ONI: In the cancer care continuum, whose responsibility is it to address breakthrough pain: the oncologist, oncology nurse, the primary care physician, a palliative care specialist?
Dr. Craig: I think everyone has some responsibility in screening, assessing, and treating all types of pain, including noncancer pain in cancer patients. I think it is important to have at least nonspecialists (primary care physicians, etc) thinking about the concept and asking patients about it.
Ms. Bennett: Ideally, every clinician who comes in touch with the patient should address pain and pain treatment. The reality is that healthcare professionals are already overburdened, so patients have become more sophisticated in advocating for themselves.
The survey was conducted in 2009 (October 2 to October 29) with 545 adults responding.
|•||96% said they experienced breakthrough cancer pain at least once a month.|
|•||82% said breakthrough cancer pain negatively affects their emotional health.|
|•||87% said breakthrough cancer pain has affected their medical treatment.|
|•||75% said breakthrough cancer pain is one of the most challenging aspects of having cancer.|
|•||67% said they have experienced medical-related financial issues as a result of breakthrough cancer pain.|
|•||52% said their healthcare provider described breakthrough cancer pain as a normal side effect of cancer or its treatment.|
|•||14% said they visited the emergency room more often.|
ONI: Do you think there is concern that asking cancer patients to serve as their own pain advocates will add to an already stressful situation?
Ms. Bennett: So often people with pain feel disempowered; they feel like no one is listening to them. Or they have a caregiver who wants to be more involved in the patient's treatment process but they don't know what to do. Using a pain diary with a pain scale gets the patients and caregivers more engaged in the process.
For example, the pain diary may show the patient that her breakthrough pain is related to a specific activity. Or does it come at the end of the medication dose? The clinician can then adjust the treatment plan.
Dr. Craig: Empowering patients to take part in their medical care can be very useful. However, many providers don't have the time or focus to use patient-collected data unless [the patient is] specifically being evaluated/treated for chronic pain. Primary MDs won't do this and, in my experience, pain management specialists and palliative care physicians rarely do it. But it can be useful, like a diabetic patient tracking his morning blood sugars to assist in the management of his diabetes mellitus.
ONI: There are plenty of pain assessment tools available today. What are some of the pros and cons of pain scales?
Dr. Kronenberg: Most pain scales ask patients to rate their pain from zero to 10. But if you ask a patient in pain to rate his experience, he isn't going to say 'Today, my pain is a 3.481.' We are not born with this concept that we can put a number on pain. People who work in the area of pain management think it's easy to rate pain, but that's not always the case for the patient. I prefer pain scales that offer some descriptive language along with the number. The physician or nurse needs to share what the numbers mean and it's important for patients to understand that they have to stay within this language.
|FDA-approved opioids (rapid-onset)||Other opioids commonly used (short-acting)|
|Actiq [oral transmucosal fentanyl(Drug information on fentanyl) citrate (OTFC)]||Codeine|
|Fentora [fentanyl buccal tablet (FBT)]||Hydrocodone|
|Onsolis [fentanyl buccal soluble film (FBSF)]||Hydromorphone|
Ms. Bennett: One major issue is that physicians are not actually using pain scales as often as they should. The Alliance of State Pain Initiatives surveyed doctors in Georgia and Washington. Less than half of the responding doctors said they used any kind of scale or standardized tool to assess their patients' pain as part of the conversation.
The pain scale and diary are empowerment tools and they open the pain dialogue between patients and practitioners. If patients understand that the clinician is going to use this pain tracking tool to deliver better care, they will do it.