|Year : 2017 | Volume
| Issue : 1 | Page : 8-12
Pain assessment and management in cancer patients
Mariam K Dabbous, Fouad R Sakr, Etwal P Bouraad, Jihan H Safwan, Marwan G Akel, Michelle M Cherfan
School of Pharmacy, Lebanese International University, Beirut, Lebanon
|Date of Submission||11-Nov-2016|
|Date of Acceptance||15-Dec-2016|
|Date of Web Publication||1-Feb-2017|
Fouad R Sakr
Saleem Salam, Beirut
Source of Support: None, Conflict of Interest: None
Background: Pain is one of the most common associated symptoms in cancer patients. It develops a number of devastating physical and psychological symptoms. Aim: The purpose of this study is to evaluate the current pain assessment and management plans in cancer patients. Settings and Design: This prospective multicenter observational study was carried out in 3 university hospitals in Lebanon over 6 months from October 2014 to April 2015. Materials and Methods: Men and women aged 18 years and above were observed if they have had any type of cancer, more than 1 day of hospitalization, cancer-related pain, and receiving analgesics. A total of 508 patients were screened over 1 year, where 100 patients have met the eligibility criteria and were observed. The primary outcome measure was an evaluation of pain assessment adherence to the National Comprehensive Cancer Network (NCCN) guidelines. Secondary outcomes included evaluation of adherence of pain management approaches. Statistical Analysis Used: Data were analyzed with SPSS version 21.0. Adherence to the guideline recommendations for assessment was compared using t-test, whereas, adherence to guideline recommendations for treatment was compared using linear regression. Results and Conclusions: Most patients were not adhered to the pain assessment guidelines (82% vs. 18%, P = 0.002), where although patients were assessed by a health-care provider during initial hospitalization, yet, no tool was used for assessment, and there was no documentation of measured pain intensity. For the pain management adherence, 76% were adhered versus 24% were not adhered, P = 0.006. The mis-adherence was in the choice of opioid agent (61.8% vs. 38.2%, P = 0.003), and dosing of these agents (75.5% vs. 24.5%, P< 0.001). Well adherence was observed in terms of nonopioid analgesics use (72.5% were adhered vs. 27.5% were not, P = 0.01). Poor overall adherence to NCCN guidelines was found, and the gaps were related to pain assessment and management recommendations.
Keywords: Cancer, management plans, nonopioid analgesics, opioids, pain assessment
|How to cite this article:|
Dabbous MK, Sakr FR, Bouraad EP, Safwan JH, Akel MG, Cherfan MM. Pain assessment and management in cancer patients
. J Health Res Rev 2017;4:8-12
|How to cite this URL:|
Dabbous MK, Sakr FR, Bouraad EP, Safwan JH, Akel MG, Cherfan MM. Pain assessment and management in cancer patients
. J Health Res Rev [serial online] 2017 [cited 2019 Dec 11];4:8-12. Available from: http://www.jhrr.org/text.asp?2017/4/1/8/199324
| Introduction|| |
Pain is considered one of the most common associated symptoms in cancer patients. It develops a number of devastating physical and psychological symptoms that may arise during different phases and stages of cancer. The natural history of cancer pain differs from noncancer pain, in that it may be severe at initial diagnosis, followed ideally by improvement during treatment and remission.
Pain occurs in approximately one-quarter of patients with newly diagnosed malignancies, one-third of patients undergoing treatment, and three-quarters of patients with advanced disease.
Unrelieved pain in cancer patients denies them comfort and greatly affects their activities, motivation, interactions with family and friends, and overall quality of life.
In fact, pain assessment and management remains one of the most challenging approaches among cancer patients, where optimal pain control is demanded to improve their quality of life in earlier and advanced stages.,
Pain is what the person says it is and exists whenever he or she says it does, and patient's self-report of pain is the standard of care.
Thus, a comprehensive pain assessment plan including existence, intensity, location, description, and duration of pain is an essential tool to evaluate the need and significance of treatment adequacy. After adequate pain assessment, the discipline of pain management involves several principles including appropriate pharmacological and nonpharmacological pain approaches, as well as, addressing psychological issues.
Opioids remain the cornerstone therapeutic option implicated to alleviate pain in oncological settings. The use and abuse of opioids in clinical settings was well identified in a study conducted in other country, yet no literature on this subject exists with respect to Lebanon. Hence, we prospectively observed three different Lebanese university hospitals to evaluate the current pain assessment and management plans in cancer patients.
| Materials and Methods|| |
Evaluation of cancer pain management was a multicenter, prospective, and observational study designed to follow up patients with cancer pain on opioid and nonopioid analgesic therapies.
This study was done over 6 months from October 2014 to April 2015 in three university hospitals in Lebanon. An operations committee, with assistance from oncology medical specialists at study participating centers, was responsible for the design, conduct, and reporting of the study. All patients provided written informed consent. The study was approved by institutional review board of all participating centers. Patient's eligible if they were 18 years of age and above; had any type of cancer, including both solid and liquid tumors, with the presence of cancer-related pain. Reasons for exclusion were pediatric patients, oncological emergencies including brain metastasis, bone fractures, and organ obstruction and perforation; and surgery as part of the treatment regimen.
All study participants were prospectively observed for their cancer pain assessment and management plans. The process was a composite of two-step procedure. The first step was reviewing the medical charts of oncology departments in each of the participating medical centers to select patients who were eligible for the study, as well as, to collect data regarding these patients. The second step, on the other hand, involved direct contact with eligible patients to compare the real and the documented cancer pain assessment and management plans.
A standard data collection sheet was used for documentation. Each data collection sheet included six distinct sections covering patients' characteristics, pain assessment plan, past medication history, current medications, side effects documented, and laboratory values.
For the patients' characteristics, each data collection sheet was filled with patient's age, gender, weight, height, social history (smoking and alcohol statuses), co-morbidities, type of malignancy, date of diagnosis, disease status, and whether receiving psychological therapy or not.
For the pain assessment plan section, the medical charts were reviewed for any documented pain measured by physicians before treatment, and for the tool of pain assessment, as well as, whether the pain was reassessed after 24–48 h after treatment. In addition, within this section, we contacted patients directly to assess for the real presence of pain, intensity of pain (mild, moderate, or severe, using a verbal numerical rating scale), description of pain (somatic, visceral, or neuropathic), duration of pain (continuous or intermittent), and characteristics of pain (throbbing, burning, sharp, shooting, and/or diffused).
The section of past medication history was also filled via direct contact with patients or their caregivers regarding their previous use of opioid and nonopioid analgesics, and based on this patients were classified as opioid naïve or tolerant.
With respect to the current medications section, it was divided into opioid analgesics and nonopioid analgesics. Considering the opioid analgesics division first, the medical charts were accessed to determine whether the patient was initially started on opioid therapy, the opioid agent used, the route of administration, and whether the patient is receiving continuous, rescue dosing, or both; as well as, whether dose switching was applied adequately after 24 h and opioid rotation was applied adequately after development of nontolerable adverse events. On the other hand, for the division of nonopioid analgesics, medical charts were also reviewed to determine whether the patient was receiving non-opioid analgesics, and their types (acetaminophen, NSAIDs, corticosteroids, anticonvulsants, antidepressant, and/or others).
Similarly, the section of side effects documented involved direct contact with eligible patients to assess for the development of any significant opioid-related adverse drug reactions including constipation, nausea, pruritus, and respiratory depression. Moreover, medical charts were also accessed to check whether patients have received preventative and/or treatment measures for these opioid adverse reactions.
Finally, the charts were reviewed for routine lab data and thus the section of lab values was filled to determine patients' renal and hepatic functions.
The primary end point was a composite of evaluation of pain assessment adherence to the National Comprehensive Cancer Network (NCCN) guidelines in nononcological emergency cancer patients, initially and after management.
The secondary end point was a composite of evaluation of pain management approaches, including choice of analgesics, dosage forms, dosing, duration of treatment, and preventive measures; and adherence of the current implicated strategies to the NCCN guidelines.
Data were analyzed with SPSS (Statistical Package for the Social Sciences; Chicago, IL, USA). Patients sample size was determined based on 95% confidence interval (CI), and calculated through openepi toolkit. Patients' baseline characteristics were expressed in terms of frequencies. Overall adherence to the guideline recommendations for assessment was compared using t-test. Composite of assessment by health-care provider, tool used for assessment, and reassessment after treatment was expressed in terms of frequencies. The adherence to guideline recommendations for choice of opioid agents, dosing of opioid agents, and nonopioid analgesics use was compared using linear regression.
Statistically significant nonadherence and adherence differences were interpreted as P of 0.05 with 95% CI.
A total of 508 patients were screened over a period of 1 year, among which, 100 patients were observed [Figure 1]. [Table 1] demonstrates the baseline characteristics for these patients. 51% were male versus 49% female. For the age: 64.7% were in the range of 50–79 years, 31.5% were in the range of 18–49 years and 3.8% were above 80 years. For the smoking status: 63.7% were smokers versus 36.3% nonsmokers. For the type of malignancy: 25.5% had hematological tumor versus 74.5% solid tumor. For the metastasis: 50% were with metastasis versus 50% were not. Finally for the date of diagnosis: 62.8% were diagnosed between 1 and 5 years, 32.4% <5 years, and 4.8% above 5 years.
| Results|| |
Most patients were not adhered to the pain assessment guidelines 82% versus 18%, P = 0.002 (CI: 42.95–54.41), where although patients were assessed by a health-care provider during initial hospitalization 95% versus 5% with P < 0.001 (CI: 38.95–60.95], yet, no tool was used for assessment 16% versus 84% with P < 0.001 (CI: 29.43–65.43], and there was no documentation of measured pain intensity, as well as, reassessment after treatment intervention was not routinely performed, 3% versus 97% with P < 0.001 (CI 40.68–60.68] [Table 2]. For the pain management adherence, 76% were adhered versus 24% were not, P = 0.006 (CI: 9.9–14.9). The mis-adherence was in the choice of opioid agent, 61.8% versus 38.2%, P = 0.003 (CI 3.24–4.9); and in its dosing, 75.5% versus 24.5%, P = 0.001 (CI: 9.94–14.95). Well adherence was observed in terms of nonopioid analgesics use, 72.5% were adhered versus 27.5% were not, P = 0.01 (CI: 0.5–0.4) [Table 3].
In the Lebanese hospital settings, although cancer pain was assessed after initial hospitalization, yet, the use of pain scale is recommended. It contributes to overall improvement in analgesic therapy. Documentation of pain intensity is demanded on regular basis, since pain is not a static condition and tends to change over time. Reassessment post therapy is necessary to evaluate further treatment modifications. Cancer pain management mis-adherence to the guidelines involves the choice of opioid agent. As well, mis-adherence was in opioid dosing titration, conversion and rotation.
| Discussion|| |
Pain is one of the major factors affecting health-related quality of life in cancer patients, and its optimal management can improve quality of life. Unrelieved pain has a devastating effect not only on patients but also on their families and caregivers. In fact, it affects multiple domains in their lives, including the psychological, social, spiritual, and existential; and may precipitate hopelessness and make desire for death more likely. Poorly controlled pain also may increase patient anxiety and concerns related to disease progression and death. During cancer, multiple factors can interfere with opioid responses including disease progression, side effects, the type and temporal pattern of the pain syndrome, as well as, individual pharmacokinetic and pharmacodynamic factors.
The NCCN developed pain assessment and management guidelines to improve patients' quality of life. The guidelines contains several required components; pain intensity must be quantified by the patient, whenever possible, as the algorithm bases therapeutic decisions on a numerical value assigned to the severity of the pain. A formal comprehensive pain assessment must be performed, and reassessment of pain intensity must be performed at specified intervals to ensure that the therapy selected is having the desired effect. Furthermore, psychosocial support must be available, and specific educational material must be provided to the patient.
Moreover, the guidelines provide specific suggestions for titrating and rotating opioids, escalation of their dosage, and management of their adverse effects; as well as, when and how to proceed to other techniques and/or interventions for the management of cancer pain.
Morphine is generally considered the standard starting opioid of choice, yet, no single opioid is optimal for all patients. In general, the short half-life opioid agonists are preferred because they can be more easily titrated than the long half-life analgesics. Furthermore, oral route is preferred for administration of chronic opioid therapy. The oral route should be considered first in patients who can take oral medications unless a rapid onset of analgesia is required or the patient experiences side effects associated with the oral administration. Whereas, intravenous route is considered for faster analgesia because of the short lag-time between injection and effect (peak 15 min) in comparison with oral dosing (peak 60 min).,,, Transdermal agents are not indicated for rapid opioid titration, and only should be recommended after pain is controlled by other opioids. Opioids are usually associated with a number of serious adverse events, hence, proper management is necessary to prevent and reduce these events.,,
Patients experiencing neuropathic pain should be considered for the use of co-analgesics in order to enhance response to opioid therapy; also, patients experiencing pain crisis due to neural structures or bones should be considered for the use of corticosteroids as co-analgesics but with caution for long-term adverse effects.,
A number of studies have been conducted to evaluate current approaches being used in pain assessment and management. Håkonsen et al., conducted a retrospective multicenter study in Scotland to measure adherence of current pain practice to specific cancer pain guidelines criteria. The study that was published in 2008 confirmed good overall adherence, yet, there were gaps in the criteria related to pain assessment, and implementation of opioids in management plans.
Another study in the form of survey, by Carulla Torrent, et al., was conducted in Spain using a questionnaire to identify the medical oncologists' perception about pain management in their patients. The study was published in 2007 and concluded that pain has to be evaluated using validated scales with greater attention to management. Moreover, Shaheen et al., published in 2010 a prospective survey study that was conducted in the United States of America to identify common errors in opioids use. The study concluded that most common errors occur in strategy, conversion, rotation, and titration of opioids, as well as in the use of adjunctive analgesia.
We found that meperidine was frequently prescribed to cancer patients, although the guideline warns its use. Meperidine is predominantly a µ receptor agonist, and it exerts its chief pharmacological action on the central nervous system (CNS) and the neural elements in the bowel. Meperidine is no longer recommended for the treatment of chronic pain because of concerns over metabolite toxicity. Sometimes it causes CNS excitation, characterized by tremors, muscle twitches, and seizures; these effects are due largely to accumulation of a metabolite, normeperidine. As with morphine, respiratory depression is responsible for an accumulation of CO2, which, in turn, leads to cerebrovascular dilation, increased cerebral blood flow, and elevation of cerebrospinal fluid pressure. It should not be used for longer than 48 h or in doses >600 mg/day.,,,
Furthermore, mis-adherence was in terms of opioid dosing strategies, particularly failure to order oral or sustained release opioid agents, where most patients received continuous intravenous infusion regardless whether patient is opioid naïve or tolerant; use of multiple opioids from same class, inadequate trial of initial opioid, discontinue opioids inappropriately and incorrectly, make more than one change at a time, and give prophylaxis for opioids side effects. For instance, in the Lebanese hospital settings patients were not following such dosing strategy; where after 24 h following up the patient, if acceptable comfort from pain has been achieved, the total 24 h dose is to be converted into a maintenance and breakthrough dosing., An extended-release oral opioid, if feasible, or other extended-release formulation (e.g., transdermal fentanyl), or other long-acting agent (e.g., methadone) are recommended for maintenance dosing to provide background analgesia for control of chronic persistent pain controlled on stable doses of short-acting opioids.,,,, Whereas, breakthrough dosing is a rescue dose of 10–20% of the total 24 h dose, given on as needed basis, using short-acting opioids for pain not relieved by extended release opioids including breakthrough pain or acute exacerbations of pain, activity or position related pain, or pain at the end of dosing interval.
Our study has several limitations. First, our study focused on cancer patients without any oncological emergency, excluding all patients with pain related to procedures or with any oncological emergency, so this might limit generalizability of our data. Second, upon data collection, sometimes we depended on the caregiver to answer our questions; this may carry certain bias related to pain assessment. Finally, we did not focus on the use of adjuvant analgesics, so further research is necessary to determine its role in reducing overall opioidal dose in cancer patient.
| Conclusions|| |
Mis-adherence identified by our study should stimulate broader healthcare professionals' education in basic principles of pain assessment, effective opioid use, and support further investigation to identify the underlying issues in various practice settings.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]