Transcript Chapter 16 Cholinesterase Inhibitors

Chapter 29
Pain Management in Patients
with Cancer
Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc.
Pain Management in Patients
with Cancer
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Pathophysiology of pain
Management strategy
Assessment and ongoing evaluation
Drug therapy
Nondrug therapy
Pain management in special populations
Patient education
The Joint Commission (TJC) pain
management standards
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Pathophysiology of Pain
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What is pain?
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Unpleasant sensory and emotional experience
associated with actual or potential tissue damage
The most reliable method of assessing pain is to
have the patient describe his or her experience.
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Pathophysiology of Pain
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Neurophysiologic basis of painful sensations
Nociceptive pain vs. neuropathic pain
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Nociceptive pain
• Results from injury to tissues
• Two forms: somatic and visceral pain
Neuropathic pain
• Results from injury to peripheral nerves
• Responds poorly to opioids
Pain in cancer patients
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Management Strategy
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ASK about pain regularly.
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Assess pain systematically.
BELIEVE the patient and family in their reports of
pain and what relieves it.
CHOOSE pain control options appropriate for the
patient, family, and setting.
DELIVER interventions in a timely, logical,
coordinated fashion.
EMPOWER patients and their families.
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Enable patients to control their treatment to the greatest
extent possible.
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Assessment and Ongoing Evaluation
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Comprehensive initial assessment
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Intensity and character of pain
Physical and neurologic examination
Diagnostic tests
Psychosocial assessment
Pain intensity scales
Ongoing evaluation
Barriers to assessment
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Comprehensive Initial Assessment
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The primary objective: to characterize the
pain and identify its cause
Assessment of pain intensity and character:
the patient’s self-report
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Onset and temporal pattern
Location
Quality
Intensity
Modulating factors
Previous treatment
Impact
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Fig. 29–1. Flow chart for pain management in patients with cancer.
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Comprehensive Initial Assessment
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Physical and neurologic examinations
Diagnostic tests
Psychosocial assessment
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Directed at both patient and family
Pain intensity scales
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Fig. 29–2. Linear pain intensity scales.
*If used as a graphic rating scale, a 10-cm baseline is recommended.
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Fig. 29–3. Wong-Baker FACES pain rating scale.
Explain to the patient that the first face represents a person who feels happy because he or she
has no pain, and that the other faces represent people who feel sad because they have pain,
ranging from a little to a lot. Explain that face 10 represents a person who hurts as much as you
can imagine, but that you don’t have to be crying to feel this bad. Ask the patient to choose the
face that best reflects how he or she is feeling. The numbers below the faces correspond to the
values in the numeric pain scale shown in Figure 29–2.
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Ongoing Evaluation
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Reassess frequently
Evaluate after sufficient time has elapsed
Be alert for the development of new pain
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Barriers to Assessment
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Inaccurate reporting by patient
Under-reporting by patient
Language and cultural barriers
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Drug Therapy
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Nonopioid analgesics
Opioid analgesics
Adjuvant analgesics
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Drug Therapy
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WHO analgesic ladder
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Step 1: mild to moderate pain
• Nonopioid analgesic
• NSAIDs and acetaminophen
 Step 2: more severe pain
• Add opioid analgesic, oxycodone, hydrocodone
 Step 3: severe pain
• Substitute powerful opioid—morphine, fentanyl
WHO = World Health Organization.
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Fig. 29–4. The World Health Organization (WHO) analgesic ladder for cancer pain management.
Note that steps represent pain intensity. Accordingly, if a patient has intense pain at the outset,
then treatment can be initiated with an opioid (step 2), rather than trying a nonopioid first (step 1).
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Nonopioid Analgesics
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Nonsteroidal anti-inflammatory drugs
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NSAIDs (aspirin, ibuprofen)
Acetaminophen
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Acetaminophen (Tylenol, others)
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Opioid Analgesics
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Mechanism of action and classification
Tolerance and physical dependence
Addiction
Drug selection
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Preferred opioids
Opioid rotation
Opioids to use with special caution
Dosage
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Drug Selection
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Pure opioid agonists are preferred for all
cancer patients
Opioid rotation
Dosage should be individualized
Use with caution
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Methadone (Dolophine), levorphanol (LevoDromoran), codeine
Avoid
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Meperidine (Demerol)
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Routes of Administration
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Oral
Rectal
Transdermal
Intravenous and subcutaneous
Intramuscular
Intraspinal
Intraventricular
Patient-controlled analgesia
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Managing Breakthrough Pain
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Patients may experience transient episodes
of moderate to severe breakthrough pain
Access to rescue medication
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Strong opioid with rapid onset and short duration
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Managing Side Effects
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Respiratory depression
Constipation
Sedation
Nausea and vomiting
Other side effects
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Adjuvant Analgesics
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Used to complement the effects of opioids—
not used as substitutes
Tricyclic antidepressants
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Amitriptyline (Elavil)
Antiseizure drugs
Local anesthetics/antidysrhythmics
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Adjuvant Analgesics
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CNS stimulants
Antihistamines
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Hydroxyzine (Vistaril)
Glucocorticoids
Bisphosphonates
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Invasive Procedures
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Neurolytic nerve block
Neurosurgery
Tumor surgery
Radiation therapy
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Physical and Psychosocial
Interventions
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Physical interventions
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Heat
Cold
Massage
Exercise
Acupuncture and transcutaneous electrical nerve
stimulation
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Physical and Psychosocial
Interventions
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Psychosocial interventions
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Relaxation and imagery
Cognitive distraction
Peer support groups
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Pain Management in Special
Populations
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Older adults
Young children
Opioid abusers
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Older Adults
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Heightened drug sensitivity
Undertreatment of pain
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Misconceptions
• Belief that elderly patients are insensitive to pain
• Belief that elderly patients can tolerate pain well
• Belief that elderly patients are highly sensitive to opioid
side effects
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Increased risks of side effects and adverse
interactions
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Young Children
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Assessment
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Verbal children
Preverbal and nonverbal children
Treatment
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Opioid Abusers
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Two primary obligations
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Try to relieve the pain
Avoid giving opioids simply because the patient
wants to get high
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Patient Education
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General issues
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Drug therapy
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Nature and causes of pain
Assessment/importance of honest self-reporting
Plans for drug and nondrug therapy
Tolerance
Physical dependence and addiction
Fear of severe side effects
Nondrug therapy
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Focuses on psychosocial interventions
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The Joint Commission Pain
Management Standards
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Purpose is to make assessment and
management of pain a priority in healthcare
Compliance is mandatory
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