NEW YORK--The "right" dose of pain medication is the
one that works, Ronald Blum, MD, said at a conference on cancer
pain sponsored by Cancer Care, Inc. But that simple maxim is not
so easy to follow.
Cancer pain is complex, and treating it involves routinely assessing
a patient's pain. "Clearly, one of the barriers is that we
don't ask our patients, Hello, how are you? How do you feel? Are
you in pain?" said Dr. Blum, deputy director, Kaplan Comprehensive
Cancer Center, New York University Medical Center.
"We need to assess the location of the pain, the temporal
pattern, and the quality, to differentiate between somatic pain,
nociceptive pain, in particular, and neuropathic pain. Questions
such as, What makes the pain worse, What makes it better, help
us decide on interventions."
How Do You Feel? Five
Dr. Blum and his patients use a visual analogue scale rated from
1 to 10 to communicate about pain. "My patients will come
in, and I'll say, how are you? And they'll say--Five. We've established
a way of communicating. You can apply the same concept to establishing
the relief of a particular intervention. They'll say--I got a
four out of it."
Cancer pain is "different," Dr. Blum said, in that there
is a known pathology, patients may have more than one site of
disease, and there may be multiple etiologies. The pain could
be from the treatment, the disease, or a mixture of the two. Patients
also bring their pre-cancer pain history of varying durations
and patterns, he said.
Some types of pain may have reversible causes, and clinicians
should look out for them, Dr. Blum said. "A physical examination
is essential, as well as appropriate laboratory, radiologic, and
pathologic diagnoses. I can't tell you how embarrassing it is
for everyone when I am asked to see a patient who has, say, severe
unrelieved hip pain, and all I do is roll back the sheet and see
that the patient has a fracture of the hip that has gone unnoticed."