Making a Difference in the Management of Pain

At a symposium held in conjunction with the Twenty-Seventh Annual Congress of the Oncology Nursing Society, three well known professionals in palliative care, oncology, and pain management presented the latest information on addressing the undertreatment of cancer pain. Topics included identifying barriers to effective pain management, examining the ethical principles and processes of pain management, and developing and implementing strategies to improve pain management practices.

This program was supported by an educational grant from Purdue Pharma L.P.

Speakers

Undertreatment of Pain: How Did We Get Here and Where Are We Going?  

“The role of the oncology nurse is the very foundation of pain management in patients with cancer, and is essential in ensuring careful assessment and in overcoming the barriers that can result in the undertreatment of cancer pain,” said Neil Ellison, MD, Director, Palliative and Supportive Medicine, Geisinger Medical Center, Danville, Pennsylvania. According to Dr. Ellison, an awareness of both barriers and the ethical principles commonly used in pain management can help guide oncology professionals in providing optimal pain management for persons with cancer.

Reviewing the Ethical Principles
The ethical principles that are commonly used in pain management include beneficence, non-maleficence, autonomy, and justice. As part of the principles of beneficence and non-maleficence, it is morally acceptable to provide care that is beneficent, even if side effects are harmful, if these effects are unavoidable and unintended. “However, the fear ofhastening death with opioid analgesic use is common. Unfortunately, despite little evidence of a risk of respiratory depression from opioid use or hastened death from pain medications [Fohr 1998], many health professionals continue to believe in the double effect of such agents,” said Dr. Ellison. According to Dr. Ellison, autonomy, the most important ethical principle in pain management, dictates that each individual be able to form, revise, and pursue his or her life’s plans. Finally, the principle of justice requires that all pain management resources be allocated to all patients fairly.

Addressing Barriers to Pain Management
Studies by Cleeland (1994) and Breitbart (1994) have demonstrated inadequate analgesic medication in 85% of patients with AIDS and in 42% of those with cancer. In addition, certain populations have been shown to be at an increased risk. Indeed, Cleeland and colleagues (1994) found that membership in a racial minority, age older than 70 years, andfemale gender were predictors of inadequate analgesia. Another group, Wolfe and colleagues (2000), found that an astounding 76% of 103 children who were dying with cancer had pain. In another study, Morrison and colleagues (2000) showed that the majority of New York City pharmacies in predominately non-White neighborhoods did not have sufficient opioids to treat a person insevere pain.

“Although 85% to 95% of acute pain or pain in the terminally ill should be relatively easy for a primary care physician to control, undertreatment of pain remains a problem,” said Dr. Ellison. In 1994, Cleeland and colleagues reported several barriers to cancer pain management, including inadequate pain assessment (76%), physician reluctance to prescribe opioids (61%), and inadequate knowledge of pain management (52%) in healthcare providers as well as reluctance to report pain (62%) and to take opioids (62%) in patients. The need for improved pain education in health professionals has been reinforced by others (Ferrell et al, Joranson et al). “Fortunately, significant educational and policy changes have been made in the last decade, with the Joint Commission on Accreditation of Healthcare Organizations mandating pain management guidelines and about 50% of state boards thus far developing and adopting guidelines,” Dr. Ellison said.

Discerning between Tolerance, Dependence, and Addiction
A main factor in the undertreatment of cancer pain is a fear held by both health professionals and patients—the fear of addiction to pain medications. Indeed, Ward and colleagues reported patients’ fear of addiction and potential effects on cognitive ability and also the need to choose between treating their disease or their pain. For this reason, it is important for oncology professionals to understand the difference between drug tolerance, physical dependence, and true addiction. Tolerance is a state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drug’s effects over time. Physical dependence is a state of adaptation that is manifested by a drug class-specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of drug, and/or administration of an antagonist. Addiction is a primary chronic neurobiologic disease, characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving (AAPM, APS, ASAM 2001). Epidemiologic data demonstrate that true iatrogenic addiction is rare in cancer and other patient populations (Porter & Jick 1980; Perry & Heldrich 1982; Medine & Diamond 1977). “Oncology professionals need to make every effort to ensure that their colleagues—and their patients—are educated about pain management,” said Dr. Ellison.

In closing, Dr. Ellison emphasized the importance of 1) being educated about opioid (Table 1) and other pain medication use and 2) advocating for effective pain management for patients with cancer. “We need to assess for pain carefully, to believe our patients’ self-reports, and to confront the barriers that result in undertreatment of cancer pain. No patient with cancer should live or die with unrelieved pain,” he concluded.

Table 1. Facts about Opioid Use for Cancer Pain Management

• Prior myelosuppressive chemotherapy
• Assessment should be done by patient self-report whenever possible
• Opioid rotation/titration is expected
• Opioids do not usually cause toxicity that occurs after several weeks of use
• Rapid breakthrough pain usually means disease progression, and not tolerance
• Around-the-clock and prophylactic dosing is recommended
• Aggressive management of opioid-related toxicities is mandatory
• Respiratory depression should be reversed when necessary, with slow titration of naloxone
• Adequate “breakthrough pain” medications should be readily available (10% to 15% of 24-hr dose)
• Family/caregivers should accept the goals of adequate pain management
• There is no predictable correlation between plasma opioid level and analgesic efficacy or toxicity
• There is no maximum dose of opioids
• For unrelieved pain, dose increments of 25% to 33% are necessary, regardless

Ethical Principles and Process: Framework for Holistic Care of the Patient in Pain

Blanche was a 73-year-old retired English teacher who was witty, wise, and independent. An auto accident, which resulted in Blanche’s being pinned under a car, led to her hospitalization. Despite receiving intravenous (IV) meperidine, Blanche continued to rate her pain as a 12 (1-10 scale). It was later discovered that the IV had punctured a vein, and Blanche’s hand had filled up with meperidine. Thereafter, Blanche received other pain medications as well, but still rated her pain as an 8. Her physician commented that Blanche was “wimpy” about pain, and was reluctant to prescribe her more pain medications. Eventually, Blanche’s broken bones healed, but she stopped eating and ultimately died of kidney failure. “Might Blanche’s outcome have been different if she had received proper pain management? I will always wonder,” said Rodney Bolejack, DMin, friend of Blanche, and Chaplain, VistaCare Hospice, Temple, Texas. According to Rev. Bolejack, the ethics of pain management are always personal to someone. The framework for ethics in pain management requires three main considerations: the principles that guide us, the person who may be or may become in pain, and the process by which pain concerns are engaged.

The Principles
The experience of pain may be dehumanizing, humiliating, threatening to one’s autonomy and personhood, and in its extreme, detrimental to one’s will to live (Post et al). Health professionals need to be mindful of the broad scope of effects of pain when considering the ethical principles of pain management: autonomy, beneficence, non-maleficence, and justice. Autonomy requires respect of a patient’s liberty to determine his or her own course of action. In persons with cancer, this requires that health professionals maintain and provide current knowledge, so the patient can make truly informed decisions. In addition, healthcare staff can help identify key questions for patients to raise with their physician. Patients have the right to revise their wishes at any time, provided that they are competent to do so. The principle of beneficence, the duty to do good, dictates that health professionals apply patient rights, give compassion with their care, and balance the potential harm resulting from doing, or not doing, the good. In terms of non-maleficence, the obligation to “do no harm,” health providers need to remember that patients can experience harm in many ways, including being misled or not believed. “Health professionals should also remember that unrelieved pain has been found to inhibit the immune system and perhaps even enhance tumor growth [McCafferty & Pissaro] as well as slow recovery rates, create an unnecessary burden for patients and families, and increase healthcare costs [O’Leary],” said Rev. Bolejack. Finally, justice requires that patients be given all the good that they rightfully deserve, and that such good be distributed fairly to all groups. Indeed, the American Bar Association recently urged the full support of the right of individuals who are in pain to be informed, to choose, and to receive effective pain and symptom evaluation, management, and monitoring, regardless of unintended analgesic tolerance, physical dependence, or hastened death.

The Person
According to Rev. Bolejack, the ethical principles of cancer pain management require that the needs, wishes, and preferences of each individual patient be considered and respected. “This requires whole-person pain assessments for whole-person care, including not only physical but also emotional and spiritual care,” he explained. For this reason, health professionals need to listen to and know the person with pain, and to understand how his or her values, spiritual beliefs, culture, and other personal factors may influence his or her care preferences. “Health professionals should ask the patient what kinds of pain [eg, physical, spiritual, emotional] he or she has, what meaning the experience of pain has for him or her, and what expectations he or she has for pain management,” Rev. Bolejack noted.

The Process
Achieving effective pain management also entails ensuring a process (Table 1) by which ethical issues may be reported, discussed, and resolved. Indeed, developing a model for institutional dialogue on the ethics of pain management facilitates the empowerment of patients and staff and encourages the use of the ethics process, said Rev. Bolejack. In addition, such a dialogue serves to ensure current knowledge of pain assessment, management, monitoring, myths and fears regarding medications, and legal liabilities regarding the undertreatment of pain.

In closing, Rev. Bolejack noted that “as part of the ethics discussion, it is critical for health professionals to develop self-awareness with regard to their own values and beliefs about pain. This self-awareness will allow them to assess whether their own views might facilitate or interfere with a primary goal of all oncology professionals—to ensure effective pain management for their patients with cancer.”

Table 1. The Process of Addressing Ethical Issues in Cancer Pain Management

Step 1: Develop and discuss
  • Develop a response system
  • Conduct case studies prior to actual need
Step 2: Discover and discuss
  • Include the patient
  • Evaluate the need
  • Communicate questions and concerns to staff and patient
  • Apply ethical principles and pain management knowledge
  • Identify alternatives and how each affects patient
Step 3: Determine and discuss
  • Generate a solution
  • Commit to a decision in consultation with patient
  • Document, document, document
Step 4: Deliver and discuss
  • Implement, implement, implement
  • Establish trial periods if needed
  • Evaluate: follow-up and follow through
  • Include the patient

Improving Pain Management: Lessons from the Masters

“As oncology professionals, we know how to manage most pain, and still pain remains undertreated,” said Carol Curtiss, MSN, RN, Program Chair, Clinical Nurse Specialist Consultant, Curtiss Consulting, Greenfield, Massachusetts. According to Ms. Curtiss, oncology nurses must advocate for effective pain management for people with cancer and for the institutional change needed to achieve this goal. “As part of this process, we must also realize that people with pain are the masters, the experts, on their own pain,” she said.

Improving Pain Management in Clinical Practice
Unrelieved pain causes significant physiologic changes, including those of the immune system and nervous system. Indeed, unrelieved pain may reshape the nervous system to produce exaggerated pain responses in the future. Despite the recently released Joint Commission on Accreditation of Healthcare Organizations (JCAHO) Pain Management Standards (2000), unrelieved pain persists as a problem for people with cancer. In improving clinical practice, it is important to adhere to the principles of adequate pain management (Table 1), and to develop and implement an institutional commitment to pain care. “Forming an interdisciplinary work group, analyzing current practices, developing and implementing a standard of practice, and establishing accountability for pain management issues are all key components of building the foundation for improvements in pain management practice,” Ms. Curtiss said.

Additional steps in this improvement process include providing information about interventions to facilitate orders and implementation of orders, promising patients a quick response to pain, providing education about pain management and pain medications, and continually evaluating the practice and process to achieve improvement (Gordon 2000, APS 1995). “Education about pain management must be provided to health professionals, patients, and the public to allay unwarranted fears and impart accurate information,” Ms. Curtiss explained. However, the speaker cautioned that education alone does not result in change. Providing strong mentorship and monitoring (with identification of unacceptable practices), and identifying pain assessment and management as core competencies are among the factors needed to “light the fire” and achieve change.

Educating Health Professionals, Empowering Patients
Studies repeatedly show significant barriers to adequate pain management, two of which include: 1) health professionals underestimate moderately severe to severe pain in their patients, particularly if the patient looks good, and 2) health professionals and patients alike fear addiction to pain medications (Jacox et al 1994, APS 1999). First, routine screening, assessment, and re-assessment is key to pain management, with the patient’s self-report of his or her own pain being paramount. Secondly, pain management should focus on prevention of pain whenever possible, scheduling medications for persistent or predictable pain. When pain is prevented, however, patients will not “appear” to be in pain. Next, oncology nurse leaders need to teach other health professionals about pain management, including the use of medications, appropriate schedules, and expected side effects and ways to include nondrug interventions in the plan. Oncology nurses also need to impart this and other pain management information to their patients, so that patients may be informed and empowered in their own care.

Ms. Curtiss also noted the importance of key resources in helping oncology nurses to be knowledgeable and effective in improving pain management practices. The JCAHO standards, for example, identify inadequate pain management as substandard care. Oncology nurses can utilize the JCAHO standards with administrators and colleagues to initiate and maintain improvements. The Federation of State Medical Boards publication on the elements of appropriate prescribing (1998) includes information to help guide nurse practitioners and physicians in prescribing opioids properly. In approaching pain management at the end of life, many guidelines and position statements are available, including those of the Oncology Nursing Society, American Society of Clinical Oncology, American Medical Association, and the American Nurses Association (ANA). The ANA (1995), for example, asserts that “the promotion of comfort and aggressive efforts to relieve pain in dying patients are obligations of the nurse…Nurses should not hesitate to use full and effective doses of pain medication for proper management of pain in the dying… .”

“Indeed,” Ms. Curtiss concluded, “providing pain relief is not a matter of discretion, but a matter of obligation. Oncology nurses can play an essential role in improving overall pain management by utilizing sound clinical practice to change both clinical care and institutional and healthcare systems.”

Table 1. Principles of Adequate Pain Management
•Consider the person with pain to be the expert
• Provide systematic and ongoing assessment
• Combine drug and nondrug interventions in an order that manages pain effectively
• Adjust medications to individual response
• Perform ongoing evaluation of the effect of the plan on pain
• Communicate the plan to others
• Identify and deal with barriers