Ch. 29: Pain Management with Cancer Flashcards Preview

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Flashcards in Ch. 29: Pain Management with Cancer Deck (28):

Patient Concerns

- not being a "good" patient
- reluctance to take pain medication
- fear of addiction or being thought an addict
- worries about unmanageable side effects
- concern about becoming tolerant to pain med
- inability to pay for treatment


Healthcare System Barriers

- low priority given to cancer pain
- inadequate reimbursement
- restrictive reguation of controlled substances
- treatment is unavailable or access is limited


Healthcare Professionals

- inadequate knowledge of pain management
- poor assessment of pain
- fear of patient addiction
- concern about side effects and tolerance
- resistance to report pain
- fear of distracting HCP from treating cancer
- fear the pain means the cancer is worse


Pathophysiology of Pain: What is Pain

- unpleasent sensory and emotional experience associated with actual or potential tissue damage
- most reliable method of assessing pain is to have patient describe his or her experience
- pain is inherently personal and subjective


Nociceptive Pain vs. Neuropathic Pain

- results from injury to tissues; 2 forms: somatic and visceral pain
- results from injury to peripheral nerves; responds poorly to opioids


Pain in Cancer Patients

- direct invasion of surrounding tissues: nerves, muscles, and visceral organs
- metastatic invasion at distinct sites
- therapeutic interventions:
surgery (phantom limb)


Management Strategy

- ASK about pain regularly
- BELIEVE patient and family
- CHOOSEpain control options appropriate
- DELIVER interventions in timely, logical, coordinated fashion
- EMPOWER patients and families


Assessment and Ongoing Evaluation

- comprehensive initial assessment:intensity, physical and neurological examination, diagnostic tests, psychosocial assessment, pain intensity scales
- ongoing evaluation
- barriers to assessment


Comprehensive Initial Assessment

- primary objective is to characterize the pain and identify its cause
- assessment of pain intensity and character


Ongoing Evaluation

- reassess frequently
- evaluate after sufficent time has elapsed
- be alert for the development of new pain


Barreirs to Assessment

- inaccurate reporting by patient
- underreporting by patient
- language and cultural barriers


Drug Therapy

Nonopiod analgesics: NSAIDS and acetaminophen
- opiod analgesics: oxycodone, fentanyl, and morphine
- adjuvant analgesics:


WHO Analgesic Ladder

step 1: mild to moderate pain (NSAIDS and acetaminophen; nonopioid analgesics)
step 2: more severe pain (add an opioid analgesic, oxycodone, or hydrocodone)
step 3: severe pain (substitute a powerful opioid such as morphine or fentanyl


NSAIDS Principles

- aspirin and ibuprofen
- pain relief, supression of inflammation, and reduction of fever
- adverse effects: gastric ulceration, acute renal failure, and bleeding
- all except aspirin increase the risk of thrombotic events
- do not cause tolerance, physical dependence, or psychological dependence



- inhibit COX-1 and COX-2
- greater risk of thrombotic events
- Thrombocytopenia



- inhibit COX in CNS but not periphery
- combine with an opioid can produce greater analgesic than either drug alone
- lacks anti-flammatory actions
- does not inhibit platelet actions or promote gastric ulceration, renal failure, or thrombotic events
- drug interactions: Alcohol= fatal liver damage and Warfarin= increase risk of bleeding


Drug Selection

- pure opioid agonists are preferred for all cancer patients
- opioid rotation
- dosage should be individualized
- use with caution: methadone, and codeine
- avoid meperidine


Routes of Admin

- oral (preferred)


Managing Breakthrough Pain

- may experience transient episodes of moderate to severe breakthrough pain
- access to resuce medication:
strong opioid with rapid onset and short duration, immediate release oral morphine, transmucosal fentanyl, fentanyl nasal spray


Managing Side Effects

- resp. depression: Naloxone
- constipation: stool softeners, laxatives, methylnaltrexone
- sedation: CNS stimulant (caffeine, methylphenidate)
- nausea and vomiting: antiemetic or serotonin antagonist
- itching: antihistamine


Adjuvant Analgesics

- used to complement the effects of opiods; not used as substitutes
- enhance analgesia caused by opioids
- help manage concurrent symptoms that exacerbate pain
- treat side effects caused by opioids


Adjuvant Analgesics Ex.

- tricyclic antidepressants
- antiseizure drugs
- local anesthetics/antidysrhythmics
- CNS stimulants
- antihistamines
- glucocorticoids
- bisphosphonates


Invasive Procedures

- Neurolytic nerve block
- neurosurgery
- tumor surgery
- radiation therapy


Physical Interventions

- heat, cold
- massage, exercise
- acupunture and transcutaneous electrical nerve stimulation


Psychosocial Interventions

- relaxation and imagery
- cognitive distraction
- peer support groups


Pain Management in Special Populations: older adults

- heightened drug sensitivity
- undertreatment of pain
- misconceptions: insensitive to pain, can tolerate pain well, highly sensitive to opioid side effects
- increased risk of side effects and adverse interactions


Pain Management in Special Populations: Young Children

- experience more pain from chemotherapy and other interventions from cancer itself


Pain Management in Special Populations: Opioid Abusers

- HCP must try to relieve the pain and avoid opioids simply because the patient wants to get high