We've noticed that you're using an ad blocker

Our content is brought to you free of charge because of the support of our advertisers. To continue enjoying our content, please turn off your ad blocker.

It's off now Dismiss How do I disable my ad blocker?
❌

How to disable your ad blocker for our site:

Adblock / Adblock Plus
  • Click on the AdBlock / AdBlock Plus icon on the top right of your browser.
  • Click “Don’t run on pages on this domain.” OR “Enabled on this site.”
  • Close this help box and click "It's off now".
Firefox Tracking Prevention
  • If you are Private Browsing in Firefox, "Tracking Protection" may casue the adblock notice to show. It can be temporarily disabled by clicking the "shield" icon in the address bar.
  • Close this help box and click "It's off now".
Ghostery
  • Click the Ghostery icon on your browser.
  • In Ghostery versions < 6.0 click “Whitelist site.” in version 6.0 click “Trust site.”
  • Close this help box and click "It's off now".
uBlock / uBlock Origin
  • Click the uBlock / uBlock Origin icon on your browser.
  • Click the “power” button in the menu that appears to whitelist the current website
  • Close this help box and click "It's off now".
  • ONCOLOGY
  • News
  • Blogs
  • Topics
  • Hematology
  • Image IQ
  • Podcasts
  • Videos
  • Slideshows
  • Conferences

Modern Medicine Network
  • Login
  • Register
Skip to main content
Modern Medicine Network
  • Login
  • Register
Menu
User
Home
  • ONCOLOGY
  • News
  • Blogs
  • Topics
  • Hematology
  • Image IQ
  • Podcasts
  • Videos
  • Slideshows
  • Conferences

SUBSCRIBE: Print / eNewsletter

Thorough Pain Assessment: A Nursing Imperative

  • Jeannine M. Brant, PhD, APRN, AOCN, FAAN
Oct 20, 2010
Volume: 
24
Issue: 
10
  • Oncology Nursing

The assessment and management of breakthrough pain in patients with cancer is pivotal to comprehensive pain and symptom management, and good cancer care. In this issue of Oncology Nurse Edition, Barton Bobb and Patrick Coyne have provided an excellent overview of breakthrough pain, with a focused challenge to oncology nurses to ramp up efforts to improve this deleterious and difficult-to-control problem. The authors have included a thorough description of breakthrough pain, key assessment tips, an overview of barriers that interfere with optimal control, and management strategies.

This commentary will continue to discuss the significance of managing breakthrough pain, with a focus on more comprehensive assessment and pharmacologic approaches, the mainstay of breakthrough pain management.

SIGNIFICANCE OF THE PROBLEM
The Cochrane review estimates the prevalence of breakthrough pain to range from 19% to 95%,[1] but many investigators indicate that the rate is closer to 64% to 86%.[2,3] Importantly, a recent survey by the American Pain Foundation underscored the magnitude of impact of this syndrome: it found 75% of patients responding viewed breakthrough cancer pain as one of the most challenging aspects of having cancer.[4] Furthermore, over half of the patients surveyed (53%) rated their pain as severe, or scoring an 8, 9, or 10 on a scale of 0–10, with 10 being the worst pain imaginable. The majority of patients also reported that pain wakes them from a deep sleep at least once per month (73%), affects their ability to perform household tasks (76%), and affects their desire to participate in some activities (83%).

CONDUCTING A MORE COMPREHENSIVE PAIN ASSESSMENT
The management of breakthrough pain begins with assessment, and pain assessment is a primary nursing responsibility. While many nurses have become skilled at screening patients for the presence of pain and then determining the intensity of pain according to a 0-to-10 scale, a more thorough assessment of pain that includes quality and temporal factors is imperative in addressing the problem of breakthrough pain. Pain quality assists in diagnosis of the specific pain syndrome (eg, nociceptive or neuropathic) so that coanalgesics can be individually tailored for each patient.[5] For example, anticonvulsants are helpful in management of neuropathic pain, and control of the underlying pain may indirectly control the breakthrough component of the pain. Asking about the temporal aspects of pain or the experience of pain over time focuses in on the characteristics of the individual pain experience.[6] The American Pain Foundation recommends the following temporal assessment questions:

• Do you have sudden, brief periods of increased pain (breakthrough pain)?

• How many episodes of this type of pain do you experience on a daily basis?

• Do certain activities cause the pain to occur or does the pain happen unpredictably?

• Which medicines do you take to manage this type of pain?

Nurses should keep these additional screening questions in mind and further investigate a positive response to any of them. For example, if the patient identifies specific activities that trigger the pain, further discussion about these activities with the patient is indicated, along with instruction about self-care strategies that can be employed by the patient. This information is often rolled into the individualized plan of care.

PHARMACOLOGIC MANAGEMENT OF BREAKTHROUGH PAIN
As indicated by Bobb and Coyne, assistive devices and other nonpharmacologic modalities are important in the management of breakthrough pain, but pharmacologic therapy is the mainstay treatment. Long-acting (LA) opioids provide around-the-clock coverage of pain and usually help with baseline control of pain and with associated breakthrough pain. Fishbain recommends that the LA dose be increased for appropriate pain management if the patient experiences four or more episodes of breakthrough pain per day,[7] but increasing the LA dose may medicate the patient beyond the breakthrough episode and contribute to untoward side effects such as sedation, depending on the characteristics of the breakthrough episode.

Fast-acting agents may be most appropriate for breakthrough pain, especially if the episodes are short. Therefore, knowledge of the pharmacokinetic properties of opioids is critical in addressing breakthrough pain. Intravenous opioids are one option if venous access is available. Most intravenous opioids peak within a few minutes, with fentanyl reaching its peak effect fastest. Transmucosal and buccal fentanyl are the fastest-acting orally administered opioids. Using these routes, some of the drug is absorbed in the oral cavity, while the remaining drug is swallowed and absorbed orally. In addition to the fast onset of action, fentanyl has a short half-life when given by this route; therefore, blood levels dissipate rapidly, preventing an accumulation of unwanted side effects. Three preparations of orally administered fentanyl are available: transmucosal fentanyl (Actiq), fentanyl buccal tablets (Fentora), and fentanyl buccal soluble film (Onsolis). More thorough review of these agents is available in the literature and within the prescribing guidelines of each agent.

In addition to opioids, coanalgesics provide another option for breakthrough pain. Nonsteroidal anti-inflammatory agents are helpful for bone-related pain. As previously mentioned, anticonvulsants are helpful in neuropathic pain, but other agents such as clonidine, tricyclic antidepressants, and local anesthetics may provide benefit. Corticosteroids are helpful for many pain syndromes.[8] Recently, a woman in my institution who had metastatic non–small-cell lung cancer with brachial plexopathy and severe incident pain was successfully managed with LA opioids, corticosteroids, lidocaine patches over the extremity, and transmucosal fentanyl. Overall, nurses are on the frontline in the assessment and management of breakthrough pain. A diligent individualized approach can help to ensure successful management of breakthrough pain and lessen the burden it adds to the cancer experience.

References: 

References

1. Zeppetella G, Ribeiro MD: Opioids for the management of breakthrough (episodic) pain in cancer patients. Cochrane Database Syst Rev Jan 25 (1): CD004311, 2006.

2. Fine PG, Busch MA: Characterization of breakthrough pain by hospice patients and their caregivers. J Pain Symptom Manage 16(3):179–183, 1998.

3. Portenoy RK, Hagen NA: Breakthrough pain: Definition, prevalence and characteristics. Pain 41(3):273–281, 1990.

4. American Pain Foundation: Breakthrough Cancer Pain Is Top Challenge for Cancer Patients, Even When Using Pain Treatments, A New Survey Reveals. Available at:

http://www.painfoundation.org/newsroom/press-releases/2010/breakthrough-.... Accessed on September 26, 2010.

American Pain Society: Principles of analgesic use in the treatment of acute pain and cancer pain, sixth ed. Glenview, IL, APS Press, 2008.

5. Soares LG, Chan VW: The rationale for a multimodal approach in the management of breakthrough cancer pain: A review. Am J Hosp Palliat Care 24(5):430–439, 2007.

6. Bennett, D, Burton, AW, Fishman SM, et al: Consensus panel recommendations for the assessment and management of breakthrough pain, part 1: Assessment. J Clin Pharm Ther 30:296–301, 2005.

7. Fishbain DA: Pharmacotherapeutic management of breakthrough pain in patients with chronic persistent pain. Am J Manag Care 14(5 Suppl 1): S123–S128, 2008.

Financial Disclosure: The author has no significant financial interest or other relationship with the manufacturers of any products or providers of any service mentioned in this article.

Related Articles

  • Unmet Needs During Extended Survivorship
  • Endings & Beginnings—Grief, Loss, and Letting Go
  • Creating a Win/Win Through Teaching Patient Responsibility
  • The Most Overlooked Symptom in Cancer Care
  • Aprepitant Warrants More Study for CINV in Patients on FOLFOX for CRC

Resource Topics rightRail

  • Resource Topics
  • Partner Content
Breast Cancer
Lung Cancer
Prostate Cancer
Colorectal Cancer
Melanoma
Cutaneous T-Cell Lymphomas: Mycosis Fungoides and Sézary Syndrome
3 Keys to Success in the Oncology Care Model

Current Issue

Oncology Vol 32 No 4
Apr 15, 2018 Vol 32 No 4
Digital Edition
Subscribe
Connect with Us
  • Twitter
  • Facebook
  • LinkedIn
  • RSS
Modern Medicine Network
  • Home
  • About Us
  • Advertise
  • Advertiser Terms
  • Privacy statement
  • Terms & Conditions
  • Editorial & Advertising Policy
  • Editorial Board
  • Contact Us
Modern Medicine Network
© UBM 2018, All rights reserved.
Reproduction in whole or in part is prohibited.