BeCOn OWN Educational Program Modules. Module 2 Diagnosis and assessment of cancer pain Date of...
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Transcript of BeCOn OWN Educational Program Modules. Module 2 Diagnosis and assessment of cancer pain Date of...
BeCOn OWN Educational Program
Modules
Module 2Diagnosis and assessment of cancer pain
Date of preparation: June 2015 HQ/EFF/15/0024a
Contents
Evaluation of pain and intervention
Guidelines on pain assessment
Assessment tools
Interventions to improve management of pain
Evaluation of pain and intervention
Evaluation is a vital first step in management of cancer pain
Assessment of cancer pain demands an understanding of not only the physical problem, but also the psychological, social and spiritual component’s of the patient’s suffering
It is best achieved by a team approach
The responsibility for evaluation lies primarily with the physician, but certain components may be undertaken by other healthcare workers
Syrjala KL, et al. J Clin Oncol. 2014;32(16):1703-11.
Early intervention is key in reliefof cancer pain and related outcomes
Early intervention and relief of cancer-related pain may reducethe risk of central sensitisation or “windup,” which is associatedwith the transition from acute to chronic pain
The early relief of cancer-related pain may reduce a number of physical and psychological burdens on the patient: anorexia, insomnia, reduced cognition,incapacity, fatigue, reduced quality of life, reduced social interaction,psychological and existential distress and impaired coping skills
Pergolizzi JV, et al. Pain Pract. 2014 Dec 3. doi: 10.1111/papr.12253. [Epub ahead of print].
Nearly half of patients are undertreated
Apolone G, et al. Br J Cancer. 2009;100(10):1566-74.
Even at specialised centres, patients are classified as potentially undertreated in 9.8–55.3% of cases
Recruitment centre
Adjuvant therapy
Time of recruiting Lower % Upper
Hospice No New 11.6 30.4 49.2
Hospice No Old 4.7 17.1 29.6
Hospice Yes New 6.8 20.0 33.3
Hospice Yes Old 0.7 9.8 18.8
Pall+Pain No New 46.8 55.3 64.0
Pall+Pain No Old 20.5 30.5 40.5
Pall+Pain Yes New 26.7 35.3 44.0
Pall+Pain Yes Old 7.7 11.8 15.9
Oncology No New 27.1 39.3 51.6
Oncology No Old 26.4 31.2 36.0
Oncology Yes New 16.8 26.2 35.6
Oncology Yes Old 13.2 16.3 19.4
0 10 20 30 40 50 60 70
% PMI-
Overall = 25.2%
PMI, pain management index
Cancer pain is undertreated
Breivik H, et al. Ann Oncol. 2009;20(8):1420-33.
European survey of 5,084 patients with various types of cancer across 11 countries and Israel
Patie
nts
(%)
80
70
60
50
40
30
20
10
0 Moderate to severe pain
at least once a month
56%44%
69%
50%63%
Described pain as severe
Pain-related difficulties
with everyday activities
QoL was not considered a
priority by HCP
Reported BTcP
There is a large variability of undertreatment across studies and settings
A systematic review covering 26 studies from 1987 up to 2007 that adopted the Pain Management Index (PMI) to assess the rate of potentially undertreated patient showed a rate from 8% to 82% with a weighted mean of 43%
Despite the large variability in adequate treatment of pain, it remains undertreated
Deandrea S, et al. Ann Oncol. 2008;19(12):1985-91.
Characteristics of studies
No. of studies
Range of negativePMI (%)
Year 1944-2000 12 27-79
2001-2007 14 8-82
Geographic area
United States 8 8-65
Europe 8 9-82
Asia 9 27-79
Economic level
GNI per capita < $20,000 8 31-79
GNI per capita $20,000 - $40,000 7 13-82
GNI per capita ≥ $40,000 11 8-65
Setting Specific for cancer patients or hospice 15 8-79
Not specific 5 29-74
Mixed 5 9-82
Stage of disease
At least 68.8% metastatic 8 13-65
<68.8% metastatic 12 29-82
Mean age of the sample
≥58 years 11 27-79
<57 years 11 8-82
Total 26 8-82
Update of systematic review of undertreatment of patients with cancer
Updated systematic review included observational and experimental studies reporting negative PMI scores for adults with cancer and pain published from 2007 to 2013
In the new set of 20 articles, there was a decrease in undertreatment of approximately 25% (from 43.4 to 31.8%)
In the whole sample, the proportion of undertreated patients fell from 2007 to 2013, and an association was confirmed between negative PMI score, economic level and nonspecific setting for cancer pain
The undertreatment of pain decreased, however, as approximately one third of patients still do not receive pain medication proportional to their pain intensity
Greco MT et al. J Clin Oncol. 2014;32:4149-54.
Inadequate pain assessment is a leading barrier to adequate pain management
Recognition of pain should begin at pre-diagnosis
Pain assessment should include detailed history, psychosocial evaluation and physical examination
Baseline pain assessment, reassessment and analgesia efficacy must be documented within the patient's record
– In one study, 27% of patients said their doctor does not always ask them about their pain
– In another, only 7.9% had documentation of their pain and evidence of reassessment
Schute C. Ulster Med J. 2013;82(1):40-2.De Conno F, et al. European pain in cancer (EPIC) survey: a report. London: Medical Imprint; 2007. Available online from: http://www.paineurope.com/ fileadmin/userupload/Issues/EPICSurvey/EPICReportFinal.pdf. Last accessed Nov 2012.Sun VC, et al. J Pain Symptom Manage. 2007;34(4):359–69.
Inadequate pain management can be attributed to several types of barriers
Patient-related barriers
HCP-related barriers
Healthcare-system-related
barriers
Lack of knowledge and skill
Affective factors
Availability of pain and palliative care
specialists
Limits on access to opioids
Poor pain assessmentCognitive
factors
HCP – healthcare professional
Reluctance of physicians to
prescribe opioids
Kwon JH. J Clin Oncol. 2014;32(16):1727-33.
Fear of addiction, tolerance, adverse effects, respiratory
depression
Adherence to analgesic regimens
The main steps in evaluation of cancer pain (i)
1. Believe the patient’s report of pain
2. Initiate discussions about pain
3. Evaluate the severity of pain
4. Take a detailed history of the pain
5. Evaluate the psychological state of the patient
Cancer Pain Relief. World Health Organization. Available at: http://whqlibdoc.who.int/publications/9241544821.pdf. Accessed 11 Mar 2015.
The main steps in evaluation of cancer pain (ii)
6. Perform a careful physical examination
7. Order and personally review any necessary investigations
8. Consider alternative methods of pain control
9. Monitor the results of treatment
Cancer Pain Relief. World Health Organization. Available at: http://whqlibdoc.who.int/publications/9241544821.pdf. Accessed 11 Mar 2015.
Asking key questions can provide important insights into the patient’s pain
Onset of pain?
Frequency of pain?
Site of pain?
Radiation of pain
Quality (character) of pain?
Intensity (severity) of pain?
Duration of pain?
Exacerbating factors?
Relieving factors?
Response to analgesics?
Response to other interventions?
Associated symptoms?
Interference with activities of daily living?
More effective management of pain requiresasking the right questions
Davies A, et al. Eur J Pain. 2009;13(4):331-8.
LIDOCAINE: a mnemonic device to guidethe clinician in asking leading questions
Pergolizzi JV, et al. Pain Pract. 2014 Dec 3. doi: 10.1111/papr.12253. [Epub ahead of print].
Focus Sample questions
LIDOCAINE
Location Where is your pain? Where does it go?
Intensity How bad is the pain?
Directionality Where does the pain go? Does the pain travel? Does it jump around or switch sides?
Occurrence How long have you been experiencing this pain? Do you remember when it started?
Character What does the pain feel like?
Alleviating Does anything improve your pain? Does anything make the pain go away?
Inciting Does anything seem to make the pain worse?
Neutral factors Are there things that do not seem to affect the pain at all, one way or the other?
Effect on function Does this pain affect your sleep? Are you limited in some of your everyday activities? Have you given up doing some of the things you used to enjoy?
Pain management index (PMI)
Cleeland CS, et al. N Engl J Med. 1994;330:592-596.
The PMI compares the most potent analgesic prescribed for a patientwith the reported level of the worst pain of that patient
The PMI, computed by subtracting the pain level from the analgesic level,ranges from −3 (a patient with severe pain receiving no analgesic drugs) to +3(a patient receiving morphine or an equivalent and reporting no pain)
Negative scores are considered to indicate pain undertreatment, and scoresof 0 or higher are considered a conservative indicator of acceptable treatment
WHO analgesic drug level
Pain Intensity No drugs(0)
NSAID(I)
Weak opioids(II)
Strong opioids(III)
No pain 0 +1 +2 +3
Mild (1-3) -1 0 +1 +2
Moderate (4-7) -2 -1 0 +1
Severe (8-10) -3 -2 -1 0
Guidelines on pain assessment
ESMO guidelines for adequate assessment of pain at any stage of disease (i)
Ripamonti CI, et al. Ann Oncol. 2012 Oct;23 Suppl 7:vii139-54.
1. Assess and re-assess the pain
Causes, onset, type, site, absence/presence of radiating pain, duration, intensity,relief and temporal patterns of the pain, number of breakthrough pains,pain syndrome, inferred pathophysiology, pain at rest and/or moving
Presence of the trigger factors and the signs and symptoms associated with the pain
Presence of the relieving factors
Use of analgesics and their efficacy and tolerability
Require the description of the pain quality
ESMO guidelines for adequate assessment of pain at any stage of disease (ii)
2. Assess and re-assess the patientClinical situation by complete/specific physical examination and specific radiological and/or biochemical investigations
Presence of interference of pain with the patient’s daily activities, work, social life, sleep patterns, appetite, sexual functioning, mood, well-being, coping
Impact of pain, disease and therapy on physical, psychological and social conditions
Presence of a caregiver, psychological status, degree of awareness of disease, anxiety and depression and suicidal ideation, his/her social environment, quality of life, spiritual concerns/needs, problems in communication, personality disorders
Presence and intensity of signs, physical and/or emotional symptoms associated with cancer pain syndromes
Presence of comorbidities (i.e. diabetic, renal and/or hepatic failure etc.)
Functional status
Presence of opioidophobia or misconception related to pain treatment
Alcohol and/or substance abuse
Ripamonti CI, et al. Ann Oncol. 2012 Oct;23 Suppl 7:vii139-54.
ESMO guidelines for adequate assessment of pain at any stage of disease (iii)
3. Assess and re-assess your ability to inform and to communicate with the patient and the family
Take time to spend with the patient and family to understand their needs
Ripamonti CI, et al. Ann Oncol. 2012 Oct;23 Suppl 7:vii139-54.
ESMO recommendations on assessment of pain
1. The intensity of pain and the treatment outcomes should be regularly assessedusing (i) VAS, (ii) VRS or (iii) NRS
2. When cognitive deficits are severe, observation of pain-related behaviours and discomfort (i.e. facial expression, body movements, verbalisation or vocalisations, changes in interpersonal interactions, changes in routine activity) is an alternative strategy for assessing the presence of pain (but not intensity)
3. Observation of pain-related behaviours and discomfort is indicated in patients with cognitive impairment to assess the presence of pain (expert and panel consensus)
4. The assessment of all components of suffering such as psychosocial distressshould be considered and evaluated
Ripamonti CI, et al. Ann Oncol. 2012 Oct;23 Suppl 7:vii139-54.
Assessment tools
Validated and most frequently used pain assessment tools
Ripamonti CI, et al. Ann Oncol. 2012 Oct;23 Suppl 7:vii139-54.
Validated assessment tools for assessment of pain
Visual analogue scale VAS
Worstpain
Nopain
10 cm
Nopain1 Very
severeSevereModerateMildVerymild2 3 4 5 6
Verbal rating scale VRS
Numerical rating scale NRS
Worstpain
Nopain 0 101 2 3 4 5 6 7 8 9
Wong-Baker FACES scale
Bieri D, et al. Pain Manage Nurs. 1990;41:139-150.
Wong-Baker FACESTM Pain Rating Scale
2 4 6 8 100
Hurtsworst
Hurtswhole lot
Hurtslittle more
Hurtslittle bit
Nohurt
Hurtseven more
The Wong-Baker FACES scale is reliable and easy to administer
Body pain diagramBody pain diagrams can assist in assessment of pain
Visser EJ, et al. Pain Pract. 2014 Dec 3. doi: 10.1111/papr.12263.
The Critical-Care Pain Observation Toolcan be used in uncommunicative patients
Gélinas C, et al. J Adv Nurs. 2009;65(1):203-16.
Indicator Description Score
Facial expression No muscular tension observed Relaxed, neutral 0
Presence of frowning, brow lowering, orbit tightening and levator contraction Tense 1
All of the above facial movements plus eyelid tightly closed Grimacing 2
Body movements Does not move at all (does not necessarily mean absence of pain) Absence of movements 0
Slow, cautious movements, touching or rubbing the pain site, seeking attention through movements Protection 1
Pulling tube, attempting to sit up, moving limbs/thrashing, not following commands, striking at staff, trying to climb out of bed Restlessness 2
Muscle tension No resistance to passive movements Relaxed 0
Evaluation by passive flexion and extension of upper extremities
Resistance to passive movements Tense, rigid 1
Strong resistance to passive movements, inability to complete them Very tense or rigid 2
Compliance with the ventilator (intubated patients)
Alarms not activated, easy ventilation Tolerating ventilator or movement 0
Alarms stop spontaneously Coughing but tolerating 1
Asynchrony: blocking ventilation, alarms frequently activated Fighting ventilator 2
OR
Vocalisation (extubated patients) Talking in normal tone or no sound Talking in normal tone or no sound 0
Sighing, moaning Sighing, moaning 1
Crying out, sobbing Crying out, sobbing 2
Total, range 0 - 8
The Brief Pain Inventory is widely used
The BPI allows patients to rate the severity of their pain and the degree to which their pain interferes with common dimensions of feeling and function
Cleeland CS, Ryan KM. Ann Acad Med Singapore. 1994;23(2):129-38.
Edmonton symptom assessment system (ESAS)as a screening tool for depression and anxiety
Anxiety or depression ESAS items score >3 can be applied as a useful, easy and rapid screening tool for assessing anxiety and depression in non-advanced patients with solid or haematological malignancies
Ripamonti CI, et al. Support Care Cancer. 2014;22(3):783-93. Bruera E, et al. J Palliat Care. 1991;7(2):6-9.
Assessment of neuropathic pain
Assessment tools
Neuropathic Pain Scale
Neuropathic Pain Symptom Inventory
Tools for assessment and screening
LANSS
Neuropathic Pain Questionnaire
DN4 Questionnaire
Neuropathic Pain Scale
Galer BS, Jensen MP. Neurology. 1997;48(2):332-8.
Neuropathic Pain Symptom Inventory
Bouhassira D, et al. Pain. 2004;108(3):248-57.
Leeds Assessment of Neuropathic Symptoms and Signs (LANSS)
Bennett M. Pain. 2001;92(1-2):147-57.
Neuropathic Pain Questionnaire
Krause SJ. Clin J Pain. 2003;19(5):315-6.
DN4 Questionnaire
Bouhassira D, et al. Pain. 2005;114(1-2):29-36.
Interventions to improve management of pain
Patient-based education interventions can improve attitudes and reduce pain intensity
Bennett MI, et al. Pain. 2009;143(3):192-9.
Patient-based educational interventions are probably underused alongside more traditional analgesic approaches
Improved knowledge
and attitudes
Reduced average pain
intensity
Reduced worst pain intensity
-2.5 -2.0 -1.5 -1.0 0.5 1.0
0.04 0.52
-1.1-1.8 -0.41
-1.21 -0.78 -0.35
1.0
0.0
Compared to usual care or control, educational interventions:
Standardised educational interventionscan improve pain scores
Provision of a video and/or booklet for people with cancer pain is a feasible and effective adjunct to management of cancer pain
Lovell MR, et al. J Pain Symptom Manage. 2010;40(1):49-59.
Bookletversus SC
Videoversus SC
Booklet & Videoversus SC
-2.5 -2.0 -1.5 -1.0 -0.5 0.0 0.5
Favoursintervention
Favoursstandard care (SC)
-1.84 -0.89 0.06
-0.86-1.83 0.11
-2.17 -1.17 -0.17
P=0.07
P=0.08
P=0.02
DVD-based educational intervention
Participants were shown a DVD at baseline (V1) and at 1 week (V2)
Outcomes were assessed using Brief Pain Inventory (BPI) and Patient PainQuestionnaire (PPQ) before intervention, and at V2 and V3 (4 weeks later)
Between V1 and V2:
Total BPI improved by 9.6% (p=0.02)
PPQ scores improved by 17% (p=0.04)
There were no further improvements at V3
Capewell C, et al. Palliat Med. 2010;24(6):616-22.
DVD-based intervention is feasible and potentially effective between 7–30 days follow up
iPhone pain assessment applicationfor adolescents with cancer
Stinson JN, et al. J Med Internet Res. 2013;15(3):e51.
Compliance with the app, assessed during feasibility testing, was high and adolescents found the app likeable, easy to use and not bothersome to complete
A valid and reliable electronic diary with pain management capabilities has the capacity to result in improved pain management
Medical oncologists’ attitudes and practicein cancer pain management
Breuer B, et al. J Clin Oncol. 2011;29(36):4769-75.
Med
ian
scor
e
0
3
10
7
8
5
2
Rated their specialty highly
for ability to manage cancer
pain
Rated peers as more
conservative prescribers
Quality of pain management
training during medical school
Physician reluctance to
prescribe opioids
7
3 3
5
Poor assessment
6
Patient reluctance to take opioids
6
Survey of 2000 oncologists (overall response rate 32%)
9
6
4
1
Patient reluctance report pain
6
Barriers
Oncologists and other medical specialists who manage cancer pain have knowledge deficiencies in cancer pain management
Patient/HCP communication about pain is suboptimal
Pain assessment is suboptimal
HCP fails to prescribe adequate analgesic regimenIntentional non-adherence by patient (e.g. decision not to mask pain, fear of side effects or addiction)Unintentional non-adherence by patient – misunderstanding of dosing regimen, forgetfulnessHCP fails to consider adjuvant anticancer therapies, or non-pharmacological therapies
Patient misinterprets pain oraccepts pain as inevitable
Patient is uncertain how toseek medical attention
Patient fails to report pain
Pain changes, e.g. due todisease progression/analgesic tolerance
Pain is not re-assessed
Patientexperiences andinterprets pain
Patientinteracts with
HCP
Re-assessment
Analgesiacommenced/
altered.Anticancer & non-pharmacological
therapiesdiscussed
Steps for optimal cancer pain management
Adam R, et al. Patient Educ Couns. 2015;98(3):269-82.
Patient education, coaching and self-management for cancer pain
Lovell MR, et al. J Clin Oncol. 2014;32(16):1712-20.
The available evidence suggests that optimal strategies include those that are:
Patient-centred and tailored to individual needs
Embedded within health professional-patient communication and therapeutic relationships
Empower patients to self-manage and coordinate their care
Routinely integrated into standard cancer care
An approach that integrates patient education with processes and systems to ensure implementation of key standards for pain assessment and management and education of health professionals is most effective
Summary
Early intervention is key in achieving improved patient outcomes
There are many barriers to more effective intervention in cancer pain related to physicians, patients and healthcare systems
ESMO has issued guidelines on assessment and treatment of cancer pain
A variety of simple assessment tools for cancer pain are in common clinical use
Educational interventions, using both traditional and innovative communication tools, may be associated with improvements in pain scores