Pain Management Abstract

This essay aims at outlining and giving a critical analysis of the
fundamental nature of pain management for a patient suffering from
cancer of the neck. This paper will define pain and explain the
intricacies of pain management with specific focus on cancer paint. It
also examines the categories of pain that cancer patients experience. In
addition, the paper concentrates on a case study that outlines pain
management strategies, while also evaluating medications used in the
study, as well as their accompanying side effects. Various methods of
administering the medication are analysed, as well as the different
implications for nurses as pertaining to cancer pain management. In
accordance with the Nursing and Midwifery Council(NMC) (2010), anonymity
will be maintained, therefore the patient in this case study will be
referred to as Mr X.
Middleton-Green (2008) defined pain as: ‘an unpleasant or unlikable
emotional or sensory experience that is mainly related to or defined in
terms of potential or actual damage. It may also be defined as an
unpleasant experience or feeling that usually emanates damaging or
intense stimuli. Pain usually comes as a motivation to individuals to
withdraw themselves from harmful situations, desist from similar
situations, as well as protect the damaged part of their body as it
heals. In most cases, pain is resolved immediately after an individual
removes the painful stimulus and the body heals. However, there are
instances where pain continues even after the elimination of the
stimulus and the perceptible body healing. In some instances, pain
occurs without any detectable disease, stimulus or damage to the body.
As expected, pain affects the physical, social, psychological,
spiritual, as well as emotional aspects of the patient, especially
considering that these aspects interact in complex mechanisms
constituting the unique pain experiences of a patient.
Pain management in cancer patients
Clark (1999) says that the aim of pain management is to provide pain
control care. Pain management is defined as a branch of medicine that
involves taking interdisciplinary techniques for alleviating the
suffering of an individual, as well as enhancing their quality of life.
Calvino and Grilo (2006) explained pain management in the nursing
profession as the alleviation or reduction of pain to such a level with
which the patient is comfortable and considers acceptable. This
underlines the fact that, pain management incorporates the
pharmacological, non-pharmacological, as well as other approaches that
are necessary for the prevention and the reduction or elimination of
pain sensations. It is worth noting that pain management encompasses
different techniques including evaluating, diagnosing, treatment for
prevention or reduction, or ceasing the pain symptoms through the use of
various approved medications, or non-medical approaches and therapies.
It is always imperative that healthcare professionals recognize the
complexities that come with pain management in practical settings while
offering care for cancer patients.
Cancer patients undergo persistent, long lasting pain, especially in
cases where the disease is in advanced stages. This is also the case for
individuals who have undergone bone marrow transplantation, surgery, or
chemotherapy. According to Thapa et al (2011) the character of cancer
pain is unique, not fixed and is always returning with new complex
problems. In most cases, about 90% of cancer pain emanated from cancer
tumours, while the rest emanates from other non – related pain
generators, Breiviket al (2009, pp. 1426).
According to Farquhar-Smith (2007), improper management of pain would
have a profound impact that hinders full recovery of the patient or even
worsens the illness. In essence, pain management comes as a crucial
component of recovery, as well as the prevention of additional health
complications, which essentially leads to an improvement of the
patient’s quality of life.
Scholars state that about 70 percent of pain emanates from tumour
invasion or the compression of bone, soft tissue and neural structures.
20 percent of the pain, on the other hand, emanates from the procedures
pertaining to evaluation and treatment of the ailment. This underlines
the multifaceted severity and complex nature of cancer pain, as well as
the need for effective cancer pain management (Ko and Zhuo, 2004, pp.
107). In addition, this underlines why it is imperative that healthcare
professional incorporate a holistic approach, which should include
patients’ families in the management of pain. In instances where the
family can comprehend the conditions, as well as the type of
medications, they would be capable of giving reassurance and may become
the patient advocate.
Types of pain
Mehta et al (2011) divided pain into two groups acute and chronic.
Acute pain mainly emanates from injury, headaches, disease, and many
other conditions. In most cases, it would be alleviated once the
predisposing condition has been resolved. Chronic pain, on the other
hand, refers to severe pain that continues even after the resolution of
the condition that caused the pain. Pain can be profoundly persistent,
pervasive and degenerative.
Cancer pain
Robert (2004 pp. 38) opines that chronic pain that relates to cancer
tends to persist beyond three months. It may be considered as pain that
continues beyond the normal healing period.
Chapman (2012:14) highlighted that in cancer patients, pain tends to be
acute or chronic and originates from ‘recurring and/or progressive
tissue injury. Nurses need to recognize factors that may affect the
patient’s experience of pain such as anxiety and the meaning attached
to the pain – as pain maybe a reminder of the active nature of the
cancer and may also indicate disease progression, it is then imperative
for effective assessing and managing Mr X’s pain.
Mehat et al (2011. pp. 43) citing other health professionals indicated
that cancer patients have many different pain types affecting numerous
sites of their bodies. In essence, it is imperative that the management
process incorporates the recognition of the varied categories of pain
experienced by cancer patients, all of which incorporate their own,
unique management emphasis. It is imperative that pain management
focuses on the varied categories of pain through which patients undergo.
Case study
Mr X required chronic pain management after undergoing cancer surgery on
his neck. According to Fitzgibbon and Richard (2001) such cancer surgery
frequently causes pain. The surgery consists, of removal, or debulking
of a tumour. These procedures often result in injury to local nerves and
postoperative pain, which can later lead to chronic pain syndrome.
Surgery can induce nerve injuries which often occur after radical neck
dissection, as in the case of Mr X, the pain became severe and difficult
to manage.
Prior to starting the pain management regime for Mr X, he was thoroughly
assessed and evaluated for the severity of his pain. Following Rachel et
al (2010) accurate records of assessment and reassessment of pain and
optimized pain relief were kept for continuous evaluation. The
assessment and evaluation used was information collected from Mr X and
his medical notes, to that effect, pain assessment scales were used.
Objective measurements were meant to allow health professions and the
nurse to comprehend the intensity of pain being experienced by Mr X.
A pain chart was incorporated to gain understanding of the severity of
pain, a scale from 10 was introduced, 10 being the worst and 1 being the
least, evaluations also encompassed of examining Mr X and conducting
diagnostic tests to determine the underlying causes. It was expected the
type and severity of pain and pre-emptively managed prior to any medical
procedure, thanks to various sites of pain Mr X endured.
The various medications that were going to be used in the treatment were
considered and subsequently discussed with Mr X. The issue of toxicity
and addictiveness over prolonged use was explained to him along with
particular benefit to him concerning chronic pain he was experiencing.
Mr X was kept informed about every procedure being done and any
medication or drugs that were to be used or changed, this gave Mr X an
opportunity to ask any questions, therefore reducing any anxieties that
Mr X may have. Non-pharmacological strategies such as comfort measures,
positioning and adequate rest were also incorporated to ease Mr. X’s
pain, and discomfort. Pain is whatever the experiencing person says it
is, existing whenever he says it does (McCaffery and Pasero, 1999,
Mr X reported pain in his neck, his medical status showed an invasion of
bone cancer. He reported tenderness with constant background pain and
movement-related exacerbation, which were frequently described as
severe. Twycross et al (2008, pp 35) highlighted that neck cancer
tumours may instigate a vigorous immune response which enhances pain
sensitivity, that releases chemicals to stimulate nociceptors (nerve
cell endings that initiate the sensation of intense pain). As the
tumours grow they compress, infiltrate, cut off blood supply to, or
consume body tissues, which can cause chronic pain that Mr.X described
as periodic excruciating pain in the oral cavity, face, neck and
shoulder, and intense headaches.
Scholars have noted that pain in neck cancer is fundamentally
multi-dimensional indicator that is complex with emotional, cultural,
physical, as well as psychosocial factors as contributors to the pain
experience. It is always imperative that these factors are given
sufficient consideration and addressed appropriately so as to offer
sufficient palliation. Various studies have been done to examine the
category of pain that is experienced before, during, as well as after
treatment, as is the case of Mr X. According to research, more than a
third of cancer patients (38%) experience pain mainly emanating from the
tumour. These patients mainly comprise those suffering from soft tissue
pain, bone pain, as well as neuropathic pain. Neck cancer somatic pain
mainly emanates from ulcerative lesions, as is the case with Mr. X.
According to research, tumour invasion into the nerves, whether at the
skull’s base’s level or peripherally may result in refractory pain
syndromes, as well as neurologic deficits. There are also instances
where pain emanates from the damage of peripheral nerves during
resection (also known as neuropathic pain), as well as tissue scarring
and contracture around the shoulders and neck.
Postoperative Neck cancer pain assessment
Postoperative pain assessment proved difficult in the case of Mr. X,
thanks to the placement of tracheostomy tube, severe oral pain and loss
of speech, which increased the difficulty of communicating. However, Mr.
X had to be subjected to a careful examination and a detailed history
taken prior to the commencement of the analgesic history so as to
determine the real cause of the pain, as well as the likely role that
anti-cancer therapy would play in the treatment of the cancer and relief
of pain. It is also imperative that the physicians explore the relative
impact that analgesic drugs or techniques would have on the treatment.
In essence, radiological examination has to be done so as to come up
with an accurate evaluation of the cause of pain.
In addition, it is imperative that the physicians go beyond the
physiological and physical aspects, and examine the psychological
aspects such as how the disease and pain affects or impact’s the
family’s quality of life. Research shows that the cognitive and
emotional pain components bear more significance in cancer than in
noncancer pain. This may explain the pain that Mr. X is undergoing,
especially considering that he has already undergone surgical operation
only for the operation to be unsuccessful. The unsuccessful operation
undoubtedly comes with varied risk factors to pain including worries,
stress and anxiety among others. Scholars note that neck cancer patients
usually have numerous, unique pain syndrome or numerous locations of
pain as is the case with Mr. X. This underlines the importance of
carrying out a thorough assessment on the patient so as to ensure that
all symptoms and likely problems are put on hold.
When managing Mr X’s chronic pain it was considered the different
causes and types of pain, mild, acute or chronic. It also included a
holistic and interdisciplinary approach psychological support,
physiotherapy and occupational therapies as part of a multidisciplinary
approach. Gaining an understanding of the cause of pain was synonymous
with pain management.
Pharmacological pain control
The pharmacological options used for Mr X included pain relieving
medications and laxatives. The laxatives were introduced to prevent
constipation, which is associated with certain analgesics some
analgesics can and often cause nausea and vomiting therefore,
anti-emetics were also part of Mr Xs’ pain management.
Pharmacologic management or alleviation of cancer pain is conceptualised
as a continuum from indirect delivery of drugs i.e. systemic analgesia
to direct delivery of drugs, i.e. neuroablation and neuraxial drug
administration. Indirect systems of drug delivery depend on blood-borne
carriage of the analgesics to the receptors following systemic
absorption, administration of the drugs into the blood stream, as well
as the formation or establishment of a depot for continuous and
sustained release (Williams et al, 2010, pp 779). On the other hand,
direct systems for drug delivery involve the administration of agents in
the vicinity of the target neural tissue or into the neuraxis.
In Mr. X ‘s part, Metamizole was used instead of Ketaprofen as it was
shown to be more effective and incorporated less risks than the later.
This was especially after the third day of shoulder pain (Williams et
al, 2010, pp 779). In addition, BtxA, a neurotoxin that is known to act
on axon terminal was used in lower doses, which research has shown to be
significantly more effective than in high doses. High doses are also
known to result in antibody formation, as well as affect neuromuscular
transmission in muscle groups that were not related to the pain site
(Williams et al, 2010, pp 779). This neurotoxin proved useful especially
considering that Mr. X had undergone neck dissection, while other parts
of his body such as shoulders and dental area.
In addition, Non-steroidal anti-inflammatory drugs particularly
ibuprofen were administered together with paracetamol, codeine phosphate
and tramadol. These drugs were effective for Mr X’s acute, sharp, pain
whilst moderate and severe pain required stronger medication such as
fentanyl patch and break through oramorph. Narcotics were extremely
effective for handling his chronic pain, which did not respond to
aspirin and ibuprofen (Talmi et al, 2000, pp. 303). Initially, Mr X was
showing reluctance over the use of narcotics due to its addictive
nature, and because it is classified as opioids. Eventually Mr X agreed
to have the narcotics due to their effectiveness in managing the intense
pain he felt. The nature and effects of opiates, morphine and oxycontin
was explained to Mr X, and how narcotics may not be effective against
some forms of chronic pain. Antidepressants and anticonvulsants can be
both effective with chronic pain reduction. Anticonvulsants such
Gabapentin can stop nerve pain and Citalopram for mood disorder (Talmi
et al, 2000, pp. 303).
Non-Pharmacological treatment of neck cancer pain
As much as pharmacological techniques were recognised as significantly
effective, nonpharmacological therapies were also used in enhancing pain
management. In most cases, skin stimulation was used, where Mr. X’s
skin was stimulated in a harmless way so as to treat pain. This therapy
mainly includes therapies such as hot-cold treatments, positioning,
exercise, hydrotherapy, acupuncture and movement-restriction resting.
These techniques proved useful especially as far as alleviation of
secondary pathologies are concerned including function loss, muscle
spasm, edema, inflammation and progressive tissue damage that accompany
pain. Non-pharmacological strategies such as comfort measures,
positioning and adequate rest were utilised to reduce pain and any
associated discomfort Chapman (2012).
Mr X coped well with the pain management regime, although at certain
times he experience acute and chronic pain. Mr X exhibited a reluctance
to inform the multidisciplinary team of the severity of his pain, due to
drug tolerance, which he felt the pain during the later stage of the
illness could not be controlled. It was also highlighted that Mr X
viewed and accepted pain as the inevitable part of cancer therefore
resulting by not informing the staff.
Mr X and his family were reassured about the importance of informing the
staff in order to minimise his discomfort/pain so that his illness can
be effectively managed.
In conclusion, the pain experience by Mr X was managed effectively. The
management was very informative and enlightening in how to assess,
evaluate and control chronic pain emanating from neck cancer. Although
Mr X was reluctant to inform the staff it proved that reassurance can
and often result in gaining trust from patient and the family. It is
paramount information that was gained during the treatment of Mr X’s
pain no matter how minimal or severe.
Mr X’s illness and the subsequent care provided an insight into the
importance of treating the individual as a whole, not just his illness
which initiated sensitivity, discretion and an insight into the ethical
theories that would assist the staff to cater for his individual wishes.
This knowledge would also help towards the appropriate and relevant
choice of effective pain management drug regimes and strategies. It is
essential to recommend the need for nurses to signpost clients to other
appropriate and relevant support professionals who can also help with
pain management, such as other health care professionals, for example
psychologist and alternative therapist such as acupuncture, all can help
to alleviate pain and anxiety.
Developing a systematic approach to pain management is a key area
surrounding Mr X’s illness.
Breivik H, Cherny N, Collett B et al (2009) Cancer related pain:
apan-European survey of prevalence, treatment and patient
attitudes.Annals of Oncology. (20) 8:1420-1433.
Calvino, B., Grilo, R.M. (2006) Central pain control. Joint Bone Spine
73:1, 10-16.
Chapman, S. (2012) ‘Cancer pain part 1: causes and
classification.’Nursing Standard.London. Vol 26, No. 47:42-46.
“New Guidelines Set for Better Pain Treatment.” Medical Letter on the
CDC & FDA September 5, 2004: 95.
Clark, D. (1999) ‘Total pain’, disciplinary power and the body in
the work of Cicely Saunders, 1958-1967.Social Science & Medicine, (49)
6, 727-736.
Farquhar-Smith, P. (2007) Anatomy, phyisiology and pharmacology of pain.
Anaesthesia and Intensive Care Medicine 9: 1, 3-7
Fitzgibbon, D.R. and Richard, C.R. (2001) ‘Cancer pain: Assessment and
diagnosis.’ In: Bonica’s Management of Pain. Loeser JD, Butler SH,
Chapman CR, Turk DC, editors, Philadelphia: Lippincott Williams and
Wilkins, pp. 623-58.
International Association for the Study of Pain (2008) IASP Pain
Terminology HYPERLINK
HTMLDisplay.cfm&ContentID=1728 (Last accessed: 15/11/2012
Ko, S. M., Zhou, M. (2004) Central plasticity and persistent pain Drug
Discovery Today: Disease Models Pain and Anaesthesia 1: 2, 101-108
McCaffery,M., Pasero, C. (1999) Pain:A Clinical Manual. St Louis, MO:
Mehta, A., Cohen, S. R., Ezer, H., Carnevale, F. A., Ducharme, F.
(2011) ‘Striving to Respond to Palliative Care Patients’ Pain at
Home: A Puzzle for Family Caregivers’ Oncology Nursing Forum • Vol.
38, No. 1
Middleton-Green L (2008) Managing total pain at the end of life: a case
study analysis.Nursing Standard. 23, 6, 41-46.
Nursing & Midwifery Council (2010) Professional Code of Conduct. London:
Raphael, J., Ahmedzai, S., Hester, J., Urch, C., Barrie , J.,
Williams, J., Farquhar-Smith, P., Fallon, M., Hoskin, P., Robb, K., .
Bennett, I. M., Haines, R., Johnson, M., Bhaskar, A., Chong, S.,
Duarte, R., Sparkes, E. (2010) ‘Palliative Care Section: Cancer
Pain: Part 1: Pathophysiology Oncological, Pharmacological, and
Psychological Treatments: A Perspective from the British Pain Society
Endorsed by the UK Association of Palliative Medicine and the Royal
College of General Practitioner’ Pain Medicine, Wiley Periodicals,
Inc: London, 11: 742–764
Robb, K., Oxberry, S. G., Bennett, M. I, Johnson, M. I., Simpson, K. H.,
Searle, R. and Cochrane, D. A (2009) ‘Systematic Review of
Transcutaneous Electrical Nerve Stimulation for Cancer Pain.’ J Pain
Symptom Manage, 37:746-53.
Robert, F. (2004). “More than Half of Patients With Major Depression
Have Chronic Pain.” Family Practice News October 15, 2004: 38.
Talmi, YP Horowitz, Z Peffer, MR Stolik-Dollberg, OC Shoshani, Y
Peleg, M Kronenberg, J (2000). Pain in the neck after neck dissection.
Otolaryngology – Head and neck surgery, Vol.123, No. 3, pp.302-306,
September 2000. ISSN: 0194-5998
Thapa, D., V Rastogi1, V. And Ahuja, V. (2011) ‘Cancer pain management
current status’ Journal of Anaesthesiology Clinical Pharmacology,
Varanasi: India, Vol. 27 Issue 2.
Twycross, R. (1994) Pain Relief In Advanced Cancer. Churchill
Livingstone, New York
Twycross R & Bennett M. (2008) ‘Cancer pain syndromes’. In: Sykes,
N., Bennet,t M.I. and Yuan, C-S.(eds) Clinical pain management: Cancer
pain. 2nd ed. London: Hodder Arnold, pp. 27–37.
Williams, J.E., Yen, J.T., Parker, G.M., Chapman, S., Kandikattu, S., &
Barbachano Y. (2010). Prevalence of pain in head and neck cancer
out-patients. Journal of Laryngology and Otology, Vol.124, No. 7, pp..
767-773, ISSN 0022-2151