Pain management in oncology patients

ABSTRACT:

Advances in veterinary medicine mean that pets are living longer, with many ‘diseases of old age, such as cancer, being managed long term. Management of pain in these patients is essential to maintain optimum quality of life. To achieve this, pain must be recognised and treated appropriately, through constant re-evaluation, tailoring analgesia to address patients’ changing needs. As in many areas of cancer treatment, veterinary nurses have an essential role to play in comfort management.

This article* aims to overview the options available – from pharmacological strategies, to nursing care, both in the hospital environment and at home, in conjunction with owners.     

Pain management in palliative care oncology patients

Palliative care is an interdisciplinary approach to relieving aversive symptoms in people with life-threatening illnesses; it aims to improve the lives of patients and their loved ones, the “patient-family unit.” Palliative care should occur in parallel with all other medical interventions. Indeed, good symptom management is important in helping patients cope with the unpleasantness associated with potentially curative or life-prolonging interventions; it is absolutely essential near the end of life. Unrelieved pain is the symptom that people fear the most. In most cases, adequate pain relief can be achieved with systemic medications alone. When systemic medications fail, due to inadequate analgesia or burdensome side effects, invasive techniques may complement, or replace, systemic therapy. Using a case-based format, we illustrate some complex issues that clinicians face and offer strategies to improve the lives of oncology patients with pain.     

Pain beliefs and perceived physical disability of patients with chronic low back pain

Cognitive-behavioural therapy and maintenance of exercise have emerged as major tools in the treatment of patients with chronic low back pain. Patients' beliefs about their problem may influence their uptake of and responses to particular treatment modalities. In particular, we hypothesised that patients' beliefs about the cause and treatment of pain may mediate changes in physical disability following participation in a multidisciplinary pain management programme. A cohort of 84 patients was invited to respond to booklets of self-report questionnaires prior to, immediately after and 3 months following participation in multidisciplinary pain management programmes. Questionnaires addressed subjects' beliefs about the nature and treatment of pain (Pain Beliefs Questionnaire), and their disability (Likert-modified Roland and Morris Disability Questionnaire, Physical Functioning scale of the Short Form-36 Health Survey, and Oswestry Low Back Pain Disability Questionnaire). Patients with chronic low back pain who more strongly endorsed 'organic' concepts about the nature and treatment of pain reported higher levels of physical disability at baseline, and displayed greater reductions in disability following participation in the pain management programmes. Reductions in reported 'organic' pain beliefs were associated with improvements in reported disability. Endorsement of 'psychological' concepts about the nature and treatment of pain was not associated with disability. These findings support a view that patients' beliefs about the nature and treatment of their pain can change during participation in a multidisciplinary pain management programme based on cognitive-behavioural intervention. Modification of these beliefs may be associated with improvements in patients' perceptions of the level of their disability.     

The chiropractor's role in pain management for oncology patients

OBJECTIVE: The purpose of this article is to present and discuss the idea that chiropractors can be key contributors to the pain management of oncology patients. DISCUSSION: Although it is an oncologist who institutes the necessary treatment for a cancer patient's primary disease process, a chiropractor can help provide noninvasive and non-pharmacologic options for decreasing pain and improving function. As part of a cancer rehabilitation team, the chiropractor can provide treatment that may significantly enhance a cancer patient's quality of life at any stage in the disease process. Treatment may benefit those patients experiencing pain from the side effects of treatment or from the disease process itself. The chiropractor's treatment may include manipulation, soft tissue techniques, physiotherapeutic modalities, exercise, and ergonomic counseling. CONCLUSION: This article describes the potential benefits of chiropractic for cancer patients in the area of pain management and quality of life. Two specific case studies are presented in which cancer patients' quality of life benefited from chiropractic treatment.     

Pain self-efficacy beliefs and pain behaviour. A prospective study

This study examined the relationship between pain self-efficacy beliefs and a range of pain behaviours, as measured by the pain behaviour questionnaire (PBQ), using a prospective design. A heterogeneous sample of 145 chronic pain patients completed sets of questionnaires on four occasions over a nine-month period. Multiple hierarchical regression analyses revealed that the subjects' confidence in their ability to perform a range of tasks despite pain (assessed at baseline), was predictive of total pain behaviour and avoidance behaviour over the nine-month study period. This finding was particularly significant because the analyses controlled for the possible effects of pain severity (at each measurement occasion), pain chronicity, age, gender, physical disability, depression, neuroticism and catastrophising. These findings suggest that pain self-efficacy beliefs are an important determinant of pain behaviours and disability associated with pain, over and above the effects of pain, distress and personality variables. In particular, higher pain self-efficacy beliefs are predictive of reduced avoidance behaviours over an extended period.     

Pain medication beliefs and medication misuse in chronic pain.

This study assessed the influence of medication beliefs, symptom severity, disability, mood, and psychiatric history on opiate medication misuse behaviors in 288 chronic pain patients. Data were gathered by questionnaires and systematic reviews of electronic medical records. The results demonstrate that patients with a history of substance abuse, compared to those without, showed greater medication misuse despite similar dosages and self-rated opiate effectiveness. Misusers believed more strongly in the potential for opiate addiction and that they required higher doses than others, but also had greater belief in opiate effectiveness and the importance of free access. Although both anxiety and substance abuse history are related to medication misuse, a multivariate analysis indicated that these factors can be seen as mediated by medication beliefs. These data suggest important roles for historical, affective, and cognitive variables in understanding medication misuse. Patients with a history of substance abuse report stronger beliefs in opiate effectiveness while simultaneously showing awareness of their addiction potential. Providers may help patients by addressing these issues prior to prescribing opiates. PERSPECTIVE: History of substance abuse is associated with increased opiate medication misuse independent of differences in reported opiate effectiveness. Self-attributions regarding opiate treatment related to need for higher doses, dose control, and addiction potential, may be important mediators of this relationship and interact with anxiety to produce heightened risk of opiate misuse.     

Staying active despite pain: Pain beliefs and experiences with activity‐related pain in patients with chronic musculoskeletal pain

Scand J Caring Sci; 2011; 25; 108–116
Staying active despite pain: Pain beliefs and experiences with activity‐related pain in patients with chronic musculoskeletal pain Objective: Maintain a level of activity and exercise is advice often given to patients with chronic musculoskeletal pain, but many patients find physical activity painful and consequently hesitate to move. Disability seems to be associated with fear of pain and there is a need to enhance our understanding of patients’ beliefs and attitudes about how fear of pain affects physical activity and why some people are active despite their pain. The aim of this research was to understand thoughts and experiences about pain related to activity in patients with musculoskeletal disorders; the situations that promoted pain and if and how fear was expressed. Methods: Five women and five men, recruited from a larger survey on fear, pain and physical activity were interviewed. The interviews were analysed by qualitative methods for themes about participants’ pain and beliefs about pain. Results: By interpreting signals from the body, patients calculated and planned their daily life to stay active despite pain and participate in their social lives. Pain was a signal with diverse meanings which, with the influence of time, seemed to change from a sign of danger to a reminder to moderate their level of activity. By experimenting with different activities, patients learned how to gradually remain or become physically active. Conclusion: Patients strived to stay active despite pain. The interpretation of pain changed over time, from a threatening signal to a signal with diverse meanings. Practice implications: The findings provide insights that may improve the educational rehabilitation of patients with musculoskeletal pain.     

Nursing attitudes and beliefs in pain assessment and management

Aims. This paper reports a study to determine nurses’ attitudes towards pain assessment tools and the relationship of these attitudes to education and experience. Background. The issue of pain management is of interest to caregivers nationally and internationally. For example, in the United States of America, the National Health and Medical Research Council set guidelines to assist clinicians in pain management. Research on whether healthcare teams use pain assessment tools has yielded contradictory findings. Methods. Using an open‐ended questionnaire developed for this study, which was based on Fishbein and Ajzen expectancy‐value model, a convenience sample of 52 nurses on an acute care unit were asked: (1) What do you believe about the assessment of pain? (2) What do you believe about the use of pain assessment tools? and (3) What do you believe about the use of pain assessment tools in improving the patient's outcome? The nurses then rated their attitudes about each belief and how each belief made them feel. The data were collected in 2003. Results. When Fishbein and Ajzen's formula for calculating attitude was used, attitude scores ranged from ?6 to 28 with an overall mean score of +8·3. The amount of education and experience of each nurse and the attitude measure in regard to the use of pain assessment tools were compared. Conclusions. The Fishbein and Ajzen model provides a useful way to obtain information on the attitude of nurses towards the use of pain assessment instruments. To provide further information, this study with an open‐ended instrument should be followed with a fixed‐response survey with a larger sample size and in various settings.     

General practitioners' fear-avoidance beliefs influence their management of patients with low back pain

The objectives of this cross-sectional study conducted in primary care practice in France were to describe general practitioners' (GPs) fear-avoidance beliefs about low back pain (LBP), investigate the impact of these beliefs on their following guidelines for bed rest, physical activities, and sick leave, and uncover factors associated with GPs' fear-avoidance beliefs. A total of 864 GPs completed a 5-part self-administered questionnaire. Parts 1, 2, and 3 concerned demographic, professional data, and personal history of back pain, respectively. Part 4 dealt with GPs' education about LBP and practice for LBP. Part 5 assessed GPs' fear-avoidance beliefs on the Fear-Avoidance Beliefs Questionnaire (FABQ). GPs' mean age was 48.2+/-7.0 years, 80% were male, 88% had been practicing for more than 10 years, and 52% reported a previous personal episode of acute LBP. Forty-six percent had participated in an educational session on LBP during the last 3 years. Mean scores for the FABQ Phys and Work were 9.6+/-4.8 and 17.5+/-6.7, respectively. Sixteen percent of participants had high rating on the FABQ Phys (FABQ Phys score>14). FABQ Phys score was associated with recommendation of bed rest or rest during sick leave (p<0.0001) for acute LBP and less advice to maintain maximum bearable physical activities (p<0.001) for chronic LBP. FABQ Work score was associated with prescribing sick leave during painful periods (p<0.005) for acute LBP and less advice to maintain maximum bearable physical activities (p<0.001) for chronic LBP. GPs' fear-avoidance beliefs about LBP negatively influence their following guidelines concerning physical and occupational activities for patients with LBP.     

Opioid misuse in oncology pain patients

The problem of therapeutic opioid misuse largely affects patients who need opioids to treat chronic pain conditions. Opioid misuse is rarely an overt clinical problem during end of life or acute pain treatment. Misuse attaches a stigma to opioid use, and makes many patients and prescribers reluctant to use these uniquely effective drugs, even when misuse is unlikely. Cancer was once an explosive, typically terminal disease and became the prototype for end-of-life opioid pain treatment. However, cancer is no longer such an explosive disease, and many cancer sufferers can now expect to have a prolonged, even normal, lifespan. They may need pain treatment, but this treatment should not be modeled on palliative care paradigms. This article describes the underlying mechanisms of opioid dependence and its progression to addiction, and suggests a cautious approach to opioid treatment of chronic cancer pain that aims to minimize the problem of misuse.     

Elder beliefs: blocks to pain management.

Elderly patients have beliefs that, if not incorporated into the pain assessment, can block pain management by interfering with the patient's willingness to acknowledge pain and provide complete and accurate information about the pain experience. Patient beliefs that can block pain management include beliefs about self-concept and the aging process; the patient role; health professionals; pain; and consequences of treatment, including addiction, xerostomia, falls, constipation, and sexual and personality problems. Optimal pain management in the elderly is based on a complete assessment of pain, which may take several patient-nurse visits. Patients tend to reveal more information about health problems with succeeding visits, even if the patient is seen by a different person each time.     

Pain management of chronic nonmalignant neuropathic pain

Chronic nonmalignant neuropathic pain is difficult to manage. A challenging case dealing with chronic neuropathic pain subsequent to thoracotomy syndrome and reflex sympathetic dystrophy syndrome is presented. Strategies and approaches to aggressively manage this type of pain are presented.