What concerns/worries do you have about taking pain medicine? Are you worried
about becoming hoked, or addicted to pain medicine?
The nurse must also assess the vital signs of the patient. The nurse must check the
medicine supply on morphine and other prescribed medicines to confirm compliance. You
may also assess the behavioural responses to pain and pain experience. Assuring the
patient that you know that pain is real and you are there to assist him in reducing it.
2. How should you, the nurse, approach this patient and family about his pain and
their concerns regarding opioids for pain control?
Health education regarding pain and pain control is vital to both patient and daughter
for appropriate management. Therapeutic communication must be observed by the nurse in
approaching them. Pain is a common problem among cancer patients occurring as a result of
malignancy and anticancer treatment. There is no doubt that uncontrolled pain can result in
many physiologic changes, as well as anxiety, anger, and depression. Social relationships,
spiritual and sexual health and the ability to perform daily activities are threatened when
pain is pervasive. Adequate pain assessment and treatment can potentially minimize or
alleviate these problems.
Pain serves as a mechanism to warn us about potential for physical harm. Pain is a
management multidimensional phenomenon and is thus difficult to define. It is a personal
and subjective experience, and no two people experience pain exactly the same manner.
Pain is an unpleasant sensory and emotional experience associated with actual or potential
tissue damage, or described in terms of such damage (International Association for the
Study of Pain (ISAP)).
Opioid analgesics suppress pain impulses but can suppress respiration and coughing by
acting on the respiratory and cough center in the medulla of the brainstem. The goal of
administering opioids is to relieve pain and improve quality of life, therefore, the route of
administration, dose, frequency of administration are determined on an individual basis.
Factors that are considered in determining the route, dose, and frequency of medication
include the characteristics of pain (e.g., expected duration and severity), the overall
status of the patient, the patients response to analgesic medications, and the patients
report of pain. Opioid analgesics are used for relief of mild, moderate, or severe pain.
Morphine sulfate may cause respiratory depression, orthostatic hypotension, and
constipation. Reminding interventions of morphine administration to patient and family
makes them at ease because they will understand the mechanism of action of the drug and
its special considerations; side effects includes:
a. Respiratory depression and sedation- caused by diminished sensitivity of the
respiratory center to carbon dioxide. A patient who receives opioids by any route
must be assessed frequently for changes in respiratory status. Specific notable
changes are shallow respirations and decreasing respiratory rate. Withhold the
medication if the respiratory rate is less than 12 breaths/min; respirations of less
than 10 breaths/ min can indicate respiratory distress. Avoid alcohol or CNS
depressants because they can cause respiratory depression. Instructing the patient
to report it to his daughter regarding these possible conditions because it needs
immediate action. Sedation, which may occur with any method of administering
opioids, is likely to occur when opioid doses are increased. However, patients often
develop tolerance quickly, that initially caused sedation. Increasing the time
between doses or reducing the dose temporarily, as prescribed, usually prevents
deep sedation from occurring. Patients at risk for sedation must be monitored
closely. Initiate safety precautions such as side rails, a night light, and supervised
ambulation.
b. Nausea and vomiting- this may be triggered due to position change but can be
prevented by having the patient change positions slowly. Adequate hydration and
the administration of antiemetic agents may also decrease the incidence of nausea.
Opioid-induced nausea and vomiting often subside within a few days.
c. Constipation- whenever a patient receives opioids, a bowel regimen should begin at
the same time. Tolerance to this side effect does not occur; rather, constipation
persists even with long-term use of opioids. Several strategies may help prevent
and treat opioid-related constipation. Mild laxatives and a high intake of fluid and
fiber may be effective in managing mild constipation. Unless contraindicated, a mild
laxative and a stool softener should be administered on a regular schedule.
Evaluation on the effectiveness of medication must be reported and assessed by the
nurse and must be noted by the attending physician. Pain must not be neglected by the
patient; hence it seeks the help of medical practitioners. Compliance on morphine sulfate is
emphasized for the effectiveness of the drug and to eliminate factors contributing to
occurrence of pain. Behavioural responses to medical treatment must also be acknowledged
by the nurse for appropriate counselling. Self-determination and discipline in managing
symptoms of cancer are the primary factors in maintaining a healthy way of living.
3. What information can you provide to both the patient and daughter about
addiction?
People with progressive pain such as the case of the patient, may require pain-relieving
medications routinely as a preventive measure. Persistent intense pain can be managed by
long-acting medications. Upon the verbalization of feelings of the patient, he is hesitating
to take pain-relieving medications routinely for fear of possible addiction. Thus, health
education is necessary because widespread cancer require routine pain-relieving
medications like morphine in order to function. Addiction means a state of dependence
produced by habitual taking of drugs. The incidence of addiction is less than 0.1% for
prolonged used. Emphasizing to the patient and significant other that he needs to take the
morphine regularly because of the severe pain he experienced. Side effects of the drug
are manageable and easy to correct rather than the intensity and severity of pain that
alters activities of daily living. It is expected that the patient is experiencing pain because
of its metastatic cancer. It should not be ignored rather it takes actions to treat the
symptom. Promoting health and prevention of further complications are essential to
maintain health and wellness.
4. What adjuvant therapy should be considered in this situation?
Adjuvant therapy are used to enhance the analgesic effect of opioids; to treat specific
pain types, such as neuropathic pain; or to treat other symptoms that can make pain worse.
These drugs are the following:
a. Anti-depressants- it helps to control tingling or burning from nerve injury caused
by the cancer or cancer therapy. It also used to treat depression.
b. Antihistamines- it helps to control nausea, insomnia, and pruritus.
c. Antianxiety drugs- used to treat muscle spasms that accompany severe pain and
also lessen anxiety.
d. Amphetamines- it enhances opioid effectiveness and reduce the drowsiness they
cause.
e. Anticonvulsants- it helps in controlling tingling or burning from nerve injury caused
by the cancer or cancer therapy.
f. Steroids- it relieves pain caused from bone metastasis, spinal cord and brain
tumors, and inflammation.
g. Bisphosphonates- it decreases pain from bone metastasis

5. What other actions/interventions are appropriate to implement in this
situation?
Prostate cancer is the most frequently diagnosed malignancy and the second leading
cause of cancer death in men. Nonpharmacologic pain management strategies are needed
to alleviate suffering of pain. Described as physical and cognitive-behavioral interventions,
many of these approaches are noninvasive, low-risk, inexpensive, easily performed and
taught, and within the scope of nursing practice. Physical interventions give comfort,
increase mobility, and alter physiologic responses. Cognitive-behavioral interventions alter
the perception of pain, reduce fear, and give patient a greater sense of control.
a. PHYSICAL INTERVENTIONS
Comfort Measures- clean, smooth sheets; soft, supportive pillows; warm
blankets; and a soothing environment have been used by nurses throughout
the history to relieve pain and suffering. These measures may be difficult to
provide in noisy environment. Position change and movement are well-known
pain relieving interventions. Moving the body, even a small amount, relieves
muscle spasm and provides a degree of pain relief.
Massage- a back rub is a good method of providing cutaneous stimulation. It
is particularly relaxing at bedtime and may block pain so as to promote more
comfortable sleep. However, you should be knowledgeable in massage
techniques so as not to increase discomfort; for example, too deep or rough
massaging may actually increase a clients pain, foot massage is particularly
helpful and cost-effective. The feet are easily accessible, and the
intervention can be applied to people in body positions.
Heat and cold applications- cold and warmth receptors activate A-beta
fibers when their temperature is within 4 to 5 C of body temperature. The
receptors are rapid adapting, requiring that the temperature be readjusted
at frequent intervals ranging from 5 to 15 minutes. Warm applications may
be achieved by warming devices (e.g., heating pads, warming towels). Cold
application also brings pain reduction or relief, and nurses can consider this
treatment. Ice may also be used to provide pain reduction or relief and to
prevent or reduce edema and inflammation.
Acupuncture- very thin metal needles are skilfully inserted into the body at
designated locations and at various depths and angles. It inserted into
meridian (energy pathways) to change energy flow; may use heat or electric
stimulation.
Acupressure- is a noninvasive method of pain reduction or relief based on
the principles of acupuncture. Pressure, massage, or other cutaneous
stimulation, such as heat or cold, is applied over acupuncture points.
b. COGNITIVE OR BEHAVIORAL INTERVENTIONS
Deep Breathing- for relaxation is easy to learn and contributes to pain relief
or reduction by reducing muscle tension and anxiety. First, the patient
clenches the fists while taking a deep breath. After holding the breath for a
moment, the patient exhales while letting the body go limp. The cycle is
followed by a slow, deep breath mimicking yawn.
Rhythmic Breathing- is both relaxation and distraction. It may also provide
effective pain reduction or relief by stimulating baroreceptors in the atria
and carotid sinuses. The method can be combined with rhythms such as
music, a ticking clock, or a metronome. This method focuses on attention
away from the pain and on the breathing and the rhythm.
Music- the exact physiologic mechanisms have not been determined;
however, several possible theories include distraction, release of endogenous
opioids, or dissociation. Music clearly provides distraction and dissociation by
focusing on the characteristics of the musical selection.
Guided imagery- helps the patient visualize a pleasant experience. The
patient is coached to visualize a scene (e.g., relaxing on a beach). The coach
instructs the patient to imagine the sensory aspects of the scene: the
sounds, sights, and emotions expressed. The more vivid the image, the more
effective intervention. Visualization may be combined with soft, lyrical,
relaxing music. Imagery relieves pain through several mechanisms. It is a
way to help people distract themselves from their pain, which may increase
their pain tolerance. Imagery may also produce a relaxation response, thus
relieving pain. Last, the image can be a healing one, designed not only to
relieve the pain but possibly also to diminish the source of the pain.
Distraction- attention is distracted away from the painful sensation or the
negative emotional arousal associated with the pain episode. The primary
theoretical explanation is that a person is able to focus attention on a
limited number of foci. Actively focusing attention on a cognitive task is
thought to limit ones ability to attend to the noxious sensation. To be
effective, the distraction task requires considerable cognitive effort.
Therapeutic touch- the human body is believed to have energy fields that
express aberrant patterns when body systems are insulted.
Meditation- it focuses on ones attention away from pain. It also provides
energy and peace to the person who is meditating. The patient simply sits
comfortably and quietly with focused attention. The focus may vary.






















What was the approach to pain treatment before opioids became common?
Barry Meier: Narcotic painkillers, or opioids, are a large class of drugs derived naturally or synthetically from the opium poppy. Some
commonly used opioids include morphine, hydrocodone, oxycodone, fentanyl and methadone. Opioids have been around for thousands of
years and have long been used to treat pain. But in the mid-1990s, there was a huge change in how doctors used these drugs. Before then,
drugs like morphine were used principally to treat pain from cancer, after surgery or at the end of life. Narcotic painkillers were also used to
treat more common kinds of pain caused by back injuries, headaches, arthritis and other conditions. But traditionally, the painkillers used in
these cases were so-called combination drugs in which an opioid was mixed with an over-the-counter pain reliever like acetaminophen.
Examples of such drugs are Percocet, which contains oxycodone, and Vicodin, which contains hydrocodone. There were other ways to treat
long-lasting, or chronic pain, though they were used less often. One method was known as the multidisciplinary approach and it was based
on the idea that chronic pain involved not only physical issues but also social and psychological ones. Patients were admitted into hospitals
and weaned off of narcotic painkillers and other drugs. Then, they were put through programs, typically lasting about three weeks, which
involved physical therapy, behavior modification and psychological counseling.
How did opioid prescribing become so widespread?
Barry Meier: In retrospect, it is hard to understand how drugs that have caused so much chaos became so widely prescribed. But the opioid
boom that unfolded over the past decade was brought about by a mixture of forces that ranged from good intentions to medical wishful
thinking to corporate profiteering.
In the past, doctors had limited prescribing opioids even to cancer patients and the dying because of addiction concerns. But in the 1980s,
researchers showed that cancer patients could be put on narcotics for months without getting addicted. That led to the idea that a much
bigger group of patients those with chronic pain from common causes could also be safely treated with opioids. And to make this happen,
pharmaceutical companies and pain specialists launched a movement in the mid-1990s known as the War on Pain to change how doctors
viewed opioids.
A pain specialist in New York, Dr. Russell Portenoy, provided the movement with its scientific underpinnings. He argued that the addiction
risks of opioids were overblown and that they were also safe to use at high doses. This idea was critical to their expanded use because a
patient often quickly adjusts to an initial dose of an opioid requiring a doctor to up the amount to provide the same painkilling effect. This
reaction, known as tolerance, can then repeat itself, leading to higher and higher dosages.
Portenoy published some small studies to support his theories. But his research might have amounted to little without the other development
that helped launched the opioid era the introduction of the drug OxyContin.
OxyContins active ingredient, oxycodone, had long been used in Perocet and other drugs. But the drug was critically different in several
ways. For one, it was pure oxycodone, making it far more powerful than Percocet. Secondly, its narcotic was packed at high doses into a
time-released tablet. And thirdly, and perhaps, most importantly, OxyContin was marketed in a way unlike any narcotic painkiller before it.
Unlike strong opioids such as morphine that were principally used inside hospitals, OxyContins maker, Purdue Pharma, aggressively
promoted it to general practitioners and family doctors. In doing so, the company claimed that that OxyContin time-release formulation would
pose an addiction risk to patients of less than one percent. And the Food and Drug Administration, in a monumental mistake, allowed the
company to say that its slow-release design was believed to be less prone to abuse than fast-acting drugs such as Percocet. (The idea was
that drug abusers preferred a drug that gave them a quick hit).
As part of the War on Pain, patient advocacy groups funded by the drug industry also successfully lobbied state lawmakers to make it
easier for doctors to prescribe narcotics. And insurers also played a critical role in driving the widespread use of opioids by cutting back on
funding for alternative treatments such as multidisciplinary programs.
In the short-term, such programs, which cost from $15,000 to $25,000, are more costly than pain pills, which run about $6,000 a year. So
insurers started insisted that doctors prescribe pills.
Chronic pain is a significant public health problem and frustrating to everyone affected by it, especially the elderly who feel
that healthcare has failed them but wish to remain in their own homes, live independently, and avoid becoming a burden to
others. Psychiatrists offer skills with pharmacological and psychological treatments now recognized as effective in the
management of chronic pain. Recent advances in the treatment of chronic pain include the diagnosis and treatment of
psychiatric co-morbidity, the application of psychiatric treatments to chronic pain, and the development of interdisciplinary
efforts to provide comprehensive health care to the patient suffering with chronic pain. The psychiatrist can provide
expertise in the examination of mental life and behavior, an understanding of the individual person and the systems in which
they interact, and facilitate the integration of the delivery of medical care with other health care professionals and medical
specialists. However, not all patients with pain require psychiatric evaluation, which should be reserved for patients who have
severe symptoms, multiple treatment failures, or problematic behaviors such as substance abuse or noncompliance. The
majority of patients can be treated exclusively and successfully by their primary physician.
The use of opioids as a treatment for non-malignant chronic pain remains a subject of considerable debate. Until recently,
opioids were reserved for use only in the treatment of acute pain and cancer pain syndromes. Non-malignant chronic pain
was considered to be unresponsive to opioids, or the use of opioids was associated with too many risks. Fears of regulatory
pressure, medication abuse and the development of tolerance create a reluctance to prescribe opioids and many studies
have documented this underutilization. Fortunately, recent studies of physicians specializing in pain, as well as those who
do not, have shown that prescription of long-term opioids is increasingly common. Surveys and open label clinical trials
support the safety and effectiveness of opioids in patients with chronic non-malignant pain.
(refs 1-6)

Efficacy
Recently, several controlled trials have documented the effectiveness of opioids in the treatment of chronic non-malignant
pain such as low back pain, post-herpetic neuralgia, and painful peripheral neuropathy. These studies support the use of
opioids to provide direct analgesic actions and not just to counteract the unpleasantness of pain. In the treatment of chronic
low back pain, transdermal fentanyl significantly decreased pain and improved functional disability.
(ref 7)

In a randomized, double-blind, placebo controlled trial, controlled-release oral opioids were more effective than tricyclic
antidepressants in decreasing the pain of post-herpetic neuralgia.
(ref 8)
Other studies have documented the presence of opioid
receptors in the peripheral tissues activated by inflammation. These findings suggest a role for opioids in the treatment of
chronic inflammatory diseases such as rheumatoid arthritis and connective tissue disorders.
The use of opioids for the treatment of non-inflammatory musculoskeletal conditions is more confusing. A randomized
double-blind, placebo-controlled crossover study of oral controlled release morphine was performed in patients with chronic
regional, soft tissue musculosketal pain conditions that were resistant to codeine, anti-inflammatory agents and anti-
depressants. Although patients experienced a decrease in pain, they did not experience significant psychological or
functional improvement.
(ref 3)
In contrast, another randomized, placebo-controlled clinical trial in patients with chronic non-
malignant pain found that treatment with controlled-release codeine reduced pain as well as pain-related disability.
(ref 1)

Risks of Abuse and Dependency
studies found that all patients who developed problems with opioid use had a prior history of substance abuse
maladaptive behaviors such as stealing or forging prescriptions rarely occur in patients suspected of dependence
Terms such as addiction, misuse, overuse, abuse, and dependence have been used inconsistently to describe various
behaviors, making interpretation of many research studies difficult. Nonetheless, studies investigating the risk of opioid
abuse have been reassuring. In one study of 12,000 medical patients treated with opioids,
(ref 9)
only 4 patients without a
history of substance abuse developed dependence on the medication. Dependence, in this article, was defined as a
psychological rather than physical dependence involving a subjective sense of need for a specific psychoactive substance,
either for its positive effects or to avoid negative effects associated with its abstinence. This now is the approved definition of
the American Society of Addiction Medicine for psychological dependence.
Dependence used alone SHOULD be reserved for physiological dependence that leads to a stereotyped withdrawal
syndrome upon discontinuation of the medication, particularly in the field of pain medicine. Unfortunately, psychological
dependence is generally confused with many terms and therefore best avoided in my opinion. The psychiatric literature is
somewhat inconsistent with the substance abuse literature, e.g., the Diagnostic and Statistical Manual, edition IV, (DSM-IV)
defines substance dependence as a more serious form of substance abuse. This maladaptive pattern of substance use is
characterized by tolerance, withdrawal, overuse, craving, inability to cut down, and excessive preoccupation with respect to
obtaining the substance. Substance abuse is characterized in the DSM-IV by use leading to failure to fulfill
roles/responsibilities, use in hazardous situations, legal problems resulting from use, and use despite negative consequences.
Other studies of chronic opioid therapy found that all patients who developed problems with opioid use had a prior history
of substance abuse. Even when the diagnosis of dependence is suspected in patients taking opioids for chronic pain,
maladaptive behaviors such as stealing or forging prescriptions rarely occur.
In a study of patients attending a clinic specializing in pain management, almost 90% of patients were taking medications.
(ref
10)
Opioid analgesics were prescribed to 70% while antidepressants and benzodiazepines were being taken by only 25% and
18%, respectively. In this population, 12% met DSM-III-R criteria for substance abuse or dependence, however, the misuse
and abuse of medications was not limited to just psychoactive substances. In a review of 24 studies of drug and alcohol
dependence in patients with chronic pain, only 7 studies used standard accepted criteria for dependence and addiction. The
prevalence of dependence/addiction in these studies ranged from 3.2-18.9%.
(ref 11)
In a study of chronic low back pain patients,
34% developed a substance use disorder, and in all cases, a history of substance abuse was present before the onset of their
chronic pain.
(ref 12)
In addition, individuals with a previous history of substance abuse prior to study entry were found to be at
increased risk for recurrence during treatment for chronic pain. The mechanism of relapse back to substance abuse in these
patients is not well understood and probably involves multiple factors; however, a cycle of pain followed by relief after taking
medications is an example of operant reinforcement of their future use. Therefore, if the patient has unresolved pain and
perceives a lack of commitment to treatment by the physician, they are at high risk for relapse into substance abuse. The
best prevention of relapse comes from aggressive treatment of pain and close follow-up to monitor the patient for signs of
relapse into dependence/addiction.
Abuse harmful use of a specific psychoactive substance
Addiction continued use of a specific psychoactive substance despite physical, psychological, or social harm
Misuse any use of a prescription drug that varies from accepted medical practice
Physical dependence physiological state of adaptation to a specific psychoactive substance characterized by the emergence
of a withdrawal syndrome during abstinence, which may be relieved in total or in part by readministration of the substance
Psychological dependence subjective sense of need for a specific psychoactive substance, either for its positive effects or to
avoid negative effects associated with its abstinence
Guidelines to Minimize Risks and Optimize Benefits
Source Type of Information
Agency for Health Care Policy and Research (1992);
(ref 13)

Cancer Pain Management Guideline Panel 1994
guidelines for the treatment of acute pain and cancer pain
The Federation of State Medical Boards (1999)
(ref 14)
guidelines for the treatment of chronic pain
The American Academy of Pain Medicine and the
American Pain Society
a consensus statement: The Use of Opioids for the Treatment of
Chronic Pain
American Geriatric Society (1998)
clinical practice guidelines for the management of chronic pain
in older persons
Short Versus Long-Acting Opioids
Opioids with a short duration of analgesic activity generally create more problems than they solve. These medications must
be taken multiple times a day often interfering with the patients daily activities including sleep. But more importantly,
opioids with short duration result in serum levels of considerable variability. Analgesia is difficult to achieve and side effects
are more likely to occur. Controlled release (CR) formulations of morphine, oxycodone, and fentanyl are now available with a
hydromorphone preparation soon to be released. Multiple studies describe the more favorable pharmacokinetic and
pharmacodynamic profiles of these medications. However, a recent study comparing CR oxycodone and CR morphine found
comparable analgesia but more vomiting occurring with CR morphine and more constipation with CR oxycodone.
(ref
15)
Transdermal fentanyl is an effective analgesic with generally fewer side effects than oral medications and over 90% of
patients choosing to continue the medication after completion of a study trial. Tolerance leading to dosage escalation is
generally not a problem in the management of patients taking long-term opioids. Standard tables comparing the drugs are
not very helpful in dose conversion, which really varies particularly because of variability with chronic administration versus
use acute/post-operative settings. Street value of the various opioid drugs varies by region of the country and there is no
consistent data. In general, most addicts like to use drugs that have high potency or fast onset of action. Therefore, the
controlled release drugs like Transdermal fentanyl have the lowest abuse potential. Oral controlled release opioids like
Oxycontin can be crushed to destroy the matrix and they become the equivalent to immediate release forms.
Side Effects
The most common side effect of chronic opioid therapy is constipation secondary to decreased gastrointestinal motility.
However, concerns about potential cognitive impairment are more often the reason opioids are not prescribed, particularly
in the elderly. However, the available research has not demonstrated deleterious effects on cognition by neuropsychological
testing or electroencephalography (EEG) except in patients prescribed multiple types of medications, especially sedatives and
hypnotics. Elderly patients are more susceptible to delirium than younger patients. Although no studies have examined this
risk of delirium in chronic pain syndromes treated with opioids, post-operative patients are less likely to develop cognitive
impairment with fentanyl than morphine. A similar study found that cognitive performance was poorer in patients receiving
hydromorphone compared to those receiving morphine.
(ref 16)
Many metabolites of opioids are excreted by the kidney
increasing toxicity in the elderly. Creatinine clearance should be monitored to minimize potential toxicity.
Discontinuation of Opioid Treatment
No treatment should be continued without benefit. If treatment is unsuccessful, it should be discontinued and patients
carefully monitored to minimize physiological withdrawal symptoms such as yawning, rhinorrhea, piloerection, perspiration,
lacrimation, mydriasis, tremors, restlessness, vomiting, muscle twitches, abdominal cramps, and anxiety. The essential
element for successful opioid detoxification is the gradual tapering of the dose. Opioid withdrawal is generally not
dangerous except in patients at risk from increased sympathetic tone, such as those with increased intracranial pressure or
unstable angina. However, opioid withdrawal is very uncomfortable and distressing to patients. Tapering opioids often
results in exacerbation of the patients primary pain symptom (rebound pain). Increases in pain can occur even if the
analgesic effects of opioid therapy had not been appreciable. Although it is generally not possible to avoid discomfort
completely, the goal of detoxification is to ameliorate withdrawal.
Several non-opioid pharmacological agents are commonly used as adjunctive agents to provide patients additional relief
from withdrawal symptoms. Clonidine, an alpha-2-adrenergic agonist that decreases adrenergic activity, is commonly
prescribed. Clonidine can help relieve many of the autonomic symptoms of opioid withdrawal such as nausea, cramps,
sweating, tachycardia, and hypertension, which result from the loss of opioid suppression of the locus ceruleus during the
withdrawal syndrome. Other adjunctive agents include nonsteroidal anti-inflammatory drugs for muscle aches, Pepto-Bismol
for diarrhea, anticholinergics for abdominal cramps, and antihistamines for insomnia and restlessness.
Summary
Opioids offer an appropriate and safe treatment for some but not all patients with non-malignant chronic pain. Experimental
research and clinical experience are needed to define those patients most likely to receive specific benefits from treatment
with opioids. The benefits of treatment are now being documented in controlled trials. Potential risks, including drug abuse
and intolerable side effects mentioned above, appear to be manageable in most cases. Anyone with chronic pain who has
failed traditional treatments should be considered for a trial of chronic long acting opioids. If they have neuropathic pain,
then opioids are now worth considering as a first line choice, especially if the patient cannot tolerate antidepressants or
anticonvulsants. A recommended approach is to start low and go slow with a willingness to increase the dose until the
person becomes toxic or delirious, complains of intolerable side effects, or gets complete relief of pain. Because patients with
chronic pain suffer many consequences of their illness, any treatment with the potential to improve their symptoms should
be prescribed and the results carefully studied.




Physical Activity and the Cancer Patient
In the past, people being treated for a chronic illness (an illness a person may live with for a long time,
like cancer or diabetes) were often told by their doctor to rest and reduce their physical activity. This is
good advice if movement causes pain, rapid heart rate, or shortness of breath. But newer research has
shown that exercise is not only safe and possible during cancer treatment, but it can improve how well
you function physically and your quality of life.
Too much rest can lead to loss of body function, muscle weakness, and reduced range of motion. So
today, many cancer care teams are urging their patients to be as physically active as possible during
cancer treatment. Many people are learning about the advantages of being physically active after
treatment, too.
Ways regular exercise may help you during cancer
treatment
Keep or improve your physical abilities (how well you can use your body to do things)
Improve balance, lower risk of falls and broken bones
Keep muscles from wasting due to inactivity
Lower the risk of heart disease
Lessen the risk of osteoporosis (weak bones that are more likely to break)
Improve blood flow to your legs and lower the risk of blood clots
Make you less dependent on others for help with normal activities of daily living
Improve your self-esteem
Lower the risk of being anxious and depressed
Lessen nausea
Improve your ability to keep social contacts
Lessen symptoms of tiredness (fatigue)
Help you control your weight
Improve your quality of life
We still dont know a lot about how exercise and physical activity affect your recovery from cancer, or their
effects on the immune system. But regular moderate exercise has been found to have health benefits for
the person with cancer.
Goals of an exercise program
During treatment
There are many reasons for being physically active during cancer treatment, but each persons exercise
program should be based on whats safe and what works best for them. It should also be something you
like doing. Your exercise plan should take into account any exercise program you already follow, what
you can do now, and any physical problems or limits you have.
Certain things affect your ability to exercise, for instance:
The type and stage of cancer you have
Your cancer treatment
Your stamina (endurance), strength, and fitness level
If you exercised before treatment, you might need to exercise less than usual or at a lower intensity
during treatment. The goal is to stay as active and fit as possible. People who were very sedentary
(inactive) before cancer treatment may need to start with short, low-intensity activity, such as short slow
walks. For older people, those with cancer that has spread to the bones or osteoporosis (bone thinning),
or problems like arthritis or peripheral neuropathy (numbness in hands or feet), safety and balance are
important to reduce the risk of falls and injuries. They may need a caregiver or health professional with
them during exercise.
Some people can safely begin or maintain their own exercise program, but many will have better results
with the help of an exercise specialist, physical therapist, or exercise physiologist. Be sure to get your
doctors OK first, and be sure that the person working with you knows about your cancer diagnosis and
any limitations you have. These specially trained professionals can help you find the type of exercise
thats right and safe for you. They can also help you figure out how often and how long you should
exercise.
Whether youre just starting exercise or continuing it, your doctor should have input on tailoring an
exercise program to meet your interests and needs. Keep your cancer team informed on how youre
doing in regards to your activity level and exercise throughout your treatment.
After treatment
When you are recovering from treatment
Many side effects get better within a few weeks after cancer treatment ends, but some can last much
longer or even emerge later. Most people are able to slowly increase exercise time and intensity. What
may be a low- or moderate-intensity activity for a healthy person may seem like a high-intensity activity for
some cancer survivors. Keep in mind that moderate exercise is defined as activity that takes as much
effort as a brisk walk.
When you are living disease-free or with stable disease
During this phase, physical activity is important to your overall health and quality of life. It may even help
some people live longer. Theres some evidence that getting to and staying at a healthy weight, eating
right, and being physically active may help reduce the risk of a second cancer as well as other serious
chronic diseases. More research is needed to be sure about these possible benefits.
The American Cancer Activity recommends that cancer survivors take these actions:
Take part in regular physical activity.
Avoid inactivity and return to normal daily activities as soon as possible after diagnosis.
Aim to exercise at least 150 minutes per week.
Include strength training exercises at least 2 days per week.
A growing number of studies have looked at the impact of physical activity on cancer recurrence and
long-term survival. (Cancer recurrence is cancer that comes back after treatment.) Exercise has been
shown to improve cardiovascular fitness, muscle strength, body composition, fatigue, anxiety, depression,
self-esteem, happiness, and several quality of life factors in cancer survivors. At least 20 studies of
people with breast, colorectal, prostate, andovarian cancer have suggested that physically active cancer
survivors have a lower risk of cancer recurrence and improved survival compared with those who are
inactive. Randomized clinical trials are still needed to better define the impact of exercise on such
outcomes.
Those who are overweight or obese after treatment should limit high-calorie foods and drinks, and
increase physical activity to promote weight loss. Those who have been treated for digestive
or lung cancers may be underweight. They may need to increase their body weight to a healthier range,
but exercise and nutrition are still important. Both groups should emphasize vegetables, fruits, and whole
grains. Its well known that obesity is linked with a higher risk of developing some cancers. Its also linked
with breast cancer recurrence, and it might be related to the recurrence of other types of cancer, too.
Exercise can help you get to and stay at a healthy weight.
Living with advanced cancer
Some level of physical activity can improve quality of life for people with certain types of cancer, even if
the disease isadvanced (has spread to many places and/or is no longer responding to treatment). But this
varies by cancer type, physical ability, health problems related to the cancer or cancer treatment, and
other illnesses. The situation can also change quickly for a person with advanced cancer, and physical
activity should be based on the persons goals, abilities, and preferences.
Precautions for cancer survivors who want to exercise
During and shortly after cancer treatment
Always check with your doctor before starting any exercise program. This is especially important if your
treatments can affect your lungs (such as the drug bleomycin or radiation to the chest), your heart (such
as the drugs doxorubicinor epirubicin), or if you are at risk for lung or heart disease. Be sure you
understand what you can and cant do.
Your cancer care team will check your blood counts during your treatment. Ask them about your
results, and if its OK for you to exercise.
Do not exercise if you have a low red blood cell count (anemia).
If you have low white blood cell counts or if you take medicines that make you less able to fight
infection, stay away from public gyms and other public places until your counts are at safe levels.
Do not exercise if the level of minerals in your blood, such as sodium and potassium, are not
normal. This can happen if you have had a lot of vomiting or diarrhea.
If its OK with your doctor, drink plenty of fluids.
Do not exercise if you have unrelieved pain, nausea/vomiting, or any other symptom that causes
you concern. Call your doctor.
Do not exercise above a moderate level of exertion without talking with your doctor first. Remember,
moderate exertion is about as much effort as a brisk walk.
If you have a catheter or feeding tube, avoid pool, lake, or ocean water and other exposures that
may causeinfections. Also, do not do resistance training that uses muscles in the area of the
catheter to keep from dislodging it. Talk with your cancer team about whats safe for you.
To avoid skin irritation, people getting radiation should not expose skin in the treatment area to the
chlorine in swimming pools.
If you feel very tired and dont feel up to exercising you can try doing 10 minutes of light exercises
every day. (Later we will discuss fatigue and exercise in more detail.)
Stay away from uneven surfaces or any weight-bearing exercises that could cause you to fall and
hurt yourself.
Do not use heavy weights or do exercise that puts too much stress on your bones if you have
osteoporosis, cancer that has spread to the bone, arthritis, nerve damage, poor vision, poor
balance, or weakness. You may be more likely to hurt yourself or break a bone.
If you have numbness in your feet or problems with balance, you are at higher risk for falls. You
might do better with a stationary reclining bicycle, for example, than a treadmill.
Watch for swollen ankles, unexplained weight gain, or shortness of breath while at rest or with a
small amount of activity. Let your doctor know if you have any of these problems.
Watch for bleeding, especially if you are taking blood thinners. Avoid any activity that puts you at
risk for falls or injury. If you notice swelling, pain, dizziness, or blurred vision, call your doctor right
away.
Things to think about when planning an exercise program
Talk to your doctor before you start any type of exercise.
Start slowly. Even if you can only do an activity for a few minutes a day it will help you. How often
and how long you do a simple activity like walking can be increased slowly. Your muscles will tell
you when you need to slow down and rest.
Try short periods of exercise with frequent rest breaks. For example, walk briskly for a few minutes,
slow down, and walk briskly again, until you have done 30 minutes of brisk activity. You can divide
the activity into three 10-minute sessions, if you need to. Youll still get the benefit of the exercise.
Try to include physical activity that uses large muscle groups such as your thighs, abdomen (belly),
chest, and back. Strength, flexibility, and aerobic fitness are all important parts of a good exercise
program.
Try to include some exercises that will help you keep lean muscle mass and bone strength, like
exercising with a resistance band or light weights.
You might want to include exercises that will increase your flexibility and keep the range of motion in
your joints.
Always start with warm-up exercises for about 2 to 3 minutes. Examples of warm-up exercises are
shoulder shrugs, lifting arms overhead, toe tapping, marching, and knee lifts. End your session with
stretching or flexibility exercises. Hold a stretch for about 15 to 30 seconds and relax. Remember to
breathe when you stretch. Examples of stretching are reaching overhead, deep breathing, and
bending over to touch your toes so that you relax all the muscle groups.
Exercise as you are able. Dont push yourself while you are in treatment. Listen to your body and
rest when you need to.
Cancer and fatigue: When you feel too tired to exercise
Most people with cancer notice that they have a lot less energy. During chemotherapy and radiation, most
patients have fatigue. Fatigue is when your body and brain feel tired. This tiredness does not get better
with rest. For many, fatigue is severe and limits their activity. But inactivity leads to muscle wasting and
loss of function.
An aerobic training program can help break this cycle. In research studies, regular exercise has been
linked to reduced fatigue. Its also linked to being able to do normal daily activities without major
problems. An aerobic exercise program can be prescribed as treatment for fatigue in cancer patients.
Talk with your doctor about this.
Tips to reduce fatigue:
Set up a daily routine that lets you be active when you feel your best.
Get regular, light-to-moderate intensity exercise.
Get fresh air.
Unless you are told otherwise, eat a balanced diet that includes protein (meat, milk, eggs, and
legumes such as peas or beans).
Drink about 8 to 10 glasses of water a day unless your doctor tells you not to. Even more fluids are
needed to prevent dehydration if youre exercising intensely, sweating, or in a hot environment.
Control your symptoms, like pain, nausea, or depression.
Keep things you use often within easy reach to save energy.
Enjoy your hobbies and other activities that give you pleasure.
Use relaxation and visualization techniques to reduce stress.
Balance activity with rest that does not interfere with nighttime sleep.
Ask for help when you need it.
Effective exercise
To make your exercise effort most effective (give you the best results), its important that you work your
heart. Notice your heart rate, your breathing, and how tired your muscles get. If you get short of breath or
very tired, rest for a few seconds, and start exercising again as you are able. When you first start, the
goal is to exercise for at least 10 minutes at a time. Go slow at first, and over the next few weeks,
increase the length of time you exercise. Be careful if youre taking blood pressure medicine that controls
your heart rate. Your heart rate will not go up, but your blood pressure can get high. Ask your doctor,
nurse, or pharmacist about this if youre not sure about your medicines.
We dont know the best level of exercise for someone with cancer. The goal is to have your exercise
program help you keep up your muscle strength and keep you able to do the things you want and need to
do. The more you exercise, the better youll be able to exercise and function. But even if planned exercise
stops, its good to keep being active by doing your normal activities as much as you can.
Keep exercise easy and fun
The key is to keep your exercise program simple and fun. Exercise and relaxation techniques are great
ways to relieve stress. Reducing stress is an important part of getting well and staying well.
Tips to help you stick to your exercise program
Set short-term and long-term goals.
Focus on having fun.
Do something different to keep it fresh. Try yoga, dancing, or tai chi.
Ask for support from others, or get friends, family, and co-workers to exercise with you.
Use charts to record your exercise progress.
Recognize and reward your achievements.
Starting an exercise program can be a big task, even for a healthy person. It may be even harder for you
if you have a chronic illness, especially if you werent used to exercising before your diagnosis. Start
slowly and build up as you are able. If you were exercising regularly before you were diagnosed with
cancer, you may need to reduce the intensity and length of your exercise sessions.
Let exercise provide you with its benefits. Remember, exercise helps:
Prevent muscle wasting
Reduce treatment side effects
Improve your fitness
Improve your quality of life
Add physical activity to your daily routine
Here are some ways to add physical activity to the things you do every day. Remember, only do what you
feel up to doing.
Walk around your neighborhood after dinner.
Ride your bike.
Mow the grass, or rake the leaves instead of using a blower.
Scrub your bathroom.
Wash and wax your car.
Play active games with kids, like freeze tag, jump rope, and the games you played when you were a
kid.
Walk a dog (one that can be controlled so that you dont trip or get pulled off balance).
Weed your garden.
Take a friend dancing, or dance in your own living room.
Use an exercise bike or treadmill, or do arm curls, squats, lunges, and crunches while watching TV.
Walk to lunch.
Park your car in the farthest parking space at work and walk to the building.
Use the stairs instead of the elevator or escalator.
Get off the bus several stops early and walk the rest of the way to work.
Make appointments for yourself in your daily planner for 10-minute walking breaks.
Form a walking club of co-workers to help you stay motivated to walk during the workday.
Wear a pedometer every day and try to increase your daily steps.
Cancer survivors may need to exercise less intensely and increase their workout at a slower rate than
people who havent had cancer. Remember, the goal is to keep up as much activity as possible. Keep it
safe, keep it fun, and make it work for you.
Surviving cancer and making it through cancer treatment are major accomplishments.
Most, if not all, survivors find a new priority in life: keeping cancer from returning. The
latest research suggests thatexercise for cancer patients may help.
If you've made it through the rough road of cancer diagnosis and treatment, you're
probably thinking about what you can do to stay healthy. But just what is the best way to
get fit, and maximize your long-term health? WebMD talked to the experts about the
best exercise for cancer patients after treatment.
Exercise for Cancer Patients: Longer Life, Less Recurrence
There's abundant evidence that exercise and eating right can help prevent people from
getting cancer. The latest information shows that exercise for cancer patients can also
keep cancer from recurring.
"Several recent studies suggest that higher levels of physical activity are associated
with a reduced risk of the cancer coming back, and a longer survival after a cancer
diagnosis," said Kerry Courneya, PhD, professor and Canada Research Chair in
Physical Activity and Cancer at the University of Alberta in Edmonton, Canada.
In studies of several different cancers, being overweight after completing treatment was
associated with shorter survival times and higher risk of cancer recurrence.
Women who exercise after completing breast cancer treatment live longer and have
less recurrence, according to recent evidence.Colorectal cancer survivors who
exercised lived longer than those who didn't, two recent clinical trials showed.
"Clearly, any cancer survivor wants to do all they can" to prevent cancer recurrence,
says Colleen Doyle, MS, RD, director of nutrition and physical activity for the American
Cancer Society. "Surely some of their goals for healthy living should be around weight
control" and exercise, she adds.
What experts suspected has now been proven. As a cancer survivor, exercising could
help you live a longer life -- free from cancer.
Exercise for Cancer Patients: What's In It For Me?
The benefits of exercise for the general population are well-publicized. But what if you're
a cancer patient?
"Exercise has many of the same benefits for cancer survivors as it does for other
adults," says Courneya. Some of these benefits include an increased level of fitness,
greater muscle strength, leaner body mass, and less weight gain.
In other words, exercise for cancer patients can make you fitter, stronger, and thinner --
like anyone else who exercises.
Exercise can also:
Improve mood.
Boost self-confidence.
Reduce fatigue.
Lower your risk of cardiovascular disease and diabetes.
Exercise for Cancer Patients: What to Do
Every person's situation is different. Before starting a moderate to vigorous exercise
program, see your doctor.
The following types of exercise can help cancer patients - and everyone else - get back
in shape:
Flexibility exercises (stretching). Virtually everyone can do flexibility exercises.
"Stretching is important to keep moving, to maintain mobility," says Doyle. If you're not
yet ready for more vigorous exercise, you should at least stay flexible.
Aerobic exercise, such as brisk walking, jogging, and swimming. This kind of exercise
burns calories and helps you lose weight. Aerobic exercise also builds cardiovascular
fitness, which lowers the risk of heart attack, stroke, and diabetes.
Resistance training (Iifting weights or isometric exercise), which builds muscle. Many
people lose muscle, but gain fat, through cancer treatment. For those with a high fat-to-
lean mass ratio, "resistance training can be especially helpful," says Doyle.
"Ideally, cancer survivors should do aerobic exercises and weight training," says
Courneya. "Both types of exercise are critical to the overall health and well-being of
cancer survivors."
An exercise specialist can help design the right program for you. Seek someone
certified by the American College of Sports Medicine.
Exercise for Cancer Patients: How Much and How Hard?
For the general population, the American Cancer Society recommends "at least 30 to 60
minutes of moderate to vigorous physical activity at least 5 days a week."
This amount of exercise is proven to reduce the risk of cancer, cardiovascular disease,
and diabetes. Experts say it that it should also be beneficial for cancer patients.
Unless you're already very active, though, you shouldn't expect yourself to achieve this
right away. As with anything else, the key is to set small, achievable goals and build on
your successes.
"If you've already been active -- keep it up!" says Doyle. "If you haven't been active,
start slowly, but start something."
Try to find an activity you enjoy. You may want to buddy up with someone at the same
fitness level. Having a friend to work out with will increase your motivation.
Exercise for Cancer Patients: What to Watch Out For
Are there any downsides to exercise for cancer patients?
"The risks for cancer survivors are not too different from the general population," says
Courneya. Musculoskeletal injuries--soreness, strains and sprains-are the most
common.
Exercise for cancer patients may carry a slightly higher risk for heart problems. It is
always a good idea to have a complete physical exam and get approval from your
oncologists before starting a moderate-to-vigorous exercise program, Courneya adds.
You didn't make it through chemo just to end up on the couch. Get together with your
doctor, get an exercise program, and get moving!
Cancer Care Physical Therapy
Cancer and its treatment can cause debilitating side effects for patients, compromising their function and quality of life.
Fortunately, research has shown that physical therapy during and after cancer treatment can help speed functional recovery, boost
immune response, reduce fatigue and reduce risk of complications in people of any age.

Patients undergoing cancer treatment may experience one or more of the following side effects:
Pain
Decreased muscle strength
Decreased bone density
Peripheral neuropathy related to chemotherapy
Fatigue
Lymphedema or swelling disorders
Difficulty walking
Difficulty sleeping
Formation of scar tissue
Postural changes
Muscle imbalances
In conjunction with your medical team, the physical therapist works with patients and caregivers to maximize their
physical abilities and comfort levels to ensure the most effective recovery. Your cancer care physical therapist can
help maximize strength and function during and after cancer treatment by addressing each of these issues through
hands-on therapy, education and exercise to increase your function and independence.

Read more about...
Importance of Physical Therapy During Cancer Treatment
Individual Assessment
Importance of Physical Therapy During Cancer Treatment
Maintaining strength during cancer treatments helps to prevent or reduce the risk of complications, such as infection, as well as to
enhance quality of life. Physical therapy helps patients and their caregivers regain a sense of hope and control over their health by
teaching proper and safe exercise to rebuild function, endurance, and muscle and bone strength. Even a small amount of exercise
can help patients decrease side effects and provide benefits such as decreased anxiety and an increased sense of control.

Comprehensive cancer institutes throughout the United States as well as the National Cancer Care Survivorship (NCCS) endorse
exercise for cancer patients.
Back to top
Individual Assessment
Your cancer care physical therapist can provide individualized physical assessment and treatment for the following:
Weakness secondary to disease, treatment or muscle atrophy
Limited flexibility/range of motion
Fatigue/decreased endurance
Pain management
Impaired balance
Decreased cardiovascular fitness/deconditioning secondary to cancer and its treatment
Scar tissue management after surgery
Osteoporosis/Osteopenia
Peripheral neuropathy -- numbness/tingling/decreased balance or walking