What is pain? How do you describe pain?
According to the Registered Nurses’ Association of Ontario, “Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such tissue damage” (IASP, as cited in RNAO, 2013).
McCaffery states that “Pain is whatever the experiencing person says it is, existing whenever he/she says it does” (McCaffery as cited in Herr et al., 2011).
When considering a patient’s pain, it is crucial to consider more than the physical pain but also consider the psychological pain, social and spiritual pain as well. Assessing our patients using the total pain concepts permits us to understand the patient and as a Nurse apply a holistic approach in addressing the pain experienced.
It is estimated that more than 80% of people with advanced cancer will experience pain. 66% of these individuals will experience moderate to severe pain. 60% will experience pain at more than one site. Murray (2016) maintains that the actual prevalence of pain is probably higher because some people do not report their pain. So, this is in reality just the tip of the iceberg so to speak.
There are a number of populations that are at risk of having their pain undertreated. These include:
- Children and the elderly
- People who are nonverbal or cognitively impaired
- People who deny pain for personal reasons
- People who are unable to communicate their pain or have difficulty doing so due to a language barrier
- People who, because of their culture, traditions, are discouraged from talking about, expressing, or managing pain
- And last but not least, people with a history of addiction.
Pain assessment is multidimensional and how important using the total pain concept in assessing the patient’s pain is so important. We also need to consider the following factors as these will impact on how the patient perceives his/her pain. Factors include:
- Religious beliefs – in some religions, embracing pain can be a way to repent for one’s sins and a way to get into heaven after one die
- Emotional status – if someone is afflicted with mental health illnesses – this will definitely impact on their perception of pain
- Culture (customs, ways of life, background, traditions) – some cultural beliefs or ways of life encourage being brave and enduring the pain. Think about being brought up whereby you were told repeatedly “suck it up buttercup” and told “don’t be a baby” when you were hurt or had pain. Being told repeatedly to “suck it up buttercup” or “don’t be a baby” will definitely impact how a person reacts to their pain. They may become very stoic and not show their pain or even tell you about for fear of being judged.
- Spiritual beliefs – For some people, having strong spiritual beliefs to help them cope with their pain will impact as well on how they respond to pain management and which interventions they might be willing to consider to managing their pain.
- Tolerance level – everyone is different and will have a different tolerance level when it comes to pain.
- Age and gender – depending on how old your patient is and whether they are male, or female will also impact on how the patient responds to pain.
- Anxiety and/or fear – anxiety and/or fear of experiencing pain will definitely impact on how the patient responds to pain.
- And lastly, wanting to be a good patient – if the patient believes that complaining of having pain equates being a demanding patient, they may withhold that information for fear of being judged as being “bad patients”.
So, as you can see, it is important for us Nurses to explore these factors and consider them as we consider promoting a holistic approach to manage the patient’s pain.
Everyone has misconceptions and/or fears when it comes to pain. Let’s look at some of the most common fears and facts that you will undoubtedly encounter and need to address.
- Cancer causes intolerable pain, which cannot be relieved. The reality is that cancer pain can be managed.
- Becoming addicted. The fact is that only 1 in 10,000 patients who take opioids to treat their pain will become addicted.
- Becoming tolerant to opioids. Opioid dose can be adjusted as much as needed and alternative medications are available.
- Unpleasant side-effects from opioids. Side-effects usually go away within a few days and simple treatments can control nausea and constipation.
- Not being a good patient. Being honest with the health care providers and informing them of the pain level is not considered being a bad patient but rather a good patient. The goal for the palliative care team is to help the patient achieve an improved quality of life and managing the patient’s pain is very important to achieve this goal.
- Talking about pain will distract the doctor from working to treat cancer. Fact is, talking about pain with the doctor will not distract him/her from working to treat cancer but rather will help them determine what treatment modalities might be most appropriate to treat the cancer. For example, if a cancer treatment is causing the patient such severe pain, why continue the treatment? Talking to the doctor about the pain, will permit the doctor to consider other treatment plans that may be just as effective and less painful for the patient.
- Cancer is getting worse. Sometimes the pain is unrelated to the cancer.
- Fear of injections. At least 90% of cancer pain can be effectively relieved by oral medications.
TYPES OF PHYSICAL PAIN
Neuropathic pain: Pain associated with peripheral nerve damage or dysfunction. It is often described as tingling, burning, cold, pins and needles, and/or electric shock-like. Pain is experienced in the areas of the body covered by the sensory function of the affected nerves.
Nociceptive pain: Pain arising from the stimulation of pain receptors within inflamed or damaged body tissue. This pain classification is further subdivided as either somatic pain or visceral pain.
Somatic pain: Pain in the skin, muscle, or bone. This type of pain may be described as throbbing, stabbing, aching, or pressure-like (e.g., bone fracture). Somatic pain is generally experienced in the location of tissue damage.
Visceral pain: Pain originating in the body’s organs. It may be described as aching, cramping, or sharp (e.g., liver capsular pain). Visceral pain may be referred to undamaged areas in non-dermatomal patterns.
Incident pain: Pain immediately following a movement or action such as weight bearing, defecation, breathing or coughing. It may be predictable or unpredictable depending on the cause.
Breakthrough pain: Transient exacerbation of regularly controlled pain that “breaks through” or is not alleviated by an individual’s regularly scheduled (and normally effective) pain medications.
Breakthrough pain is a temporary exacerbation of pain that occurs despite adequately controlled background pain. Pain episodes occurring without background pain or with poorly controlled background pain. Pain episodes occurring without background pain or with poorly controlled background pain cannot be classified as breakthrough pain.
The classical description of breakthrough pain includes rapid onset, short duration, moderate-to-severe intensity, and frequent occurrence. Although breakthrough pain can last up to 60 minutes, the typical duration of an episode is 15-30 minutes.
Another important distinguishing characteristic of breakthrough pain is its rapid onset, with escalation to maximum intensity in as little as 1 minute.
Approximately 50% of breakthrough pain episodes are precipitated by a voluntary or involuntary event. Pre-existing conditions or those that arise independently of cancer (arthritis, migraine) are recognized as a source of pain in 3%-10% of cancer patients.
Approximately 60% of cancer patients in Canada experience breakthrough pain, which significantly affects quality of life, daily activities, and psychological well-being, because the intensity of pain is often associated with the severity of the disease.
Typically, when someone is experiencing pain, we might observe the following physiological responses such as:
- ↑ heart rate
- ↑ respiratory rate
- ↑ blood pressure
- Pallor or flushing
- Dilated pupils
- Diaphoresis
- ↑ blood sugar
- ↓ gastric acid secretion and motility
- ↓ blood flow to the viscera and the skin
PAIN ASSESSMENT
Pain assessment must be completed at each admission to a new facility or each visit with the health care provider. It should also be repeated after a change in medical status and prior to, during and after a procedure.
This will include a physical assessment as well as a symptom assessment.
- Vital signs should be assessed if clinically indicated.
- Take current weight and compare to pre-treatment or last recorded with as indicated.
- Observe general appearance. Also observe painful areas for signs of infection, trauma, skin breakdown, and changes in bony structure. Observe facial features and note any grimacing. It is also important to assess posture, gait, affect, and note any guarding.
- Assess patient functional status using the Palliative Performance Scale (PPS).
- It is important to acknowledge that cognitive impairment and age-related factors may impair the patient’s ability to express pain. These factors do not decrease the ability to feel pain. Therefore, objective cues and observation is critical.
The Edmonton Symptom Assessment System revised version (ESAS-r) is a valid and reliable screening tool which can be used to identify a patient’s pain level on a scale of 0-10 (Cancer Care Ontario, 2018).
One of the other tools that is recommended and which we will also be using quite a bit is the OPQRSTUV tool. This tool is extremely comprehensive and provides you with prompts on the types of questions you can ask to assess your patient’s pain. The tool has also been adapted to assess other palliative symptoms.
- When looking at this tool you will be asking questions about the onset of the symptom
- What is provoking the symptom, what makes it better
- What is the quality … in other words ask the patient to tell you what it feels like
- (Radiating); where is the pain located
- Whether it spreads anywhere else; how severe is the pain; what is the timing of the pain – does it come and go, is it constant, is it worse at any particular time.
- What treatments the patient has used to alleviate the pain and whether these were effective or not and if the patient had any side effects from these interventions
- Ask questions about what the patient thinks is causing the pain, if there are any other symptoms with the pain and how is the pain impacting the patient and his/her family. When you are asking about values, what you are really wanting to understand is what is the patient’s goal for this pain? What is the comfort goal or acceptable level of pain? This is also a great opportunity to ask questions about their cultural, personal and spiritual values or beliefs as they relate to pain.
The Abbey Pain Scale is typically used for non-verbal patients. If using this scale, you would simply observe the patient and score according to your observations. You would be assessing vocalization, facial expression, change in body language, behavioural changes, physiological changes and physical changes. This tool is typically used in long-term care facilities and most particularly for patients with dementia.
The FLACC scale can be used for children who are between 2 months and 7 years of age or with individuals who are unable to communicate their pain.
For patients who are awake:
- Observe for at least 2-5 minutes.
- Observe legs and body uncovered.
- You may need to reposition patient or observe activity; assess body for tenseness and tone.
- You would initiate consoling interventions if needed.
If the patient is asleep:
- You would observe for at least 5 minutes or longer.
- Again, you would observe body and legs uncovered.
- If possible, you may need to reposition the patient.
- You would touch the body and assess for tenseness and tone
The Wong Baker FACES Scale can be used for any patient over the age of 3.
The Pain Assessment in Advanced Dementia Scale (PAINAD) is a particular useful tool when assessing pain for patients with dementia. This particular tool considers breathing, negative vocalization, facial expressions, body language and the ability to be consoled.
The World Health Organization (WHO) has recommended the following pain relief ladder to effectively manage pain. This particular ladder has been modified specifically for cancer pain.
- When a patient presents with complaints of pain, the practitioner would recommend a non-opioid with or without an adjuvant medication.
- If the pain persists or increases, the practitioner will then prescribe an opioid for mild or moderate pain along with or without a non-opioid and with or without an adjuvant medication.
- Should the patient’s pain persist or continues to increase in severity, the practitioner would then prescribe an opioid for moderate to severe pain with or without a non-opioid and with or without an adjuvant medication.
- If these pharmacological interventions are not effective in managing the patient’s pain, the practitioner would then consider interventional measures such as somatic or sympathetic blocks; spinal medications; spinal cord stimulator, or surgical.
- The ultimate goal is to provide freedom of pain for the patient.
All patients being considered for opioid therapy should be evaluated for substance use disorder.
Treatment with an opioid analgesic is not contraindicated in a patient with a history of substance use disorder but requires a comprehensive treatment plan. Integrate non-pharmacological treatments and adjuvant analgesics concurrent with analgesics for all levels of pain: mild, moderate or severe. Treatment choices are guided by pain intensity on a scale with 0-10 with 0 being none and 10 being the worst possible; however, when pain is expected to worsen, choosing from options for more intense pain may avoid a future medication switch.
As it relates to initiation of analgesics:
- START LOW – Start with low doses, especially with impaired renal or liver function and in the elderly.
- GO SLOW – Titrate doses gradually to analgesic response or until patient experiences unacceptable side effects. (See titration section below). May begin with less frequent dosing (e.g., q6h instead of q4h).
- BY MOUTH – While the oral route is most common as the safest and least invasive administration method, other routes (IV, subcutaneous, rectal, transdermal, transmucosal) can be used as indicated to maximize patient comfort.
- BY THE CLOCK – Regular/fixed administration schedule, such as every 4 or 6 hours, rather than only “on demand”, including waking from sleep for a scheduled dose. Once pain control achieved, switch to long-acting agents to improve compliance and sleep.
- PLAN FOR ADVERSE EFFECTS – Anticipate, monitor and manage analgesic adverse effects, including starting laxatives proactively.
- PLAN FOR BREAKTHROUGH PAIN – When starting an opioid, use immediate release with breakthrough doses (BTD) until dose is stabilized to enable timely and effective titration.
Consulting with qualified specialists such as pain specialists, oncologists, orthopedics, and/or anesthesiologists when we encounter the following situations:
- For unrelieved pain. Pain should improve on titration within 72 hours.
- For rapidly escalating pain, not responding to opioid titration, to point of concern or suffering.
- Specific situations such as: unmanageable adverse effects, toxicity, special patient populations (e.g., moderate to severe renal or liver impairment), safety concerns, substance abuse).
- Use of methadone, ketamine, lidocaine, or interventional treatment strategies.
ADVERSE EFFECTS OF OPIOIDS
The main adverse effects from taking an opioid include:
- Constipation: common side-effect; need to rule out obstruction and/or impaction before proceeding with bowel protocol.
- Nausea/vomiting: common side-effect; usually mild and temporary when first starting opioid. May need an antiemetic (e.g., metoclopramide) during the first week of opioid initiation.
- Sedation: common side-effect; usually temporary (2-4 days) when first starting or increasing opioid doses. Inform patient that it could be a matter of catching up on lost sleep due to pain. If continues, assess for other causes and consider lower dose or opioid rotation.
- Respiratory depression: very uncommon as pain serves as a stimulus, so keeps patient awake. If unable to rouse, call 911.
- Myoclonus: may occur with any dose and any route of opioid (usually high doses of opioids); possible opioid-induced neurotoxicity (especially in elderly), assess electrolytes and renal function. May precede hallucinations, agitation, delirium, and possible seizures. Patient needs assessment with doctor with possible opioid rotation or dose reduction.
- Urinary retention: usually temporary and passes within a week. Ensure constipation is not a contributing factor. Urinary retention is more common in men with prostatic hypertrophy, or those with pelvic tumors.
- Pruritus: rare; consider opioid rotation or reduction. May need an antihistamine or dose reduction.
- Reduced libido: long-term opioid therapy may suppress testosterone levels.
- Delirium: consider opioid rotation.
Acetaminophen:
Acetaminophen has analgesic and antipyretic, but not anti-inflammatory properties. Significant adverse effects of acetaminophen, particularly hepatic toxicity, and possibly renal impairment.
Due to concerns about liver toxicity, the National Comprehensive Cancer Network (NCCN) panel advises that acetaminophen should be used with caution or not used at all with combination opioid-acetaminophen products to prevent excess acetaminophen dosing.
NSAIDs
- NSAIDs produce analgesia by blocking the biosynthesis of prostaglandins which are the inflammatory mediators that initiate, cause, intensify, or maintain pain.
- History of peptic ulcer disease or gastrointestinal bleeding, advanced age (> 60 years of age), male gender, and concurrent corticosteroid or anticoagulant therapy should be considered before NSAID administration to prevent upper GI tract bleeding and perforation. What we must also remember is the risk of GI bleeding is increased in patients with untreated H. pylori infection and with chronic, rather than short-term, use of NSAIDs.
- NSAIDs should be prescribed with caution in patients older than 60 years of age or in those with compromised fluid status, renal insufficiency, concomitant administration of other nephrotoxic drugs, and renally excreted chemotherapy to prevent renal toxicities.
- In patients at high risk for cardiac toxicities such as those with a history of cardiovascular disease or at risk for cardiovascular disease or complications, NSAIDs should be discontinued if congestive heart failure or hypertension develops or worsens.
- NSAIDs taken with prescribed anticoagulants, such as warfarin or heparin, may significantly increase the risk of bleeding complications. Topical NSAIDs such as diclofenac gel or patch may be useful in this population.
METHADONE
- Due to its long half-life, high potency, and interindividual variations in pharmacokinetics, methadone, when indicated, should be started by or in consultation with an experienced pain or palliative care specialist.
- Because the starting dose may need to be titrated up, it is essential to provide the patient with access to adequate, short acting, breakthrough pain medications during the titration period.
- It is also crucial that monitor for drug accumulation and adverse effects, particularly for the first 4 to 7 days. It is important to remember and remind the patient that a steady state may not be reached for several days to 2 weeks.
- It is also important to know that high doses of methadone (120 mg and above) may lead to QTc prolongation and torsade’s de pointes, which may lead to sudden cardiac death.
- Baseline and follow-up electrocardiograms (ECGs) for patients treated with methadone is highly recommended.
- Patients and their families may need to be educated about analgesic utility of methadone.
- Some may only be familiar with methadone use for maintenance of addiction and be unaware of its utility as a potent opioid analgesic.
- Patients and caregivers should be educated on the signs of delayed sedation and respiratory depression that may occur 4 to 7 days or longer after initiation of methadone or after titrating the dosage upwards.
Pure Agonists:
- Such as morphine, oxycodone, oxymorphone, and fentanyl, are the most commonly used medications in the management of cancer pain.
- The short half-life these opioids are preferred because they can be more easily titrated than the long half-life opioids such as methadone and levorphanol.
- However, morphine, hydromorphone, hydrocodone, oxymorphone and codeine should be used with caution in patients with fluctuating renal function due to potential accumulation of renally cleared metabolites that may cause neurologic toxicities.
MORPHINE
- For morphine, oral administration is the preferred route.
- An initial dose of 5 to 15 mg or oral short-acting morphine sulphate or equivalent is recommended for opioid-naïve patients.
- Patients presenting with severe pain needing urgent relief should be treated with parenteral opioids, usually administered by the IV or SC route.
- If given parenterally, the equivalent dose is one-third of the oral dose. An initial dose of 2 to 5 mg of IV morphine sulfate or equivalent is recommended for opioid-naïve patients
Transdermal fentanyl
- Transdermal Fentanyl is not indicated for rapid opioid titration
- Should be recommended only after pain is adequately managed by other opioids in opioid-tolerant patients.
- It is usually the treatment of choice for patients who are unable to swallow; patients with poor tolerance to morphine; and patients with poor compliance.
Metabolite of hydromorphone may lead to opioid neurotoxicity, including myoclonus, hyperalgesia, and seizure.
Oxycodone is also available in combination with acetaminophen; therefore, the acetaminophen dose must be monitored for safe limits to avoid potential liver toxicity. According to Swarm et al. (2019), there is overall evidence that oxycodone provides similar analgesic and adverse effects to morphine, concluding that oxycodone and morphine could be interchangeable in the front-line treatment for cancer-related pain.
Meperidine is contraindicated for chronic pain, especially in patients with impaired renal function or dehydration, because accumulation of metabolites that are cleared renally may result in neurotoxicity such as seizures or cardiac arrhythmias.
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