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The Art and Science of Pain Management: The Nurse’s Role in Teaming with the Clinician and Empowering the Patient


Christine Miaskowski, RN, PhD, FAAN
Professor and Chairperson
Department of Physiological Nursing
University of California
School of Nursing
San Francisco, California
Terri L. Maxwell, RN, MSN, AOCN®
Executive Director
Center for Palliative Care
Department of Family Medicine
Thomas Jefferson University
Philadelphia, Pennsylvania


Improving Pain Management: A Call To Arms  

With the increasing use of multimodality cancer treatment regimens, cancer has become a chronic disease for many patients. Cancer pain is an acute and chronic problem in persons being treated for, dying from, and surviving cancer. “Data indicate that 50% of patients receiving active cancer treatment in the outpatient setting suffer from acute or chronic pain, and up to 90% of patients in the terminal disease setting have moderate or severe pain,” said Christine Miaskowski, RN, PhD, FAAN, Professor and Chairperson, Department of Physiological Nursing, University of California School of Nursing, San Francisco, California. A current Medline search revealed a significant increase in published reports on “cancer pain” over the last decade, but still far too little research on “cancer pain management.” According to Dr. Miaskowski, “These findings highlight the need for further education and research in cancer pain management.”

Incorrect Assumptions about Pain Management
Past research and clinical efforts have resulted in excellent knowledge of the barriers to effective cancer pain management, effective pharmacologic pain management regimens, and the development of much needed pain management guidelines (Table 1). Yet, cancer pain remains undertreated. “We now know the barriers. We now have not only sustained-release, but also transdermal-delivery pain medications for around-the-clock dosing. Perhaps then the reason for the ongoing undertreatment of pain lies in our own incorrect assumptions,” Dr. Miaskowski explained.

One such incorrect assumption, said Dr. Miaskowski, may be that oncology patients follow healthcare providers’ instructions regarding pain management. Though patient adherence to analgesic regimens has not been studied, related studies show patient nonadherence to range between 15% to 93% (Kaplan & Simone 1990). In their recent PRO-SELF® study, Miaskowski and colleagues evaluated patient adherence to prescribed pain regimens. While all patients should have been receiving around-the-clock medication for chronic pain and an as needed agent for breakthrough pain, 11.0% were receiving no opioid, 41.6% only an as needed opioid, 18.5% only an around-the-clock opioid, and 28.9% both agents. In examining patient adherence to pain over 5 weeks, the researchers found that up to 90% adhered to the around-the-clock agent (fentanyl patch or sustained-release opioid), while only about 21% adhered to the as needed prescribed regimen (hydrocodone, acetaminophen, codeine). “Important for oncology nurses to note, is that the number one reason patients did not take their analgesic pain medication was constipation,” Dr. Miaskowski explained.

According to Dr. Miaskowski, a second incorrect assumption in pain management is that around-the-clock dosing is more effective than as needed dosing of analgesic agents. “Indeed, the data showed that average pain and worst pain scores over the 5 weeks were essentially the same for around-the-clock and as needed regimens,” she said. In addition to the possible need for additional agents, such as nonsteroidal anti inflammatory drugs, titration of around-the-clock dosing may be key. “It is likely that the pain medications were not titrated. Patients likely developed a tolerance, the dose was not changed, and thus pain relief was inadequate,” Dr. Miaskowski said. In addition, the speaker pointed out that it is important to offer alternatives to the numeric pain scoring scales in measuring analgesic efficacy. For example, asking the patient whether the pain is the same, worse, or better may result in a more accurate response. If the patient is taking the medication and the pain is still the same or worse, titration should be considered, said Dr. Miaskowski.

The Realities of Oncology Care
“Ninety percent of oncology care is provided in the outpatient setting, yet barriers to analgesic therapy have largely been studied in inpatients,” Dr. Miaskowski noted. As cancer treatment regimens become more complex and patients live longer with their disease, the burden of symptom management falls largely on family caregivers. In one recent randomized, controlled trial, Miaskowski and colleagues tested the effectiveness of the PRO-SELF Pain Control Program compared with standard care in improving pain management in seven outpatient settings. Patients were interviewed as to their reasons for not taking their pain medications. Patients in the PRO-SELF group received additional education and coaching regarding pain management. Over 5 weeks of follow-up, results showed significantly decreased average and worst pain severities in the PRO-SELF group, compared with the standard care group. “In addition, when all medication doses were converted to morphine equivalence, the data showed that the PRO-SELF group took more analgesic and that titration occurred over the 5 weeks,” Dr. Miaskowski noted. According to Dr. Miaskowski, significantly more patients in the intervention group switched from as needed to around-the-clock dosing, with an average around-the-clock prescribed dose increase of 50 mg. Importantly, the difficulties patients reported in taking their medications included 1) inability to obtain the medication because of expense or because the pharmacy did not carry the drug, 2) inability to get information on pain management from healthcare providers, and 3) inability to manage side effects, especially constipation (Table 2). “In addition, patients experiencing multiple symptoms had difficulty managing their pain. The issue of the relation between multiple symptoms, such as pain, fatigue, and sleep disturbance, is currently under study,” Dr. Miaskowski noted.

In closing, Dr. Miaskowski emphasized, “The past decades of research and clinical experience have led to the development of valuable tools and effective pain regimens, particularly sustained-release and transdermal-delivery opioid agents.

Oncology nurses need to ask patients whether they are taking their pain medications as prescribed, and whether they are experiencing pain relief. Asking about and addressing the difficulties patients have in taking their pain medications is critical to providing optimal pain management and quality of life.”


Pain Education: Methods to Modify the Madness

“Teaching health professionals about cancer pain and its management is essential to changing behavior and ensuring optimal pain relief for patients. However, too often pain management educators use didactic methods to present information, and healthcare professionals’ attitudes—deeply held attitudes—about pain and its management go unchanged,” said Terri L. Maxwell, RN, MSN, AOCN®, Executive Director, Center for Palliative Care, Department of Family Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania. According to Ms. Maxwell, pain education includes the domains of knowledge, attitudes, and skill, with attitudes being the most challenging to alter. Ultimately, she said, the education format needs to be matched with the learning objectives. “To ensure optimal utilization of the pain knowledge and skills being taught, educators must also find ‘teachable moments’ in practice to address and change health providers’ attitudes about pain,” Ms. Maxwell explained.

Addressing Attitudes about Pain Management
The goal for healthcare professionals in improving pain management is not only to be more knowledgeable, but ultimately to change their behaviors in practice. Essential to achieving this goal is addressing the attitudes that many healthcare professionals have regarding cancer pain management. Several commonly held beliefs, or attitudes, serve as barriers for healthcare professionals in providing effective pain management (Table 1). These attitudes may evolve from direct instruction in medical or nursing school, imitation of others, pressure to conform, and observation of rewards and benefits. Importantly, utilizing standard, or didactic, teaching techniques does not work when addressing new attitudes. Instead, educators must encourage healthcare professionals, including medical students, to reflect upon pain management, by capitalizing on “teachable moments.” “If a medical student can develop the ability to reflect upon what pain is like for the patient, this is a good first step to changing attitudes and then behaviors regarding pain management,” Ms. Maxwell said. Teachable moments are those in which the practice context is available to the learner, with the learner being actively involved in clinical problem solving. “For example, I recently began teaching all interns and residents on the medical respiratory intensive care unit to have discussions with patients regarding do-not-resuscitate instructions,” Ms. Maxwell explained. Other active methods that can be used to address attitudes include the introduction of role playing to develop empathy for the patient in pain, use of role models and mentors (eg, during rounds), and use of patient stories or poems to help develop an understanding of the pain experience (Tables 2, 3). “Once healthcare provider attitudes about pain management begin to change, the facts and skills related to pain management and medications can be more readily taught and utilized,” Ms. Maxwell noted.

Addressing Knowledge about Pain Management
Information on the pathophysiology of pain, principles of assessment, pharmacologic principles, nondrug options, and ethical precepts of pain management can be taught in a variety of settings, including lecture presentations, case study reviews, and rounds discussions. “In addition, the use of self-study guides, CD roms, and videos can be highly valuable in teaching knowledge about pain management issues,” Ms. Maxwell said.

Addressing Skillabout Pain Management
“Learning the skills related to pain management is straightforward, but essential, to put knowledge and attitude into action,” said Ms. Maxwell. Such skills include performing and charting a pain assessment, prescribing non-opioid medications, prescribing opioid agents (dose calculations, conversions, titration), administering medications, managing drug toxicities, and educating patients about pain management. “New skills can best be taught using direct observation with feedback, role-playing exercises, and OSCE/simulated patients. In addition, the use of chart reviews and case studies provides opportunities for health professionals to learn about pain management skills,” Ms. Maxwell pointed out.

In closing, Ms. Maxwell emphasized that teaching only the facts about pain management will not change health professionals’ behaviors. “While nurse educators cannot reach and help to change the attitudes and behaviors of all health professionals, the goal is to reach a critical mass and facilitate the pressure to conform to new pain management standards,” the speaker concluded.

Table 1. Inaccurate Attitudes or Deeply Held Beliefs about Pain Management

• Fear of causing addiction or tolerance
• Fear of respiratory depression and the principle of “double effect”
• Belief that there is a ceiling on opioid dosage
• Belief that meperidine is the best postoperative drug
• Belief that opioids cannot be used during the pain evaluation period
• Belief that patients who have no vital sign changes or who appear comfortable are not in pain
• Belief that elderly patients cannot tolerate opioids
• Concerns about regulatory scrutiny

Table 2. Methods by Which Attitudes May Be Changed

• Information and rational argument have a limited role in changing attitudes
• The learner must be willing to give up one thing and acquire an alternative
  – Shared group values more resistant to change
  – The learner must be ready to reflect upon current attitudes and willing to change
• Teaching capitalizes on “teachable moments”
• The learner can be active and engage in real problem solving
• The learner can practice the new behavior
• The learner can reflect upon meaning, difficulties, and rewards of attitudinal change
• Teaching methods can include role playing and role reversal, role models and mentors, and use of narratives, personal reflection, video demonstrations

Table 3. Methods That Can Change Attitudes

• Role playing and role reversal
• Role modeling and mentoring

• Use of narratives, personal reflection, short stories, video, poetry, and diaries

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