Chapter 7: Pain Management in Palliative Care

Introduction

Pain is a common experience for almost all patients receiving palliative care in the United Kingdom (UK). Pain can be significant, and it may have a major negative impact on a person's quality of life; therefore, it is essential that nurses working in palliative care settings understand how to manage this issue. However, the experience of pain in the palliative care setting, and its relief and control, can be complex. In this chapter, you will study the pathophysiology of pain, the characteristics of the different types of pain, and the assessment of pain in the palliative care setting. This chapter will also describe in detail the variety of pharmacological and non-pharmacological strategies which may be used to manage various types of pain in palliative care settings, and relevant considerations associated with their use. In completing this chapter, you will be equipped with the knowledge and skills necessary for the challenging task of managing pain in the palliative care setting.

Important note

This chapter assumes a basic knowledge of human anatomy and physiology. If you feel you need to revise these concepts, you are encouraged to consult a quality nursing textbook.

Pain in the palliative care setting

Pain is defined as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage" (International Association for the Study of Pain, 2016: NP). It is a highly subjective experience - that is, it can be best identified and described only by the person who is experiencing it. The experience of pain has a variety of complex negative physical, psychological, social and spiritual impacts; consider the examples in the following table:

Physical Impacts of Pain	Psychological Impacts of Pain
Impaired mobility. Nausea. Weakness, drowsiness.	Depression, anxiety, Fear (e.g. equating pain with death). Anger, despair, hopelessness.
Social Impacts of Pain	Spiritual Impacts of Pain
Inability to work. Restricted social activity. Changes to role and function.	Loss of sense of purpose. Change to expected life journey. Feelings of being 'punished'.

Pain is a significant problem in the palliative care setting; indeed, recent research suggests that up to 70% of patients receiving palliative care report pain, and approximately half of these people experience pain which they describe as 'moderate' or 'severe'. Palliative care patients who experience the worst pain tend to: (1) be younger, (2) be in poorer general condition, and (3) have a shorter survival. Pain is often associated with other distressing symptoms such as nausea, weakness, drowsiness and psychological problems such as depression and anxiety. If it is poorly controlled, pain can significantly decrease the quality of life, and may also shorten the duration of life, of a patient receiving palliative care.

The pathophysiology and types of pain

It is important that nurses working in palliative care settings have a fundamental understanding of the pathophysiology of pain. Pain is experienced through a process known as nociception. Receptor cells referred to as nociceptors detect noxious, or pain-causing, stimuli (which may be of mechanical, thermal or chemical origin). These nociceptors transmit the noxious stimuli, as an electrical impulse, to the brain. Electrical impulses are transmitted along nerve fibres with the assistance of neurotransmitters, particularly serotonin and noradrenaline. Once the electrical impulse reaches the brain, the brain can initiate a response.

There are many different types of pain, one or more of which may be experienced by a patient in a palliative care setting. Pain is typically divided into: (1) nociceptive pain, associated with tissue damage, and (2) neuropathic pain, associated with nerve damage. Both types of pain may be: (1) constant (i.e. continuous), or (2) episodic (i.e. occurring at specific times). Different types of pain are treated using different types of analgesic medication. Review the information in the following table:

Type of Pain	Character-istics	Example	Analgesic Medication
Nociceptive somatic	Constant	Bone metastasis	Opioids (partial) Non-steroidal anti-inflammatories Paracetamol, acetaminophen Bisphosphonates Topical anti-inflammatories Tricyclic agents
Nociceptive somatic	Episodic	Pathological fracture, vertebral collapse	Opioids (partial) Nerve block
Nociceptive visceral	Constant	Liver capsular pain	Opioids (partial) Corticosteroids
Nociceptive visceral	Episodic	Tumour obstructing bowel	Opioids (partial) Anticholinergics
Neuropathic	Constant	Chemotherapy-induced painful neuropathy	Opioids (partial) Tricyclic agents Antiepileptic agents
Neuropathic	Episodic	Brachial plexopathy	Tricyclic agents Antiepileptic agents Benzodiazepines

In addition to nociceptive versus neuropathic, pain may also be classified as either: (1) acute, or (2) chronic. Read the information in the following table:

	Acute Pain	Chronic Pain
Onset and Duration	Generally sudden onset. Shorter-term duration.	Gradual or sudden onset. Longer-term duration.
Cause	A clearly-defined cause (e.g. vertebral collapse, fracture, obstruction, tumour, etc.).	Cause may not be known, or may be unclear.
Course	Pain resolves as cause is addressed.	Pain may not resolve; may cycle through periods of improvement / worsening.
Goals of Treatment	Pain control and eventual elimination.	Pain control to the greatest extent possible; enhance function and quality of life.

Nurses working in palliative care settings must also be aware of the following types of pain:

• Background pain: this is mild to moderate 'baseline' pain, which is a constant feature of a patient's condition (e.g. as with many types of cancer).
• Breakthrough pain: this is more severe 'transient' or 'episodic' pain, which may occur at various times throughout the disease progression. It may be described as:
• Paroxysmal breakthrough pain, which is idiopathic (i.e. has no clear cause).
• Incident breakthrough pain, which has a clearly-defined cause (e.g. a patient experiences a metastasis-related bone fracture or vertebral collapse).
• End-of-dose breakthrough pain, where pain is exacerbated as a result of analgesic medications in a patient's body reducing below the required therapeutic levels.

Assessment of pain in the palliative care setting

You studied the assessment of patients in palliative care settings in detail in an earlier chapter of this module; you should revise this chapter now, if required. This chapter will focus on the assessment of pain in palliative care settings. The assessment of pain in patients receiving palliative care depends on the situation; if a patient is experiencing severe, acute pain, assessment should be rapid to enable rapid intervention. If a patient is experiencing less-severe or chronic pain, a more comprehensive pain assessment should be undertaken to improve the longer-term management of their pain.

As in all nursing settings, rapid pain assessment is completed using the 'OPQRST' mnemonic

O	Onset: "When did the pain begin?"
P	Provocation and palliation: "What makes the pain worse? What helps the pain?"
Q	Quality: "Describe the pain." (E.g. sharp, dull, stabbing, etc.).
R	Region and radiation: "Where do you feel the pain? Does the pain spread to other areas of your body?"
S	Severity: "On a scale of 1 to 10, where 1 is no pain and 10 is the most severe pain you have experienced, how would you rate the pain?" (Note that there are a range of other pain scales - including visual scales for paediatric and non-verbal patients - which may be used in palliative care settings).
T	Time: "How long has the pain been present?"

At the end of life, particularly if a person is suffering from neurological / cognitive deficits, they may be unable to describe their pain (qualitatively or quantitatively), or even communicate that they are experiencing pain. In this situation, it is important that nurses observe clients for other objective indicators of pain - for example:

• An unexplained rise in heart rate and / or blood pressure.
• A change in demeanour (e.g. an increase in aggression, agitation, etc.).
• Other subtle signs (e.g. diaphoresis, pallor, etc.).

Management of pain in the palliative care setting

The first step in managing pain in the palliative care setting is to speak with the patient, with the patient's family members / carers / significant others (where appropriate), and consult with the patient's advance care planning documentation. This is important in determining and / or clarifying the patient's wishes and preferences for pain management. Various pain management strategies, described throughout the remainder of this chapter, should be discussed with the patient, and informed and collaborative decisions made.

Depending on the nature of the patient's pain, there may be a number of goals to pain management in the palliative care setting:

• Modifying the underlying disease process causing the patient's pain.
• Raising the patient's pain threshold, or modifying their perception of pain.
• Modifying the patient's environment and supporting activities of daily living.
• Interrupting the pain pathways.

Medication interventions - specific, analgesic medications - are the primary treatment for all types of pain in the palliative care setting. Analgesic medications may act by: (1) blocking receptors and preventing the transmission of electrical impulses along pain pathways, or (2) preventing the production of substances, such as the enzyme cyclooxygenase, which contribute to pain. There are three different types of analgesic medications in use in palliative care settings in the UK: 

Type of Analgesic Medication	Description	Examples
Non-opioids	Usually used for mild to moderate pain, or in combination with other medications for more severe pain.	Paracetamol. Aspirin. Non-steroidal anti-inflammatories.
Opioids	Usually used for moderate to severe pain; associated with a number of noteworthy side-effects.	Codeine. Tramadol. Morphine. Oxycodone. Fentanyl.
Adjuvants (also 'co-analgesics')	Usually used in combination with non-opioids and / or opioids, and / or for atypical pain.	Tricyclic agents. Antiepileptic agents. Corticosteroids. Anticholinergics. Benzodiazepines.

Other types of pain relieving medications used less-commonly are anaesthetics, particularly local anaesthetics which block the nerves that pass pain signals to the brain. Anaesthetics are typically used for severe intractable pain, such as that which is likely to be associated with significantly advanced terminal illnesses such as cancer.

It can be complicated to decide on the best combination of pain medications to prescribe to a person receiving palliative care. For this reason, the World Health Organisation has developed a tool known as the Analgesic Ladder. Review the following table, which illustrates the WHO's Analgesic Ladder:

		Severe Pain (unrelieved by previous step)
	Moderate Pain (unrelieved by previous step)	Strong opioid analgesic +/- non-opioid analgesic +/- an adjuvant analgesic.
Mild Pain	Mild opioid analgesic +/- non-opioid analgesic +/- an adjuvant analgesic.
Non-opioid analgesic +/- an adjuvant analgesic.

(Adapted from Faull et al., 2012: p. 120).

The following case study provides an example of the use of the WHO's Analgesic Ladder in palliative care practice:

Depending on the type of analgesic medication prescribed to a patient, it may be administered in a variety of different ways - for example:

• Enterally (i.e. orally). Enteral administration of analgesic medication is often just as effective as parenteral administration, though the onset of action may be slower.
• Parenterally (i.e. intravenously). Medications administered parenterally act quickly. Often in the palliative care setting, parenteral administration of analgesic medication involves the use of patient-controlled syringe drivers.
• Alternative routes (e.g. suppository, transdermal patch, etc.).

Analgesic medications may be:

• Regularly prescribed (i.e. with a set dose taken at set times).
• Administered as required (i.e. top-up doses taken for breakthrough pain).

Use of opioid medication in the palliative care setting

As you have seen so far throughout this chapter, one of the most common types of analgesic medication used in palliative care settings is opioids.

Opioids are particularly strong medications associated with a number of noteworthy side-effects; therefore, it is important that nurses working in palliative care settings know how to use these medications correctly, and are able to counsel patients and patients' family members / carers / significant others (where appropriate) in their effective use. Opioids are divided into two categories:

Opioids for Mild-to-Moderate Pain	Opioids for Moderate-to-Severe Pain
Codeine Dihydrocodeine Tramadol Buprenorphine	Morphine, diamorphine Oxycodone Fentanyl Methadone

It is important for nurses working in palliative care setting to be aware that opioids are associated with a range of significant side-effects. Review the following, which explains these side-effects and their management in the palliative care setting:

• Constipation: this is usually multifactorial in nature, though it can be complicated by opioids, which decrease the peristaltic action of the gastrointestinal system. Because constipation is such a common side-effect of opioid analgesics, most patients will be offered prophylactic oral aperients (usually a combination of a stimulant laxative with a stool softener). Standard nursing care to prevent / treat constipation is also used.
• Nausea and vomiting: this is due to a combination of decreased peristaltic action of the gastrointestinal system and stimulation of the medullary chemoreceptors by the opioid. Anti-emetics may be prescribed for opioid-induced nausea and vomiting. Complementary techniques - including cognitive strategies such as breathing, guided imagery and distraction - may also be effective for some patients.
• Sedation: at high doses in particular, opioid analgesics may result in some degree of sedation. Sedation is particularly common in patients with comorbid problems, such as those prescribed other sedating drugs, those with metabolic disturbances and / or those with sleep deprivation. This side-effect usually decreases within a few days to a few weeks of the commencement of opioid analgesic therapy; however, reduction of the opioid dose (if feasible), changing to an alternative opioid and / or use of a psychostimulant may also be recommended.
• Confusion and / or delirium: mild cognitive impairment is common in the period immediately following commencement of an opioid analgesic. As with sedation, these symptoms are usually transient; if the confusion and / or delirium persists, alternative causes should be investigated.
• Multifocal myoclonus: this involves involuntary twitches and jerks of the muscles and, in more severe cases, seizures. If poorly controlled, myoclonus can contribute significantly to the patient's existing pain; furthermore, it may be a sign of opioid toxicity. Usually, myoclonus requires reduction of the opioid dose (if feasible), changing to an alternative opioid and / or use of a benzodiazepine to control symptoms.
• Urinary retention: this is an uncommon but potentially significant side-effect, which results from opioid-induced smooth muscle spasm and increase in sphincter tone. Older men with a pre-existing enlarged prostate are particularly at risk of urinary retention. Reduction of the opioid dose (if feasible), changing to an alternative opioid and / or use of medications to stimulate urination may be used.
• Pruritus: this occurs due to opioid-induced histamine release. Pruritus is commonly associated with morphine, and less-commonly associated with fentanyl. If mild to moderate, itching is usually managed using topical emollients, moisturisers and / or ultraviolet light therapy; if severe, however, medications such as antihistamines may be prescribed.
• Respiratory depression: although rare, respiratory depression is the most significant complication of opioid analgesic use. Clinically-significant respiratory depression occurs with other indicators of central nervous system depression such as sedation (described earlier in this section). It is important for nurses working in palliative care settings to avoid confusing opioid-induced respiratory depression with the changes in respiration which occur naturally at the end of life.

There are a number of principles for the use of opioid analgesics in the palliative care setting with which palliative care nurses must be familiar:

• Analgesics must be selected according to the WHO's Analgesic Ladder.
• Use appropriate drug combinations to improve pain relief, where required.
• Avoid drug combinations that increase risks without improving pain relief.
• Consider the patient's age, metabolic state, organ function, coexisting disease, etc.
• Consider accumulation of metabolites, effects of / interactions with concurrent drugs, etc.
• Consider the available and preferred routes of administration.
• Consider issues which may affect the patient's ability to follow the prescribed regimen.
• Administer opioid analgesics regularly for persistent pain.
• Consider 'rescue' (or 'as required') doses for breakthrough pain.
• If opioid analgesics are to be discontinued, ensure they are tapered to avoid withdrawal.
• Systematically and regularly evaluate the effectiveness of the analgesic regimen.
• Provide the patient and their significant others with appropriate education.

Nurses in palliative care settings must be aware that many patients, for a variety of different reasons, fear and resist the use of opioid analgesic medication. One of the nurse's fundamental roles is to educate patients in palliative care settings about how these medications can be used safely and effectively. This involves correcting many of the misperceptions associated with opioid analgesics; read the information in the following table:

Misperception	Face
Opioid analgesic medications are addictive.	When used in clinical settings - including in comparatively high-dose, longer-term use for conditions such as terminal cancer - opioid analgesic medications are very rarely addictive.
Tolerance to opioid analgesic medications develops over time, and progressively higher doses will be required.	When used in clinical settings - including in comparatively high-dose, longer-term use for conditions such as terminal cancer - a patient will rarely develop tolerance to opioid analgesic medications. As a person's disease progresses, they may require higher doses of opioid analgesics.
Opioid analgesic medications are a tool of euthanasia; once these medications have been taken, end of life is near.	As explained in detail in a previous chapter of this unit, euthanasia is illegal in the UK; opioid analgesic medications are never prescribed for euthanasia. When used in clinical settings - including in comparatively high-dose, longer-term use for conditions such as terminal cancer - opioid analgesic medications will not cause death.
Allergies to opioid analgesic medications are common.	Side-effects of opioid analgesic medications (versus allergies) are relatively common; however - as described earlier in this section of the chapter - these can be managed with appropriate interventions.

Non-pharmacological interventions for pain management

As described in the previous section of this chapter, medication interventions - specific, analgesic medications - are the primary treatment for all types of pain in the palliative care setting. However, it is also important for nurses working in palliative care settings to consider complementary pain relief techniques - that is, strategies which can be used in combination with analgesic medications to potentially improve a patient's level of pain relief. Non-pharmacological interventions for pain which may be used in palliative care settings in the UK include:

• Psychological interventions, including:
  • Psychoeducation for the patient and their family members / carers / significant others. People should be taught about the aetiology of pain, the principles and methods of pain relief, options for analgesia, side-effects, associated equipment and devices, and concepts such as dependence / tolerance / addition, etc.
  • Cognitive interventions. For example, distraction - or the diversion of a patient's attention away from the pain they are experiencing - and guided imagery can both be effective in reducing pain. Coping self-statements or positive affirmations can also help a person to transition through a painful experience. Relaxation techniques can help to reduce skeletal muscle tension and relieve pain. Hypnosis can be used by a patient to control the negative thoughts related to pain.
  • Behavioural interventions. For example, a pain diary can help patients to identify triggers for and patterns in their pain experience.
  • Psychotherapeutic interventions. For example, cognitive behavioural therapy can be used to enhance a person's self-efficacy in relation to pain control.
• Physical interventions, including:
  • Positioning and movement. If a patient is in a static position for long periods of time, this can exacerbate their pain; repositioning and gentle movement, within the limits of the patient's tolerance, can assist in relieving this pain.
  • Supportive devices. For example, canes, walkers and wheelchairs can help to ease a person's pain during movement.
  • Other physical interventions - including the application of heat / cold, and the use of vibration, massage and ultrasound - may help to relieve a patient's pain.
• Neuro-stimulatory interventions, including:
  • Transcutaneous electrical nerve stimulation (TENS). This may help to disrupt the transmission of electrical impulses along pain pathways in the body.
• Invasive interventions:
  • Neuro-blockades and neuro-destructive procedures, which respectively block and destroy the nerves in a small part of the body and so prevent the transmission of electrical impulses along pain pathways.
• Integrative interventions:
  • Alternative medicine. For example, acupuncture, moxibustion and other Eastern therapies, which are based on a belief that rebalancing the energy in the body systems may help to relieve pain.
  • Mind-body interventions. For example, music therapy can help to comfort a patient and decrease their experience of pain.
  • Manipulative and body-based methods. For example, energy therapies such as therapeutic touch (e.g. Reiki) can be beneficial for some patients.

The following case study provides an example of the use of complementary therapies for pain reliefin palliative care practice:

As noted in a previous chapter of this module, it is important to highlight that many complementary therapies lack current evidence to support their efficacy. However, if they are unlikely to be harmful, and may convey some benefit (physical and / or psychological) to the patient, nurses working in palliative care settings should support patients in their use. Nurses are encouraged to familiarise themselves with the various types of complementary therapy options available to the patients in the palliative care setting in which they work.

Managing a pain crisis

A pain crisis occurs when pain is severe, uncontrolled and very distressing for a patient. A pain crisis usually involves acute breakthrough pain; however, it may also involve chronic pain which increases gradually in severity and is poorly-controlled over time (refer to the definitions of these different types of pain provided in an earlier section of this chapter). A pain crisis can have a serious negative impact on a person's quality of life, and it may also hasten their death; therefore, a pain crisis must be considered a medical emergency in the palliative care setting.

The management of a pain crisis usually involves the titration of opioid analgesia until adequate pain control is achieved. The benefits of the high-dose opioid must be balanced with the risks (as described earlier in this chapter). In patients who do not respond to opioid titration, or who develop intolerable side-effects, there are a number of alternatives:

• A parenteral non-steroidal anti-inflammatory (e.g. ketorolac).
• A parenteral steroid (e.g. dexamethasone).
• An anaesthetic (e.g. lidocaine, ketamine - via a nerve block or spinal delivery).

Sedation at the end of life

A small number of patients receiving palliative care will experience severe, uncontrolled and very distressing pain which cannot be controlled using the interventions described in the previous section of this chapter. In these cases, palliative sedation - using escalated doses of opioids and / or anaesthetic agents - may be an option. However, clear communication and documentation between the patient, their family members / carers / significant others (where appropriate), and the interdisciplinary health care is essential in these situations. Furthermore, the interdisciplinary team must be familiar with the relevant legal and ethical issues associated with the use of palliative sedation in the region in which they work. Nurses must be clear about:

• The goals of the use of palliative sedation.
• The patient's desire for resuscitation following the administration of palliative sedation.

It is important for nurses working in palliative care settings to remember that palliative sedation is not euthanasia. Rather, the goal is to relieve a patient's intractable pain.

Conclusion

As you have seen throughout this unit, pain is a common experience for almost all patients receiving palliative care in the UK. It is essential that nurses working in palliative care settings understand how to manage this issue; however, the experience of pain in the palliative care setting, and its relief and control, can be complex. In this chapter, you have studied the pathophysiology of pain, the characteristics of the different types of pain, and the assessment of pain in the palliative care setting. This chapter has also described in detail the variety of pharmacological and non-pharmacological strategies which may be used to manage various types of pain in palliative care settings, and relevant considerations associated with their use. In completing this chapter, you are equipped with the knowledge and skills necessary for the challenging task of managing pain in the palliative care setting.

References

British Pain Society. (2010). Cancer Pain Management: A Perspective from the British Pain Society, Supported by the Association for Palliative Medicine and the Royal College of General Practitioners. Retrieved from: https://www.britishpainsociety.org/static/uploads/resources/files/book_cancer_pain.pdf

Faull, C., de Caestecker, S., Nicholson, A. & Black, F. (Eds). (2012). Handbook of Palliative Care (3rd ed.). Hoboken, NJ: Wiley-Blackwell.

Greater Manchester Strategic Clinical Network. (2015). Pain and Symptom Control Guidelines: Palliative Care. Retrieved from: http://www.sah.org.uk/media/496763/scn_pain_symptom_control_guidelines_june_2015.pdf

International Association for the Study of Pain. (2016). IASP Taxonomy. Retrieved from: http://www.iasp-pain.org/Taxonomy

Klepstad, P, Kaasa, S., Cherny, N., Hanks, G. & de Conno, F. (2005). Pain and pain treatments in European palliative care units: A cross-sectional survey from the European Association for Palliative Care Research Network. Palliative Medicine, 19(6), 477-484.

Lorenz, K.A., Lynn, J., Dy, S.M., Shugarman, L.R., Wilkinson, A., Mularski, R.A., Morton, S.C., Hughes, R.G., Hilton, L.K., Magoline, M., Rhodes, S.L., Rolon, C., Sun, V.C. & Shekelle, P.G. (2008). Evidence for improving palliative care at the end of life: A systematic review. Annals of Internal Medicine, 148(2), 147-159.

Matzo M. & Witt Sherman, D. (Eds). (2010). Palliative Care Nursing: Quality to the End of Life (3rd ed.). New York, NY: Springer Publishing Company.

National Institute for Health and Care Excellence. (2016). Palliative Care for Adults: Strong Opioids for Pain Relief. Retrieved from: https://www.nice.org.uk/guidance/cg140/resources/palliative-care-for-adults-strong-opioids-for-pain-relief-35109564116677

NHS Choices. (2014). Palliative Care: Managing Pain and Other Symptoms. Retrieved from: http://www.nhs.uk/Planners/end-of-life-care/Pages/controlling-pain-and-other-symptoms.aspx

NHS Scotland. (2015). Scottish Palliative Care Guidelines: Pain Management. Retrieved from: http://www.palliativecareguidelines.scot.nhs.uk/guidelines/pain/pain-management.aspx

Example essay

A patient with end-stage cancer is admitted to hospital to receive palliative care. The patient is experience severe chronic pain with acute 'breakthrough' pain. Critically review the palliative care pain management interventions which may be used in the nursing care of this patient.

Research suggests that patients with advanced cancer in the United Kingdom (UK) are at significant risk for under-treatment of pain (Valeburg et al., 2008); indeed, up to 10% of patients with advanced cancer in the UK fail to receive effective pain relief (British Pain Society, 2010). It is therefore essential that nurses working in palliative care settings understand how to effectively manage both severe chronic and acute 'breakthrough' pain in patients with advanced cancer. With reference to relevant literature to support evidence-based best practice, this essay critically reviews the palliative care pain management interventions which may be used in the nursing care of a patient with advanced cancer experiencing severe chronic pain with acute 'breakthrough' pain. This essay demonstrates that high-quality palliative care for this patient is underpinned by the effective management of this pain, using a variety of pharmacological and non-pharmacological strategies.

The British Pain Society (2010) identifies opioid analgesics as the mainstay therapy for the management of both chronic and acute pain related to cancer. The National Institute for Health and Clinical Excellence (NICE, 2016: p. 5) state that "up to two thirds of people with cancer experience pain that needs a strong opioid" morphine in particular is a principle treatment for pain related to advanced cancer. Typically, a patient receiving palliative care is administered 10mg to 15mg of sustained-release, oral morphine twice daily, and they may also be prescribed 5mg of immediate-release, oral morphine as a 'rescue' dose for breakthrough pain (NICE, 2016). Opioids may be given via a variety of routes of administration - including orally as described and, if this is not suitable for a patient, intravenous, subcutaneously and / or via transdermal patches (NICE, 2016).

However, it is important for nurses working in palliative care settings to realise that opioid analgesics have a number of significant side-effects. As explained by NICE (2016: p. 10), "nearly all patients receiving strong opioids" will be affected by constipation at some point in their treatment. Nausea and drowsiness are also very common, unpleasant side effects, particularly when a strong opioid treatment commences or when a dose increase takes place (NICE, 2016). In addition, although these are uncommon in high-quality palliative care settings, opioid hyperalgesia, clinical opioid tolerance and opioid dependence / addiction are known side-effects of opioid administration (British Pain Society, 2010), particularly in patients who - as with the patient in this case study - experience significant pain and, therefore, require high doses of opioid analgesia. Research also fails to support the long-term use of opioids for the management of cancer pain, with the effectiveness of opioids reducing and the risk of side-effects decreasing over time (Daniell, 2006; Vestegaard et al, 2006; Ballantyne & LaForge, 2007); however, it is possible that the patient in this case study may require long-term opioid administration for pain control.

In addition to opioid analgesics, there are a variety of other medications which may be used, either alone or in appropriate combinations, in patients with acute and chronic cancer-related pain. The British Pain Society (2010) recommends non-steroidal anti-inflammatory medications (NSAIDS), bisphosphonates, sodium- and calcium-channel blockers NMDA-channel blockers, tricyclic antidepressants and GABAA-receptor antagonists in particular. However, these adjuvant analgesics are often quite limited in the type of pain against which they are effective. For example, bisphosphonates are typically only effective in cases of metastatic bone pain (Ross, 2003), and may only provide modest pain relief for patients with this type of pain (Wong & Wiffen, 2002).

There are a variety of other medical therapies which may be suitable for both chronic and acute cancer pain. Those suggested by the British Pain Society (2010) include surgery (e.g. to fix a pathological fracture of a long bone, or to stabilise a vertebral fracture, etc.), radiotherapy, chemotherapy and hormone therapy. However, there are once again significant limitations to these therapies. For example, a Cochrane review suggests that localised external beam radiotherapy may only achieve adequate pain relief in 60% of the patients to whom it is administered (Sze, 2003). In another example, hormone therapy is frequently associated with a "flare-up" of pain which, although transient, can have significant negative impacts on a person's quality of life (British Pain Society, 2010). The benefits of these therapies, as with all interventions to manage pain in patients with advanced cancer, must be balanced with the risks.

The British Pain Society (2010: p. 63) also recommends a number of "invasive procedures" for cancer pain. These include: (1) non-destructive procedures, such as nerve blockade, and (2) destructive procedures, such as nerve plexus ablation and cordotomy (British Pain Society, 2010). The evidence for these different procedures is variable, depending on the type and location of a person's cancer (British Pain Society, 2010); therefore, it is unclear whether any of these invasive procedures would be suitable for the patient in the case study on which this essay is based. Additionally, it is important to note that the side-effects of these procedures are often significant and permanent (British Pain Society, 2010). Furthermore, some invasive procedures for the management of cancer pain - including, for example, intrathecal infusion using spinal catheters - involve expert nursing care which may not be available in some palliative care settings (British Pain Society, 2010).

In addition to the interventions discussed so far in this essay, there are a variety of non-pharmacological and non-medical therapies which may be effective in supporting a patient who is experiencing acute and chronic cancer-related pain. Psychological interventions are particularly important. Research suggests that focused pain management programs, which involve teaching cancer patients cognitive and behavioural pain management strategies, may achieve a modest improvement in a person's pain scores and also increase their self-reported quality of life (Robb, 2006). Because reduced social competence, lack of social support and social engagement are all predictors of increased pain in patients with advanced cancer (Breitbard et al., 2004), psychological interventions to support a person's social function may also be important in managing their pain.

As well as the psychological therapies discussed, physical therapies may also be important in managing the pain of a person with advanced cancer. Therapeutic exercise, within the limits of the patient's tolerance, may improve a cancer patient's experience of pain (Douglas, 2005), and also their general quality of life and wellbeing. Correct posturing, particularly that which is designed to reduce imbalance and muscle spasm, may also be a useful intervention (Cheville & Tchou, 2007). The British Pain Society (2010) also recommends that nurses consider heat and cold therapy and lifestyle adjustment as physical therapies to improve pain management in patients with advanced cancer.

There are also a variety of complementary therapies which may be used in the management of pain in patients with advanced cancer. There is some limited, lower-quality evidence to suggest that aromatherapy (Fellowes, 2004), hypnotherapy (Rajasekaran, 2005) and massage (Corbin, 2005) in particular may contribute to the management of pain in patients with advanced cancer. However, nurses working in palliative care settings should recognise that, although they are widely perceived to be "safe", there are a variety of safety issues associated with the use of these therapies and, as with all the pain management interventions described in this essay, they must therefore be used with caution (British Pain Society, 2010: p. 75) and in a manner consistent with organisational policies.

It is important for nurses working in palliative care settings to recognise that the evidence for many non-pharmacological interventions in the management of both acute and chronic pain in cancer patients is inconclusive, and often "weak" (British Pain Society, 2010: p. 73). However, even if they do not relieve a patient's pain, these interventions may improve wellbeing (British Pain Society, 2010) - and this in itself can be considered a positive outcome. Nurses should be honest with patients about the uncertain outcomes associated with these interventions. Furthermore, nurses should be guided by the patient's wishes and preferences, and their organisation's policies, when implementing these interventions in practice - and, indeed, all the interventions aimed at managing the acute and chronic pain of a person with advanced cancer discussed in this essay.

In addition to managing the pain of the cancer itself, it is important for nurses working in palliative care settings to consider the importance of managing pain related to the complications of cancer. For example, vertebroplasty is considered a highly effective treatment for the severe pain associated with vertebral collapse in patients with spinal metastases (Fourney et al., 2003). Again, it is not clear whether such interventions are appropriate for the patient in the case study to which this essay relates; however, these are important considerations in the management of a patient's overall experience of pain.

With reference to relevant literature to support evidence-based best practice, this essay has critically reviewed the palliative care pain management interventions which may be used in the nursing care of a patient with advanced cancer experiencing severe chronic pain with acute 'breakthrough' pain. In particular, it has considered opioid analgesics as the mainstay therapy for the management of cancer-related pain, as well as other pharmacological and medical interventions. It has also considered a variety of non-pharmacological approaches to cancer-related pain management, including various medical and complementary therapies. This essay has demonstrated that high-quality palliative care for the patient in this case study, who is experiencing severe chronic pain with acute 'breakthrough' pain, is underpinned by the effective management of this pain, using a variety of pharmacological and non-pharmacological strategies.

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