Pain Management

Introduction

The pain associated with cancer is one of the distressing symptoms, which is experienced by patients very often. The cancer pain is occurred at any point of time during disease progression or the course of treatment. The multidimensional feature of cancer pain is characterized by different dimensions including spiritual, psychological, social and physical, which together develop the term named “total pain”. In this case, the pathophysiology of the pain and the impact of the pain on psychological, social, cultural, spiritual, physical, functional, and economic will be analyzed. In order to lower down the pain, based on the diagnosis, nursing care and pain management strategies will be reviewed. 

Pathophysiology

Generally, the pathophysiology of the cancer pain is recognized as the pains due to various stages of cancer, tumors, metastasis and the treatments (chemotherapy, radiotherapy).In this particular case, the patient with squamous cell carcinoma was diagnosed with severe pain at left side of neck and face. The pain can be occurred due to many reasons, like, bulkiness in left heterogeneous masseter muscle, thickening of soft tissue, fracture and post-treatment alterations with destruction and lytic areas in alveolar process of mandible (Smith and Saiki 2015). It can be caused because of recurrence of cancer or residual disease, pathological fracture at left mandible and post-treatment osteomyelitis (LeBaron et al. 2014). So, after diagnosis of the pain, the patient was sent to computed tomography (CT) scan of paranasal sinuses and face. After reviewing the CT scan, the pathophysiology of this pain is found to be the fracture in left mandible.

Impact of pain

A cancer patient not only experiences the physical pain, but also experiences many dimensions of that pain or the impact of the pain in his/her life. The present case study demonstrates various dimensions of pain along with psychological, social, cultural, spiritual, physical, functional, and economic sufferings experienced by the patient (Greco et al. 2014). In this case, the main objective is to manage the pain. So after interaction with the pain management team, it was found that he is concerned about various issues in his life. He is worried about the occurrence of the cancer and the terrible pain after treatment. He is tensed about the recurrence of the cancer. He is disturbed about his loss of social status and role, family concerns and loss of job. He is annoyed on his fate. He feels guilty of not being able to take care of his child and wife. He feels frustrated and helpless as he is not able to tolerate the pain. He is upset as he is depending on his family at the time, when he should fulfill their responsibilities. Gradually, his family relations are getting tensed and he is getting irritated at his 2-year-old child. In any pain, physiological sufferings can be described as emotional sufferings.

Here, the patient’s emotional or physiological impact of the pain is expressed by his feelings like, anger, helplessness, frustration and anxiousness (Booker and Herr 2016). The patient is getting anxious about the progression of the disease. He is worried about the destiny of his family after his death. He is so sure about his recurrence of the cancer that he is rejecting the treatment. This incident describes the physical impact of the pain. He is in denial stage without knowing the detailed information about his disease. This is the functional impact of the pain. The social and cultural impact of the pain is exhibited through his concerns about his social status and role (Pergolizzi et al. 2016). The economic impact of the pain is observed through his helplessness about losing job. In his situation, he is trying to find out the meaning of his condition and is blaming the God for his situation.  These feelings describe his high spiritual breakdown. 

Nursing care and the assessment of pain

Pain assessment was performed every two hours using the standard format. After each intervention pain was reassessed to identify any aggravating or alleviating factors (Aigner et al. 2014). I had to keep a track of patient’s beliefs, attitude, knowledge level and previous experiences of pain.

The pain history included previous impact of pain, methods used to relieve pain and its helpfulness and his response to opioid. It also included the stress, anxiety level in the patient, his mood, sleeping pattern, and his way of expressing the pain. The pain records highlighted his preferences of pain management along with the family expectations. This record helps to develop a pain management plan for post surgery and is completed by collaborative efforts of clinicians, patients and his family. Patient was provided with “Wong-Baker FACES scale” to know the intensity of pain with the help of rating (NRS format). In addition, pain in other body part was assessed along with its interference with other bodily movements on timely basis either verbally or through drawings (Schug and Chandrasena 2015).

Pain management strategies

The pain management strategies for this particular case include both pharmacological and non-pharmacological interventions.

Pharmacological interventions- the patient is administered with strong opioid, namely morphine (5mg per four hours) along with NSAIDs (nonsteroidal anti-inflammatory drugs) which is pregabalin (twice daily- 75 mg) and antacids (Pergolizziet al. 2016). The patient was also given stimulant laxatives to manage side effects. The supportive therapy, which was administered for jaw infection include-

• antibiotics
• clotrimazole for oral thrush-antifungal paint
• povidine iodine gargles as mouth wash (Wiffen et al. 2015)

In the subsequent visits, the dose of morphine was increased to 10mg in every four hours. As the patient was under severe anxiety and stress due to pain, he was subjected to

• pulsed radiofrequency ablation of mandibular nerve (VAS- 6/10)
• Scrambler therapy

According to Schug and Chandrasena (2015), scrambler therapy is proven to be effective for chronic oncologic pain and pain that is not relieved by morphine. It does not lead to side effects and was found effective in several patients. With further increase in pain, the morphine was administered with higher dose as SOS response. The titrated dose was stabilized at 120mg along with plain morphine of 30 mg. In addition, flupirtine, which is non-narcotic, was prescribed to subside the analgesic effect.

Non-pharmacological interventions- The patient was provided with counseling to help him deal with anxiety and manage pain. The treatment process addressed his spiritual needs. It helped patient to achieve clear view of disease and treatment. It enhanced his self esteem and gain faith in pain management. Motivational interventions are highly effective in cancer patients (Bruckenthal 2015). The patient care routine included exercises, meditation and yoga in the early hours of day. It is most effective in treatment of several firms of pain and chronic illness. Literature evidence indicates it has improved the quality of life of many patients (Ducreux e al. 2015). In addition, the patient’s family played a significant role with their continued support, affection and love that helped maintained faith and hope. Physicians and nurses maintained collaborative communication and information sharing. According to Thronæs et al. (2016), treatment of such chronic pain requires a skillful and multi-professional team with effective communication between care providers and the patient.

Analysis of clinical information pertinent to the case study

Booker and Herr (2016) believe that the psychological burden of pain can be reduced if the doctors help patients to accept their life situation. It was evident in the case study, which by joint effort from clinicians helped the patient in regaining the faith in treatment. Patient centered care is very crucial in such circumstances. Open communication from the NGO team helped the patient in getting sigh of relief.  According to LeBaron et al. (2014), family expectations and worries adversely influence the patient’s “perception of total pain”. According to Aigner et al. (2014) health care provider team must address the total cancer pain through holistic management.

Conclusion

The treatment of the patient was a combined effort from physicians of palliative care, experts from team of surgical oncology, radiology and radiation oncology, nursing staff, family members and nongovernmental organizations. Cancer treatment can never be successful without skillful and multi-professional team with effective communication between care providers and the patient.

Appendix

Case study:

A 33-year-old male patient with carcinoma of left mandibular alveobuccal complex (pT_4a N₂ M_x), was treated for past 2 years in a community hospital        cancer program. He was young, educated, and working as an administrative officer in a multinational company. He was married, had a 2-year-old son and was living in a joint family. He had a habit of cigarette smoking (six to eight cigarettes/day), tobacco chewing (four to five packs/day) since 7-8 years and was used to consume alcohol occasionally. His cancer treatments included initial surgery followed by chemotherapy and radiation therapy. Recently, he is admitted into the pain management sector due to severe pain at left side of face and neck, swelling of the left jaw, and difficulty in swallowing. According to his past medical history, the patient was diagnosed with oral ulcers on left mandibular gingival for 1 year. He was diagnosed with squamous cell carcinoma of left mandibular alveolus. He underwent commando surgery and postoperative radiotherapy – 60 Gy/30#/6 weeks. He was under regular follow-up with surgical oncology team, when suddenly he started complaining of increase in pain in left submandibular area. After referring to the pain management team, it is observed that the pain was gradually increasing in intensity since last 1 month. It was severe, throbbing, and unbearable in nature (visual analog score (VAS) – 9/10), not relieved with weak opioids. It increased on stretching of facial muscles and prevented patient from talking, eating, and brushing his teeth. There was tenderness over the left mandibular region. Patient was not able to sleep for past few days due to pain.

References

Aigner, C.J., Hernandez, M., Koyyalagunta, L. and Novy, D., 2014. The association of presurgery psychological symptoms with postsurgery pain among cancer patients receiving implantable devices for pain management.Supportive Care in Cancer, 22(9), pp.2323-2328.

Booker, S. and Herr, K., 2016. (2014) An investigation of racial differences in evidence-based cancer pain management in African American and Caucasian American older adult hospice patients. The Journal of Pain, 17(4), p.S29.

Bruckenthal, P., 2015. Motivational Interviewing in Managing Pain.

Ducreux, M., Cuhna, A.S., Caramella, C., Hollebecque, A., Burtin, P., Goéré, D., Seufferlein, T., Haustermans, K., Van Laethem, J.L., Conroy, T. and Arnold, D., 2015. Cancer of the pancreas: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Annals of Oncology,26(suppl 5), pp.v56-v68.

Greco, M.T., Roberto, A., Corli, O., Deandrea, S., Bandieri, E., Cavuto, S. and Apolone, G., 2014. Quality of cancer pain management: an update of a systematic review of undertreatment of patients with cancer. Journal of Clinical Oncology, 32(36), pp.4149-4154.

LeBaron, V., Beck, S.L., Maurer, M., Black, F. and Palat, G., 2014. An ethnographic study of barriers to cancer pain management and opioid availability in India. The oncologist, 19(5), pp.515-522.

Pergolizzi, J.V., Zampogna, G., Taylor, R., Guerrero, M., Santacruz, J.Q. and Raffa, R.B., 2016. A Guide for Pain Management in Developing Nations: The Diagnosis and Assessment of Pain in Cancer Patients. Journal of Cancer Research Updates, 5(1), pp.29-44.

Schug, S.A. and Chandrasena, C., 2015. Pain management of the cancer patient. Expert opinion on pharmacotherapy, 16(1), pp.5-15.

Smith, T.J. and Saiki, C.B., 2015, October. Cancer pain management. InMayo Clinic Proceedings (Vol. 90, No. 10, pp. 1428-1439). Elsevier.

Thronæs, M., Raj, S.X., Brunelli, C., Almberg, S.S., Vagnildhaug, O.M., Bruheim, S., Helgheim, B., Kaasa, S. and Knudsen, A.K., 2016. Is it possible to detect an improvement in cancer pain management? A comparison of two Norwegian cross-sectional studies conducted 5 years apart. Supportive Care in Cancer, 24(6), pp.2565-2574.

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