Highlights of Patient Management

The International Association for the Study of Pain defines pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. Cancer pain can be managed effectively through relatively simple means in up to 90% of the eight million Americans who have cancer or a history of cancer. Unfortunately, pain associated with cancer is frequently undertreated.[1]

Although cancer pain or associated symptoms cannot always be entirely eliminated, appropriate use of available therapies can effectively relieve pain in most patients. Pain management improves the patient’s quality of life throughout all stages of the disease. Patients with advanced cancer experience multiple concurrent symptoms with pain; therefore, optimal pain management necessitates a systematic symptom assessment and appropriate management for optimal quality of life.[2] Despite the wide range of available pain management therapies, data are insufficient to guide their use in children, adolescents, older adults, and special populations.[3]

State and local laws often restrict the medical use of opioids to relieve cancer pain, and third-party payers may not reimburse for noninvasive pain control treatments. Thus, clinicians should work with regulators, state cancer pain initiatives, or other groups to eliminate these health care system barriers to effective pain management. (These and other barriers to effective pain management are listed below.) Changes in health care delivery may create additional disincentives for clinicians to practice effective pain management.

Barriers to Effective Pain Management

• Problems related to health care professionals:
  • Inadequate knowledge of pain management.
  • Poor assessment of pain.[4]
  • Concern about regulation of controlled substances.
  • Fear of patient addiction.
  • Concern about side effects of analgesics.
  • Concern about patients becoming tolerant to analgesics.



• Problems related to patients:
  • Reluctance to report pain.
  • Concern about distracting physicians from treatment of underlying disease.
  • Fear that pain means disease is worse.
  • Concern about not being a “good” patient.
  • Reluctance to take pain medications.
  • Fear of addiction or of being thought of as an addict (this fear may be more pronounced in minority patients).[5]
  • Worries about unmanageable side effects.
  • Concern about becoming tolerant to pain medications.
  • Poor adherence with the prescribed analgesic regimen.[6]



• Problems related to the health care system:
  • Low priority given to cancer pain treatment.
  • Inadequate reimbursement.
  • The most appropriate treatment may not be reimbursed or may be too costly for patients and families.
  • Restrictive regulation of controlled substances.
  • Problems of availability of treatment or access to it.
  • Opioids unavailable in the patient’s pharmacy.

Flexibility is the key to managing cancer pain. As patients vary in diagnosis, stage of disease, responses to pain and interventions, and personal preferences, so must pain management. The recommended clinical approach outlined below emphasizes a focus on patient involvement.

1. Ask about pain regularly. Assess pain and associated symptoms systematically using brief assessment tools. Assessment should include discussion about common symptoms experienced by cancer patients and how each symptom will be treated.[2,3] Asking a patient to identify his or her most troublesome symptom is also of clinical value because the most troublesome symptom is not always the most severe, as demonstrated in a survey of 146 patients in the palliative phase of treatment for lung, gastrointestinal, or breast cancer.[7]



2. Believe patient and family reports of pain and what relieves the pain. (Caveats include patients with significant psychological/existential distress and patients with cognitive impairment.)[8,9]



3. Choose pain-control options appropriate for the patient, family, and setting.



4. Deliver interventions in a timely, logical, coordinated fashion.



5. Empower patients and their families. Enable patients to control their course as much as possible.

Effective pain management is best achieved by a team approach involving patients, their families, and health care providers. The clinician should:

• Initiate prophylactic anticonstipation measures in all patients before or during opiate administration. (Refer to the Constipation section in the Side Effects of Opioids section of this summary for more information.)



• Discuss pain and its management with patients and their families.



• Encourage patients to be active participants in their care.



• Reassure patients who are reluctant to report pain that there are many safe and effective ways to relieve pain.



• Consider the cost of proposed drugs and technologies.



• Share documented pain assessment and management with other clinicians treating the patient.



• Know state/local regulations for controlled substances.

References

1. Weiss SC, Emanuel LL, Fairclough DL, et al.: Understanding the experience of pain in terminally ill patients. Lancet 357 (9265): 1311-5, 2001.  [PUBMED Abstract]
   
   
2. Meuser T, Pietruck C, Radbruch L, et al.: Symptoms during cancer pain treatment following WHO-guidelines: a longitudinal follow-up study of symptom prevalence, severity and etiology. Pain 93 (3): 247-57, 2001.  [PUBMED Abstract]
   
   
3. Patrick DL, Ferketich SL, Frame PS, et al.: National Institutes of Health State-of-the-Science Conference Statement: Symptom Management in Cancer: Pain, Depression, and Fatigue, July 15-17, 2002. J Natl Cancer Inst 95 (15): 1110-7, 2003.  [PUBMED Abstract]
   
   
4. Bruera E, Willey JS, Ewert-Flannagan PA, et al.: Pain intensity assessment by bedside nurses and palliative care consultants: a retrospective study. Support Care Cancer 13 (4): 228-31, 2005.  [PUBMED Abstract]
   
   
5. Anderson KO, Richman SP, Hurley J, et al.: Cancer pain management among underserved minority outpatients: perceived needs and barriers to optimal control. Cancer 94 (8): 2295-304, 2002.  [PUBMED Abstract]
   
   
6. Miaskowski C, Dodd MJ, West C, et al.: Lack of adherence with the analgesic regimen: a significant barrier to effective cancer pain management. J Clin Oncol 19 (23): 4275-9, 2001.  [PUBMED Abstract]
   
   
7. Hoekstra J, Vernooij-Dassen MJ, de Vos R, et al.: The added value of assessing the 'most troublesome' symptom among patients with cancer in the palliative phase. Patient Educ Couns 65 (2): 223-9, 2007.  [PUBMED Abstract]
   
   
8. Allen RS, Haley WE, Small BJ, et al.: Pain reports by older hospice cancer patients and family caregivers: the role of cognitive functioning. Gerontologist 42 (4): 507-14, 2002.  [PUBMED Abstract]
   
   
9. Bruera E, Sweeney C, Willey J, et al.: Perception of discomfort by relatives and nurses in unresponsive terminally ill patients with cancer: a prospective study. J Pain Symptom Manage 26 (3): 818-26, 2003.  [PUBMED Abstract]
   
   

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