COMMENT
Pain management in cancer nursing
© 2014 MA Healthcare Ltd
P
ain is a common and distressing symptom for patients with cancer. Accurate assessment and up-to-date knowledge can help nurses to improve its management. It is estimated that one-third of patients having active cancer treatment will experience pain, the prevalence increasing to two-thirds for patients with advanced disease. Worryingly, there is compelling evidence that still, in many cases, pain resulting from cancer or cancer therapies is under-treated and poorly managed (Foley, 2011). This can inevitably cause significant distress and poor quality of life for patients. Improvements in the management of cancer pain are called for, and nurses caring for this group of patients are in a key position to support this. One of the most important aspects of effective pain management is accurate assessment. Identifying the underlying cause of the pain is vital when considering the best and most appropriate management strategy. Failure to accurately assess patients has been identified as one of the reasons that cancer pain is poorly managed (National Institute for Health and Care Excellence (NICE), 2012). In many situations, the cause of pain is the cancer itself. Knowledge of the stage and extent of the patient’s disease, and sites of metastases, will help to establish if this is the main source of pain. Other causes may include constipation or infection, which require quite different management and are potentially reversible. It is only through thorough history-taking and assessment of the patient’s pain that the accurate cause can be identified and the most effective treatment commenced. Other barriers to effective cancer pain management for patients have been identified. A lack of knowledge on behalf of health professionals is a key one.This lack of knowledge can be related to different types of cancer pain. Kaasa (2013) talks about how the shift of focus onto different types of cancer pain, for example, neuropathic pain and breakthrough cancer pain, has been key to improvements in effective management. It is essential, however, that nurses keep up to date with knowledge surrounding these different types of pain and how to assess for them. Examples include awareness of assessment tools such as the Leeds assessment of neuropathic symptoms and signs (LANSS) (Bennett, 2005) to identify predominantly neuropathic pain and the diagnostic algorithm to diagnose breakthrough cancer pain and
distinguish it from uncontrolled background pain (Davies et al, 2009). By keeping up to date and having good background knowledge, nurses are in a better position to accurately assess and contribute to the effective management of cancer pain. Lack of knowledge surrounding analgesics has also been highlighted as a barrier to effective cancer pain management. It is estimated that 70–90% of pain caused by cancer can be effectively managed by the appropriate use of analgesics (Foley, 2011), the rest potentially requiring other modalities such as interventional techniques or radiotherapy. Despite guidelines such as the World Health Organization (WHO) (1986) three-step analgesic ladder and the NICE (2012) guidance on opioids in palliative care, there is still a lack of knowledge surrounding the effective use of analgesics. These guidelines are widely available and nurses need to be aware of the different types of analgesics, their indications and how to use them effectively. Each patient is different, so their responses to pain and analgesics will be different, making individualised care planning paramount. Suitable analgesics for the patient and their particular pain need to be selected, and in the case of opioids, individually titrated according to response. Patients’ responses to medications need to be assessed in order to establish their effectiveness for the pain. This will give an indication, particularly in the case of opioids, as to whether doses should be increased or alternatives considered. Nurses need to give patients time and the opportunity to report and describe their pain if they are to get a clear picture of how well analgesics are working and pain is being managed. Some nurses rely on their own observations rather than directly asking patients about their pain. This approach does not enable adequate assessment. There is also evidence to suggest that patients’ reluctance to report pain is a factor in its inadequate control, which highlights the importance of ensuring our patients feel that they are being listened to. A knowledge of the side effects of analgesics and prompt recognition of these is also important. Misunderstanding surrounding the use of strong opioids has proved to be another barrier to effective pain control for patients with cancer. Hesitation in prescribing opioids exists among health professionals, despite good evidence for their efficacy and safety in treating cancer pain. This can lead to a delay in prescribing
British Journal of Nursing, 2014 (Oncology Supplement), Vol 23, No 10
opioids for patients with pain. Up-to-date knowledge of this group of analgesics and indications for their use is key to improving attitudes towards their prescription for cancer pain. Concerns may also exist among patients regarding taking opioid medications. Nurses with a good knowledge base will be in a better position to educate and reassure patients about the safety of these medications and provisions for their careful monitoring. A good awareness of non-pharmacological strategies for managing cancer pain is also important. Relaxation and visualisation techniques can be beneficial for patients, as well as talking and listening therapies such as counselling and cognitive behavioural therapy (CBT). One of the ways these types of strategies are thought to help is by reducing fear and anxiety, emotions that can lower the pain threshold (Mehta and Chan, 2008). Nurses should establish where they can access this support for patients as these strategies can complement analgesic regimens, leading to improved pain management and wellbeing. Nurses need to be proactive in updating their skills and knowledge around managing pain in patients with cancer. The more well informed nurses are, the more effective they will be at managing this distressing and debilitating BJN symptom for patients. Bennett M (2001) The LANSS Pain Scale: the Leeds assessment of neuropathic symptoms and signs. Pain 92(12): 147-57 Davies AN, Dickman A, Reid C, Stevens AM, Zeppetella G (2009) The management of cancer-related breakthrough pain: recommendations of a task group of the Science Committee of the Association for Palliative Medicine of Great Britain and Ireland. Eur J Pain 13(4): 331-8. doi: 10.1016/j.ejpain.2008.06.014. Epub 2008 Foley KM (2011) How well is cancer pain treated? Palliat Med 25(5): 398-401. doi: 10.1177/0269216311400480 Kaasa S (2013) Interview: Cancer pain management: the last decade and looking forward. Pain Manag 3(6): 431-4. doi: 10.2217/pmt.13.56 Mehta A, Chan L (2008) Understanding of the Concept of ‘Total Pain’. Journal of Hospice and Palliative Nursing 10(1): 26-32 National Institute for Health and Care Excellence (2012) Opioids in palliative care: safe and effective prescribing of strong opioids for pain in palliative care of adults. NICE, London World Health Organization (1986) Cancer Pain Relief. WHO, Geneva
Jo Thompson
Supportive and Palliative Care Clinical Nurse Specialist, Royal Surrey County Hospital NHS Foundation Trust, Surrey
Update your knowledge by attending the 1st National Cancer Pain Update. Register now at www.cancerpainupdate.co.uk
S17
British Journal of Nursing. Downloaded from magonlinelibrary.com by 138.253.100.121 on December 9, 2015. For personal use only. No other uses without permission. . All rights reserved.
Pain management in cancer nursing
© 2014 MA Healthcare Ltd
P
ain is a common and distressing symptom for patients with cancer. Accurate assessment and up-to-date knowledge can help nurses to improve its management. It is estimated that one-third of patients having active cancer treatment will experience pain, the prevalence increasing to two-thirds for patients with advanced disease. Worryingly, there is compelling evidence that still, in many cases, pain resulting from cancer or cancer therapies is under-treated and poorly managed (Foley, 2011). This can inevitably cause significant distress and poor quality of life for patients. Improvements in the management of cancer pain are called for, and nurses caring for this group of patients are in a key position to support this. One of the most important aspects of effective pain management is accurate assessment. Identifying the underlying cause of the pain is vital when considering the best and most appropriate management strategy. Failure to accurately assess patients has been identified as one of the reasons that cancer pain is poorly managed (National Institute for Health and Care Excellence (NICE), 2012). In many situations, the cause of pain is the cancer itself. Knowledge of the stage and extent of the patient’s disease, and sites of metastases, will help to establish if this is the main source of pain. Other causes may include constipation or infection, which require quite different management and are potentially reversible. It is only through thorough history-taking and assessment of the patient’s pain that the accurate cause can be identified and the most effective treatment commenced. Other barriers to effective cancer pain management for patients have been identified. A lack of knowledge on behalf of health professionals is a key one.This lack of knowledge can be related to different types of cancer pain. Kaasa (2013) talks about how the shift of focus onto different types of cancer pain, for example, neuropathic pain and breakthrough cancer pain, has been key to improvements in effective management. It is essential, however, that nurses keep up to date with knowledge surrounding these different types of pain and how to assess for them. Examples include awareness of assessment tools such as the Leeds assessment of neuropathic symptoms and signs (LANSS) (Bennett, 2005) to identify predominantly neuropathic pain and the diagnostic algorithm to diagnose breakthrough cancer pain and
distinguish it from uncontrolled background pain (Davies et al, 2009). By keeping up to date and having good background knowledge, nurses are in a better position to accurately assess and contribute to the effective management of cancer pain. Lack of knowledge surrounding analgesics has also been highlighted as a barrier to effective cancer pain management. It is estimated that 70–90% of pain caused by cancer can be effectively managed by the appropriate use of analgesics (Foley, 2011), the rest potentially requiring other modalities such as interventional techniques or radiotherapy. Despite guidelines such as the World Health Organization (WHO) (1986) three-step analgesic ladder and the NICE (2012) guidance on opioids in palliative care, there is still a lack of knowledge surrounding the effective use of analgesics. These guidelines are widely available and nurses need to be aware of the different types of analgesics, their indications and how to use them effectively. Each patient is different, so their responses to pain and analgesics will be different, making individualised care planning paramount. Suitable analgesics for the patient and their particular pain need to be selected, and in the case of opioids, individually titrated according to response. Patients’ responses to medications need to be assessed in order to establish their effectiveness for the pain. This will give an indication, particularly in the case of opioids, as to whether doses should be increased or alternatives considered. Nurses need to give patients time and the opportunity to report and describe their pain if they are to get a clear picture of how well analgesics are working and pain is being managed. Some nurses rely on their own observations rather than directly asking patients about their pain. This approach does not enable adequate assessment. There is also evidence to suggest that patients’ reluctance to report pain is a factor in its inadequate control, which highlights the importance of ensuring our patients feel that they are being listened to. A knowledge of the side effects of analgesics and prompt recognition of these is also important. Misunderstanding surrounding the use of strong opioids has proved to be another barrier to effective pain control for patients with cancer. Hesitation in prescribing opioids exists among health professionals, despite good evidence for their efficacy and safety in treating cancer pain. This can lead to a delay in prescribing
British Journal of Nursing, 2014 (Oncology Supplement), Vol 23, No 10
opioids for patients with pain. Up-to-date knowledge of this group of analgesics and indications for their use is key to improving attitudes towards their prescription for cancer pain. Concerns may also exist among patients regarding taking opioid medications. Nurses with a good knowledge base will be in a better position to educate and reassure patients about the safety of these medications and provisions for their careful monitoring. A good awareness of non-pharmacological strategies for managing cancer pain is also important. Relaxation and visualisation techniques can be beneficial for patients, as well as talking and listening therapies such as counselling and cognitive behavioural therapy (CBT). One of the ways these types of strategies are thought to help is by reducing fear and anxiety, emotions that can lower the pain threshold (Mehta and Chan, 2008). Nurses should establish where they can access this support for patients as these strategies can complement analgesic regimens, leading to improved pain management and wellbeing. Nurses need to be proactive in updating their skills and knowledge around managing pain in patients with cancer. The more well informed nurses are, the more effective they will be at managing this distressing and debilitating BJN symptom for patients. Bennett M (2001) The LANSS Pain Scale: the Leeds assessment of neuropathic symptoms and signs. Pain 92(12): 147-57 Davies AN, Dickman A, Reid C, Stevens AM, Zeppetella G (2009) The management of cancer-related breakthrough pain: recommendations of a task group of the Science Committee of the Association for Palliative Medicine of Great Britain and Ireland. Eur J Pain 13(4): 331-8. doi: 10.1016/j.ejpain.2008.06.014. Epub 2008 Foley KM (2011) How well is cancer pain treated? Palliat Med 25(5): 398-401. doi: 10.1177/0269216311400480 Kaasa S (2013) Interview: Cancer pain management: the last decade and looking forward. Pain Manag 3(6): 431-4. doi: 10.2217/pmt.13.56 Mehta A, Chan L (2008) Understanding of the Concept of ‘Total Pain’. Journal of Hospice and Palliative Nursing 10(1): 26-32 National Institute for Health and Care Excellence (2012) Opioids in palliative care: safe and effective prescribing of strong opioids for pain in palliative care of adults. NICE, London World Health Organization (1986) Cancer Pain Relief. WHO, Geneva
Jo Thompson
Supportive and Palliative Care Clinical Nurse Specialist, Royal Surrey County Hospital NHS Foundation Trust, Surrey
Update your knowledge by attending the 1st National Cancer Pain Update. Register now at www.cancerpainupdate.co.uk
S17
British Journal of Nursing. Downloaded from magonlinelibrary.com by 138.253.100.121 on December 9, 2015. For personal use only. No other uses without permission. . All rights reserved.
