Sharon A Stephen, PhD, ARNP, ACHPN

September 23, 2014

` Case-based presentation selected to discuss:

◦ Pain assessment ◦ Barriers to adequate pain relief ◦ Pharmacologic interventions ◦ Non-Pharmacologic interventions ◦ Role of the oncology nurse

` Primary aim is to treat the underlying cause of the pain, the cancer

` In addition, always treat the pain itself ` Marilyn Birchman 2012

CAREGIVER DISTRESS

PHYSICAL EMOTIONAL SOCIAL SPIRITUAL

` Subjective sensation ◦ Pain is whatever the person says it is when they

experience it (Pasero & McCaffery, 2011) ◦ Unpleasant ◦ Both a sensory & emotional experience

Nociceptive ` Sources: organs, bone, joint,

muscle, skin, connective tissue ` Examples: arthritis, tumors,

gall stones, muscle strain ` Character: dull, aching,

pressure, tender ` Responds to traditional pain

medicines & therapies

Neuropathic ` Source: peripheral nerve or

CNS pathology ` Examples: postherpetic

neuralgia, diabetic neuropathy, spinal stenosis

` Character: shooting, burning, electric shock, tingling

` Requires different types of medications than nociceptive pain

E N E C Core Curriculum L

Goals of Pain Assessment Determine pain diagnosis • Etiology of pain • Nociceptive or neuropathic pain • Acute, chronic, acute on chronic • Response to pain interventions

` Comprehensive (OLDCART) ` Precise location(s) & pattern

of radiation ` Intensity ` Quality of pain (characteristic) ` Effect of treatment ` Impact on function ` Seek out symptoms clusters

(insomnia, fatigue, anxiety, depression)

` Allodynia

` Hyperalgesia

` Tolerance

E N E C Core Curriculum L

Barriers to Pain Relief

• Importance of discussing barriers • Specific barriers

– Professionals – Health care systems – Risk Evaluation and Mitigation

Strategy (REMS) – Patients/families

Paice, 2010; Pasero & McCaffery, 2011

E N E C Core Curriculum L

Sound Familiar? A Case Study Patient History

• Max, 37-year-old male with metastatic colorectal cancer

• Iraqi War Veteran- lost his leg in combat

• Married with 2 children • Oncologist is anxious to

start chemotherapy • No discussion by the

surgeon or oncologist about “goals  of  care”

Issues Related to Pain • Incisional pain poorly

managed • Stump phantom pain has

never been addressed • Patient is afraid of

“narcotics”  addiction • Wife is afraid he will

become tolerant of drugs • Surgeon is sending him

home with oxycodone and lorazepam

E N E C Core Curriculum L

Stop and Consider: Providing Care for Max • Is Max a candidate for palliative care? • What  are  the  barriers  regarding  Max’s  pain  relief? • Are there culture issues related to him being a Veteran? • Is there an ethical issue regarding poor pain management? • Are  there  additional  medications  Max’s  should  be  instructed  to  take? • How could his diagnosis + pain issues affect him physiologically, and

spiritually? • Are  you  comfortable  sending  him  home  with  a  pain  score  of  “8”?

` 56 y/o female with metastatic bladder cancer

` C/o persistent back pain ` New patient visit for

treatment planning ` Ambulatory but function

limited by pain, fatigue & weakness

` Depressed ` Poor social support ` Unemployed CNA

` Previous experience with pain medication ` What medications? ` What doses? ` Efficacy? ` Side effects? ` Attitudes?

Step 1: Non-opioids Step 2: Opioids +/- Non-opioids Step 3: Opioids +/- Adjuvants +/- Non-

opioids AGS, 2009; APS, 2008;

Pasero & McCaffery, 2010; Paice, 2010

` For mild to moderate pain ` Best for nociceptive pain ` Dosing ` Scheduled dose for continuous pain ` Watch out for APAP in combination

products AGS, 2009

` Inflammation (Bone pain) ` Effective for mild to moderate pain ` Caution in renal, hepatic, gastric,

cardiovascular problems ` Risk of adverse events (GI bleeding)

increases with age

AGS, 2009; Paice, 2010

` Effective for pain regardless of pathophysiology

` Safe for older adults when carefully initiated & titrated; start low, go slow

` Many routes; oral route best for

most effective pain relief

AGS, 2009; Paice, 2010

` Sedation ` Nausea and vomiting ` Constipation ` Urinary retention ` Confusion ` Dysphoria, hallucinations ` Myoclonus (rare, on low doses) ` Respiratory depression (rare)

` Does not go away with time ` Nearly universal side effect of opioids &

other analgesics ` Prevention is essential ` Laxative needs to be scheduled

` Methods for switching from one opioid to another or administration routes (po to IV)

` Use of equianalgesic tables is necessary ` Double check calculation with PharmD or

RN ` Keep in mind the issue of “incomplete

cross-tolerance” ` Reduce dose by 30-50% when changing

drugs

` Sustained release medications ` Immediate release for breakthrough pain ` Distinguish types of breakthrough pain

` Medications developed and marketed for another medical condition (e.g., depression) but found also to be effective for pain

` Target neuropathic pain

` Anticonvulsants ` Antidepressants ` Local anesthetics ` Corticosteroids

` Minimal systemic side effects ` Indicated for neuropathic pain but can be

effective in musculoskeletal pain as well ` Lidocaine gel, EMLA® & Lidoderm©

` Intra-articular steroid injections

` Epidural steroid injections ` Neurolytic blocks ` Neuroablative procedures

Eisenberg, 1995; Furlan, 2001; Wong et al, 2004

` Radiation therapy

` Palliative surgery

` Chemotherapy

` Physical treatments ◦ (heat, cold, exercise, TENS)

` Integrative treatments ◦ Massage therapy ◦ Music ◦ Acupuncture

` Cognitive/psychological interventions ◦ Hypnosis ◦ Imagery ◦ Support groups ◦ Redirecting thinking/distraction

◦ NCI www.cancer.gov Pain (PDQ)

` Pain relief is contingent on adequate assessment & use of both drug & nondrug therapies

` Pain extends beyond physical causes to other causes of suffering & existential distress

` Interdisciplinary team crucial in chronic and/or refractory pain

` 7 tips for managing cancer pain ◦ Control pain before it becomes severe ◦ Patients should seek out the best pain relief ◦ Quantify your pain ◦ Call your nurse or doctor about pain ◦ Remember that you have many treatment options ◦ Do not let fear of addiction prevent you from taking

medication to manage pain ◦ Follow directions when taking pain medications

◦ BettyFerrellPhD (2014) City of Hope Breakthroughs. Accessed using Twitter

` McPherson, M.L. (2010). Demystifying opioid

conversion calculations: A guide for effective dosing. Bethesda, MD:ASHP.

` NCCN Guidelines, Adult Cancer Pain. ` http://www.nccn.org

` Pain Resource Center (prc.coh.org) ` Pasero & McCaffery (2011). Pain assessment &

pharmacologic management. Elsevier Mosby ` UpToDate. Assessment of cancer pain, updated 7/10/2014

` http://www.uptodate.com/contents

` The End-of-Life Nursing Education Consortium (ELNEC) Project is a national end-of-life educational program administered by City of Hope National Medical Center (COH) and the American Association of Colleges of Nursing (AACN) designed to enhance palliative care in nursing. The ELNEC Project was originally funded by a grant from the Robert Wood Johnson Foundation with additional support from funding organizations (the National Cancer Institute, Aetna Foundation, Archstone Foundation, and California HealthCare Foundation). Materials are copyrighted by COH and AACN and are used with permission. Further information about the ELNEC Project can be found at www.aacn.nche.edu/ELNEC.