Review of Barriers to Effective Cancer Pain Management

Pain management is an important indicator of a patient’s quality of life because pain is the most feared of all the symptoms associated with cancer. Unfortunately, ineffective and inadequate cancer pain management remains a major problem in the clinical setting despite the availability of pain assessment tools, and effective pharmacological and technological advances in pain management.

the beliefs patients have about pain could be the major hindrance in achieving optimal cancer pain control.

Yates, Patsy M. and Edwards, Helen E. and Nash, Robyn E. and Walsh, Anne M. and

Fentiman, Belinda J. and Skerman, Helen M. and McDowell, Jan K. and Najman,

Jake M. (2002) Barriers to Effective Cancer Pain Management: A Survey of

Hospitalized Cancer Patients in Australia. Journal of Pain and Symptom Management

23(5):393-405.

Reluctance to use analgesics and inadequate reporting of pain have been well documented as barriers to optimal cancer pain management

Despite the fact that cancer pain can be controlled in 90% to 95% of patients with effective pharmacologic and nonpharmacologic approaches, unfortunately, unrelieved pain remains highly prevalent

patient beliefs about pain control also are a primary obstacle to effective pain management

Enhancing management of cancer pain: Contribution of the internal working model

Lin, Chia-chin Ph.D., R.N. Cancer Nursing

Issue: Volume 21(2), April 1998, pp 90-96

Assessment of patients’ beliefs or concerns about pain and pain treatment, meanings associated with pain experiences, intentions to follow prescribed treatment, and expectations about relief of pain comprise the crucial first step in successful management of cancer pain. Clinicians are in an important position to assess these components within the patient’s internal working model. However, it may not be correct to assume that patients are the only group in need of assessment. Family caregivers play a crucial role in pain management for patients with cancer.

Patients’ reluctance to report pain and to use analgesics are considered major barriers to pain management.

Despite scientific and medical advances that have provided a better understanding of pain and its treatment, much pain still goes unrelieved

The most frequently mentioned barriers for both patients and professionals were knowledge deficits, inadequate pain assessment and misconceptions regarding pain.

Nurses need to be aware of the barriers, the patient’s fears in particular because nurses are exquisitely trained to address these fears with their patients and often have the most intimate relationships with their patients. They have the insight to be aware of what might be serving as an obstacle to good pain control.

Overcoming Patient-related Barriers to Cancer Pain Management for Home Care Patients: A Pilot Study

Chang, Ming-Chuan MS, RN; Chang, Yue-Cune PhD; Chiou, Jeng-Fong MD, MS; Tsou, Tsung-Shan PhD; Lin, Chia-Chin PhD, RN

Cancer Nursing

Issue: Volume 25(6), December 2002, pp 470-476

Studies have demonstrated that patients don’t want to talk about symptoms with their oncologist, because they are afraid to distract the oncologist from the cancer care and are concerned that if they report symptoms they won’t be a candidate for clinical trials. Through their skills and education, nurses can address these concerns with patients and family members. Pain management really needs to be directed not just to the patient but also to the family. You could have done the best education for the patient, but if the spouse is very anxious about opioids, he or she will send messages to the patient to withhold the drug.

Morphine is the most commonly used opioid agent for moderate-to-severe pain because it’s widely available in a variety of doses and forms,

Physical and psychosocial methods can also be used with drugs or alone to help control pain in cancer patients.

Several studies have documented that cancer pain is often undertreated.4 Unrelieved pain can have profound consequences for the patient and his or her family. It can lead to depression, loss of sleep, and poor appetite; prevent the dying patient from experiencing enjoyment; and create a sense of hopelessness. It has frequently been cited as a major justification for those who seek legalization of physician-assisted suicide and euthanasia. Yet, most pain at the end of life can be treated with simple measures.4 The physician needs to be not only skillful in effective pain management at the end of life but must also appreciate the special approaches to pain management and drug prescribing in the older patient.5

Whereas pharmacologic interventions are the mainstay for chronic pain management, nonpharmacologic approaches may be very beneficial and synergistic to drug treatments

Neurosensory stimulation techniques such as acupuncture and transcutaneous electrical nerve stimulation (TENS) can be helpful. Massage, exercise, heat and cold, and other interventions administered by a physical therapist can offer pain relief. Psychological approaches, such as counseling, music therapy, and biofeedback, as well as spiritual interventions, can be an aid to relieve pain.9,21 Osteopathic manipulative therapy offers an additional effective strategy to pain management.24 Effective pain management is truly interdisciplinary. It is important that the physician recognize the role that multiple health care professionals have in the management of pain at the end of life.5,7,17

Morphine is the opioid drug of choice; it is versatile, affordable and readily available.

It is administered orally and has a half-life of about 2 – 2.5 hours. Except in

patients in renal failure, it has no danger of accumulation.

As per WHO recommendation, [6] oral route is the preferred route of administration for cancer pain.

Identifying patient barriers to analgesic use is an important nursing consideration. Patient barriers influence pain reporting of pain, adherence to analgesic therapy, and quality of life. Early assessment and intervention for these barriers are essential, and may be effective in ensuring adequate analgesic use and in identifying appropriate nonpharmacologic pain therapies.

Recent research supports some of the older methods of nonpharmacological pain control such as distraction, especially humor; relaxation using the patient’s own memory of peaceful events; and cutaneous stimulation, especially use of cold. Cutaneous stimulation may even be effectively used at sites other than the site of pain

The role of non-pharmacological approaches to pain management is evolving, and it is likely that some non-pharmacological and complementary therapies may have an important contribution to make to holistic patient care. However there is no strong evidence to support their analgesic effectiveness, particularly in cancer pain.

Hypnotic relaxation is the most frequently cited form of non-pharmacologic cognitive pain control. Hypnotic relaxation may be defined as a deeply relaxed state involving mental imagery (Woody et al, 1992; Hammond and Elkins, 1994; Elkins, 1997). Hypnotic relaxation in the treatment of cancer patients involves the use of relaxation and mental imagery to induce relaxation, reduce anxiety and distress, and help patients detach themselves from obsessional thoughts (Araoz, 1983). Hypnotic relaxation has been found to be of significant benefit in reducing anxiety (Wadden and Anderton, 1982; Elkins, 1986). Furthermore, patients who develop anxiety disorders may be more hypnotizable than others (Frankel, 1974).

In the use of hypnotic relaxation for pain management, the focus is on instructing the patient in relaxation and mental imagery. The patient learns a cognitive method of pain management which is utilized at the discretion of the patient and within the patient’s own control. The successful effect is to introduce a non‑pharmacologic method of pain control that may decrease unnecessary dependency on analgesics for pain. Hypnotic relaxation is a safe method, which, when properly used, has no harmful side effects.

Cancer patients frequently experience anxiety due to anticipation about the illness, anticipation of potential treatment-related side effects such as nausea and vomiting, or anticipation of entering the final stages of life (Roberts et al, 1997). Kraft studied hypnotic relaxation in the management of 12 terminally ill cancer patients and reported a reduction in anxiety and depression (Kraft, 1990). Our experience has indicated that hypnotherapy is well accepted by cancer patients and is a powerful adjunct to the usual standard of oncology care (Marcus et al, 2003 a, b, c, d; 2004 a, b, c).

Pain should be considered in its totality of impact. Pain must also be considered in its temporal existence. Every patient will be able remember a time prior to the advent of the cancer and its attendant pain. Pain exists in the moment, and that is generally the patient’s primary concern. The clinician needs to keep in mind that the pain should be treated in a prophylactic manner. When pain is present, a certain amount of anxiety must be considered to be in evidence. The anxiety may be overtly visible or it may be covertly in evidence by its conspicuous absence. Anxiety may manifest itself in the family. Understanding and awareness of the patient’s anxiety about impending pain and the clinician’s role in preventive management needs to be conveyed to the patient to allay this anxiety.

Interventions such as hypnosis can increase the patient’s feeling of self-efficacy and mastery of their internal and external environments. As the patient becomes less anxious and increasingly competent in their use of self-hypnosis to manage their pain, their attendant anxiety frequently is diminished. This may have a similar effect on the family system as family members see their loved ones coping better with the pain.