Pain is one of the most common symptoms experienced by people with cancer (WHO, 1996). Consequently, health-care professionals must make optimum pain management for such patients a priority, especially within the context of the increasing global incidence of cancer.
Janette Barrie, MSc, RN
Pain Management Sister, Wishaw General Hospital, Lanarkshire Acute Hospitals NHS Trust
The World Health Organization’s three-step analgesic ladder (WHO, 1987) offers a theoretical framework for managing cancer pain and remains the clinical model used in developing most local guidelines. However, despite substantial evidence to suggest that 70-90% of patients with cancer pain could obtain complete relief with oral analgesics, moderate to severe pain is being reported by 70-80% of them at some stage of their illness (Cleary and Carbone, 1995).
The literature indicates that the main reason for this may be the way analgesics are prescribed - that is, inappropriate selection of analgesics, inappropriate doses and failure to provide rescue doses of analgesics for breakthrough pain (Foley, 1995).
What is breakthrough pain?
Breakthrough pain is becoming an accepted classification: it is defined as a transitory exacerbation of pain in patients whose background pain is generally well controlled by regularly administered opioid analgesics (Portenoy and Hagen, 1990).
There are several types of pain, some of which can be characterised as breakthrough:
- Recurrent acute
- End-of-dose failure.
Typically, breakthrough pain is quick onset, of one to three minutes’ duration and it occurs one to four times per day (Portenoy and Hagen, 1990). This presents a challenge to health professionals to ensure prompt and successful management. A good starting point is to undertake a comprehensive assessment, to help identify the cause and nature of the pain and possibly exclude a more severe pain syndrome (Portenoy et al, 1999).
Understanding patients’ pain
Many studies document the under-treatment of cancer pain in many clinical settings (Coluzzi, 1996; Ferrell et al, 1995) despite the availability of published guidelines. One of the most significant barriers to effective pain management is incomplete and inconsistent assessment and documentation (Paice, 1999). Indeed, an earlier study by Paice et al (1991) concluded that the lack of documentation led to ‘a lack of consistent care and the inability to evaluate the effectiveness of pain therapies’.
Failure to conduct an adequate assessment of pain and documentation of pain management may be interpreted as under-treatment of pain and could result in allegations of serious professional misconduct or litigation. As nurses, we should be mindful of our legal responsibilities to ensure accurate documentation (NMC, 2002).
We must also acknowledge our moral responsibilities as Copp (1990) eloquently illustrates, stating: ‘Pain is a bond between nurse and patient. Pain management is a pact between them. All too often the physician does not hear the pleading as he exercises his option to leave the scene. The patient and nurse cannot leave - as much as they may like to do so. How they work out pain management agreeable to both is the essence of nursing care.’
There are many tools to facilitate a thorough assessment of cancer pain and breakthrough pain. They include the McGill Pain Questionnaire (Melzack, 1975), numeric rating scales (Jenson et al, 1999) and visual analogue scales (Gaston-Johansson, 1996). The European Association of Palliative Care recommends the Brief Pain Inventory (BPI) as the tool of choice in clinical studies (Cleeland and Ryan, 1994). Although many of these tools, such as the BPI, may be appropriate for the purposes of pain research, others focus on measuring the present pain intensity without considering the impact.
Bruera and Watanabe (1994) suggest that pain measurement should not be carried out in isolation - other symptoms should also be taken into account to allow a comprehensive understanding of the pain characteristics, the impact of the pain and what the pain means to the individual. This supports Portenoy and Hagen (1990), who state: ‘Just as the impact of pain must carefully be judged in those who are clearly suffering, it is also axiomatic in the clinical management of cancer pain that the degree of suffering, and the factors contributing to it, must be evaluated as part of a comprehensive pain assessment.’
Breakthrough pain is significant, with many patients describing the episodes as severe to excruciating (Portenoy et al, 1999). Portenoy and colleagues report that frequent episodes of breakthrough pain are distressing for both the patient and their carer, resulting in a negative impact on their physiological and psychological well-being. This finding is supported by work by Coyle et al (1990), who comment that, of those patients who describe their breakthrough episodes as moderate to severe, 94% state that their ability to be active is extremely limited by these experiences.
The differences in the patient’s, carer’s and health-care professional’s perceptions of pain is well documented (Ferrell et al, 1994). Because of the subjective nature of pain, it is extremely likely that the carer’s and the health-care professional’s perceptions will differ from the patient’s direct experience of pain. Family members may also be reluctant to acknowledge pain for fear that the disease is progressing. Ironically, a study carried out by Houts et al (1996) found that patients often under-reported pain to protect their families.
In order to treat breakthrough pain effectively and efficiently patients must have the opportunity to communicate about their pain. However, there are many obstacles to overcome if patients are to do so effectively (Morrison, 2000; McCaffery and Pasero, 1998; WHO, 1998). These include fear of addiction and concerns about the side-effects of opioid medication, such as constipation and opioid tolerance. Furthermore, patients may have concerns that the opioid may not be effective ‘when the time comes’, and the desire to be a good patient. There are also barriers from the side of the professional (Wells et al, 2001), such as:
- Inadequate knowledge of pain management
- Poor assessment
- Concern over the use of controlled drugs
- Commonly held myths and misconceptions about addiction
- Concerns about side-effects.
Treatments for breakthrough pain
The pharmacological management of cancer pain is based on the WHO analgesic ladder, which facilitates a systematic approach to prescribing and administering regular analgesics. It has been shown to be effective in 85% of patients experiencing cancer pain (Hanks et al, 2001).
- Step 1 represents mild pain, where the use of paracetamol or a non-steroidal anti-inflammatory drug (NSAID) is recommended. It is important to take into account the potential adverse effects of NSAIDs in relation to gastric and renal problems
- Step 2 should be considered for moderate pain - it recommends analgesics such as co-codamol (30mg codeine phosphate/500mg paracetamol), or dihydrocodeine
- Step 3 is advised in cases of severe pain, where the use of opioids is recommended. Inherent in this framework is the potential to include adjuvant analgesics at any stage.
Analgesics should be given orally, at specified times, in accordance with the advice on the WHO ladder (WHO, 1996). Ideally, states the European Association for Palliative Care, two types of formulation are required - normal release, for dose titration, and controlled release, for maintenance of background pain.
Providing adequate pain relief while ensuring minimal side-effects can be a challenge. However, through initial titration using a normal-release opioid every four hours, with the same dose available for breakthrough, the total 24-hour opioid requirement can be established. The subjective nature of pain makes it impossible to categorically state a standard starting dose - this must be established on an individual basis.
According to the WHO (1996), background pain can be successfully managed using long-acting opioids, such as controlled releases of morphine, oxycodone and hydromorphone, or transdermal fentanyl. However, because breakthrough pain can be of rapid onset, a fast-acting preparation should be available. Medication for breakthrough pain should be immediately accessible and provide rapid onset with the least potential for side-effects. To achieve this the medication of choice should be:
- Simple and convenient to administer
- Require little expertise or preparation
- Quick onset
- Well tolerated
- Achieve high patient satisfaction.
The oral route is commonly seen as the most convenient way to administer breakthrough analgesia, perhaps due to practicality and cost. However, many oral preparations reach peak plasma levels after around 30-45 minutes and remain in the bloodstream for several hours, increasing the potential for side-effects such as sedation (Simmonds, 1999).
Morphine is considered the ‘gold standard’ for cancer pain relief. It is almost entirely absorbed by the body when administered orally but, due to the pharmacokinetics of morphine, its systemic availability is about 30% (Hoskin et al, 1989).
The European Association of Palliative Care recommends oral transmucosal fentanyl citrate (OTFC) as an alternative for treating breakthrough pain in patients stabilised on regular oral morphine (Hanks et al, 2001).
With a rapid onset of about five to 15 minutes and a short duration of about two hours, it may offer many of the qualities necessary for prompt treatment.
A double-blind comparative study (Coluzzi et al, 2001) compared fentanyl citrate with normal-release morphine and found that the fentanyl citrate was the more effective of the two drugs for treating breakthrough pain. In addition, 94% of the patients randomised to the fentanyl citrate group chose to continue using it to manage their breakthrough pain after the study had finished.
However, transmucosal fentanyl citrate may not be suitable in all circumstances. The patient must be physically able to administer the lozenge, and their mouth must be sufficiently moist to allow absorption to occur. Nevertheless, transmucosal fentanyl citrate provides effective relief of breakthrough pain in cancer and offers patients an alternative to the traditional approach.
Patients with cancer can experience frequent episodes of breakthrough pain, especially if the background pain is rated as moderate to severe. This can be distressing for the patient and their family, and requires fast and efficient treatment. The choice of treatment must be tailored to the need of each individual and, in order to achieve this, accurate ongoing assessment and communication are essential.
Despite the availability of the WHO step-ladder approach, which offers a theoretical framework to facilitate a logical approach to the management of cancer pain, patients with cancer continue to experience and report pain. The appropriate choice of analgesic titrated to the needs of each individual is crucial to ensure the effective management of breakthrough pain.
The increasing incidence of cancer worldwide means that we are increasingly likely to face the challenge of ensuring adequate management of cancer pain - professionally and perhaps personally. It is therefore crucial that we do all we can to ensure that we are equipped to meet it.
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