Pain management was a primary topic at the 28th Annual Congress of the Oncology Nursing Society. Areas that were discussed included measurement of pain, appropriate dosing, patient and caregiver education, and multicultural perspectives.

Cancer-related Pain

When people are diagnosed with cancer, pain remains one of the most feared symptoms for both the patient and their families. According to the International Association for the Study of Pain, the definition of pain is “an unpleasant sensory and emotional experience associated with the actual or potential tissue damage or described in terms of such damage.” If not adequately managed, pain may have a tremendous effect on quality of life. From the time of diagnosis through the intermediate phase of illness, 30% - 45% of cancer patients will experience moderate to severe pain. As the disease advances, pain incidence increases to 70% - 90%.

Despite the claim that 90% of adult cancer patients’ pain can be relieved, uncontrolled cancer related pain is still a concern, particularly in the outpatient setting. Recent research indicates that most cancer patients are under treated for pain. In a study comparing treatment of patients with opioid drugs to the Agency for Health Care Policy and Research (AHCPR) recommended opioid dosage for body weight, 75% of patients were under-prescribed and 25% were over-prescribed. Only 6% of male patients were taking the appropriate doses. Most patients in each pain intensity group were under-prescribed.

Measurement of Pain

Implementation of pain standards dictated by the Joint Commission for Accreditation of Health Care Organization (JCAHC) was partially successful in a hospital-based radiation center. In a recent study, nurses working in the radiation oncology department underwent intense training related to the etiology, assessment, and management of various types of pain. Upon completion of the training, nurses received a resource notebook to utilize in the clinic. The center plans to develop individual report cards to be provided to individual physicians and their primary nurses, which will facilitate continued review of the teaching tools. 

Current Treatment Standards

The World Health Organization Analgesic Ladder Approach for Relief of Cancer Pain is a guide for the treatment of pain according to severity. Recommended treatment for mild, moderate, and severe pain are as follows:

Mild to Moderate Pain (1-3) Non-opioids are the first choice of treatment for mild to moderate pain. This includes medication such as acetaminophen (Tylenol®) or a nonsteriodal anti-inflammatory drug. Adjuvant drugs may be added if a specific need is identified.

Moderate to Severe Pain (4-6) Patients with moderate to severe pain who have not responded to the first step should receive an opioid. These medications may include codeine, hydrocodone, dilhydrocodiene, oxycodone, propoxyphene, and tramadol. Acetaminophen or a nonsteriodal may be added. Adjuvant drugs may also be added as indicated.

Severe Pain (7-10) Patients with severe pain or who have not achieved pain relief from the previous step will usually receive a opioid. Opioids for severe pain may include morphine, oxycodone, hydromorphone, methadone, levophanol, or fentanyl. A non-opioid analgesic and/or adjuvant drug may be added as circumstances indicates.

Educating Caregivers and Patients

Educating both patients and caregivers about pain and options for pain management may improvement the effectiveness of treatment. Clinical research has revealed that patients who were more knowledgeable regarding pain control also demonstrated higher perceived control of their pain. These findings also show a relationship between high perceived control of pain and decreased severity and distress.

Results from a survey completed by 75 family members attending an outpatient oncology clinic with a relative who experienced cancer pain support the contention that educating caregivers about pain management may improve the patient’s treatment. All family caregivers stated that they wanted to be more involved in pain management. However, almost 20% reported difficulty talking to their relative about pain, and 14% experienced difficulty giving medication. Furthermore, caregivers over the age of 55 reported greater difficulty communicating with health care providers and family or friends regarding pain than caregivers under the age of 55 years. Caregivers who rated their relative’s pain as 5 or more, reported higher levels of distress and lower satisfaction with pain management. Further research is required to identify techniques that may help caregivers achieve better pain management for their patient.

MultiCultural Perspectives

Cultural influences may play an important role in the management of cancer related pain. The increasing cultural diversity of the United States presents new challenges for oncology nurses. A study conducted in Hispanic cancer inpatients revealed that, while Hispanics believe that medication is important in pain control, acute pain is under-managed in this population. Further research is warranted to provide appropriate cultural assessment and promote more effective pain management in Hispanics.

Ongoing research is aimed at attaining insight into how nurses can better care for the culturally diverse patient with prostate cancer. Specifically, a descriptive study is being conducted to evaluate cultural differences in self-reporting pain among Japanese-American men with prostate cancer.

Conclusion

While adequate management of pain is recognized as a critical component of treating cancer patients, many still experience pain that is ineffectively managed. Education of health care professions, patients, and caregivers is an important factor for improving pain management. Also, recognizing that cultural influences may impact pain management is important for helping oncology nurses learn to deal with an increasingly multicultural population. Further research in these areas will help define and improve pain management and quality of life for cancer patients.

References

1. Keogh E, Cochrane M. Anxiety, sensitivity, cognitive biases, and the experience of pain. The Journal of Pain 2002;3(4):320-329.

2. Oncology Nursing Society. ONS Position Paper on Pain. Pittsburgh; 2002.

3. Chen H, Wilkie D, Huang H. Opiod Prescritption for Cancer Pain Management. Proceedings form the 2003 Annual Meeting of the Oncology Nursing Society. Abstract #147.

4. Waring J, Gosselin T. An Institutional Experience With The Implementation of Joint Commission On Accreditation of Health Care Organization Pain. Proceedings form the 2003 Annual Meeting of the Oncology Nursing Society. Abstract #150.

5. MaCaffery M, Passero C. Pain: clinical manual (2nd Ed.) St. Louis: Mosby; 1999.

6. Riley-Doucet C, Vallerand A, Hasenau S, Templin T. Cancer-Related Pain In The Outpatient Clinic. Proceedings form the 2003 Annual Meeting of the Oncology Nursing Society. Abstract #148.

7. Yates P, Skermman H, Edwards, H. The Influence of Caregiver Age and Gender, And Patient Clinical Factors on Family Caregivers’ Perceptions Of And Involvement In Cancer Pain Management. Proceedings form the 2003 Annual Meeting of the Oncology Nursing Society. Abstract #143.

8. McNeil J, Sherwood G. Hispanic Perspectives About beliefs and Remedies For Acute Pain.Proceedings form the 2003 Annual Meeting of the Oncology Nursing Society. Abstract #146.

9. Kowalski M. A Pilot Study Comparing Pain Intensity, Information Seeking, and Adjustment and Prostate Cancer and Metastasis in First-Generation Japanese American Men and Third-Generation Europena American Men. Proceedings form the 2003 Annual Meeting of the Oncology Nursing Society. Abstract #148