Chronic Somatic Pain Management in Palliative Care for a Patient with Urologic Cancer

Introduction

One of the most common and complex issues in health care relates to the management of pain. Pain is a global occurrence estimated to affect at least 8% of children and 20% of adults at any given moment (Buga & Sarria, 2012). Furthermore, evidence suggests that pain is one of the main reasons for primary care consultations, illustrating the need for effective pain management strategies. In the clinical context, pain can be understood as an unpleasant emotional and sensory experience connected to potential or actual tissue damage (Moayedi & Davis, 2013). Here, it is important to reiterate that the perception of pain is quite subjective, and is not always connected to a pathology, further complicating the identification of treatment for the underlying cause. Nevertheless, pain management can involve surgical, pharmacological and non-pharmacological procedures, depending on the identification of the underlying factors, as well as the multisystemic nature of pain. Despite the evidence suggesting the importance of pain management in healthcare delivery, there is a dearth of literature analysing and synthesising studies and evidence of interprofessional pain management in palliative care, and the role of the various professionals involved in such a process. As such, anchored on a review of peer-reviewed and relevant literature, the current paper provides a critical analysis of the process of the management of chronic somatic pain, with the objective of informing evidence-based practice.

Pathophysiology and Theories of Pain

An analysis of the management of pain must be anchored on an understanding of the pathophysiology and the various theories underpinning pain management.   Up until the 1960’s, the main view in the scientific and medical community relating to pain had been anchored on the specificity theory of pain. The main premise of the specificity theory of pain was informed by Descartes’ discussion of pain path, using the analogy of tagging on one end of the rope to strike at a bell at the other end of the rope (Moayedi & Davis, 2013). According to the specificity theory, particular stimuli have particular receptors, which go to a location in the brain, which then identifies the quality of pain (Mano & Seymour, 2015). As such, any unpleasant stimulus applied to the surface of the skin causes a sensation of pain. However, as scholars and practitioners would come to realise much later, observed facts relating to pain could not be explained using such a simplistic theory. The realisation of the inadequacy of the specificity theory was prompted by data relating to the high variability of the connection between nociceptive stimuli and the individual’s pain experience (Moayedi & Davis, 2013). In other words, since the same kind of injury can trigger varying quality and intensity of pain in different individuals or even in the same person at varying instances, depending on their past experiences, the context they view themselves to be in, and the previous state of their bodies, pain cannot be attributed to some particular stimulus in a predictable way.

An alternative theory that solves the specificity theory problems is the gate theory, which was aimed at explaining the inconsistency in the connection between nociceptive stimuli and pain perception. The main proposition of the gate theory is that there is a gate-like system that controls all information relating to pain on its way to the brain. The gate theory postulates that noxious stimulus from the outlying nociceptors are transmitted to the spinal cord through small fibres with slow conduction velocity and large myelinated fibers with speedier conduction velocity (Moayedi & Davis, 2013). As illustrated in figure 1, the gate is seen as a neural system, which functions as a regulating or modulating mechanism that governs the range of nerve-impulse transmission from the fringe to the spinal cord transmission cells. In sum, the gate theory succeeds in explaining the great variability that exists in the connection between stimuli and pain experience.

Figure 1: Illustrating the gate theory mechanism. Adapted from Moayedi and Davis (2013)

 

Of these theories, the gate theory is best suited for understanding somatic pain in urologic cancer patients. As indicated by Buga and Sarria (2012), somatic pain in cancer patients is often caused metastatic bone disease or tissue inflammation. In this respect, bone pain is hypothesised to be caused by either a release of inflammatory mediators, direct stimulation of nociceptors in the periosteum, or an elevation in interosseal pressure. Such variability in the possible causes of the pain are often reflected in the variability in the way patients describe their pain symptoms, though this type of pain is often described as sharp in nature and well localised.

Pain Management

In urologic cancer patients, somatic pain is often characterised by impairment in quality of life as well as overall distress, which may be influenced by any of various losses. While the pain may contribute immensely to such suffering, there are numerous other factors such as progressive physical impairment, experiencing other symptoms, and psychological disturbances. As indicated by Lovell et al. (2013), the biopsychosocial model of chronic pain acknowledges pain as combination of physical dysfunction, coping strategies and beliefs, illness behaviour, distress, and social interaction. This view is supported by Mercadante et al. (2013), who indicates that the numerous factors that contribute towards the perception of chronic pain often mean that such pain may not respond effectively to a single treatment approach.

Pharmacologic Therapy

One line of treatment in somatic pain is the use of pharmacologic therapies. Evidence show that while somatic pain may be responsive to opioids, using an added three-step therapy approach has established benefits (Ripamonti et al., 2012). The mainstay of pharmacologic therapy for somatic pain in cancer patients is Nonsteroidal anti-inflammatory drugs (NSAIDs), which function by inhibiting cyclooxygenase. Cyclooxygenase is responsible for catalysing the conversion of arachidonic acid to leukotrienes and prostaglandins (Lovell et al., 2013). Since NSAIDs do not activate opioid receptors, they can be used safely alongside opioids. However, while much of the evidence points to the effectiveness of NSAIDs in relieving pain related to bone metastasis (Mercadante et al. 2013; Ripamonti et al., 2012), there are some significant side effects that should be observed in pharmacologic therapy. Some of the main side-effects include renal toxicity, gastrointestinal bleeding, and hepatic dysfunction, while minor adverse effects include vomiting, heartburn, dyspepsia, nausea, constipation, and bloating (Schneider, Voltz & Gaertner, 2012). Furthermore, there a review of the available literature did not discover any conclusive evidence to suggest the use prioritisation of any one NSAID as more effective than the others. Nevertheless, the use of nonacetylated salicylates like choline magnesium trisalicylate has been recommended as they tend to have fewer negative gastrointestinal side-effects and fewer negative effects on platelet aggregation compared to aspirin. In fact, evidence suggests that nonacetylated salicylates are favoured among certain physicians (Stanos & Galluzzi, 2013). Other favoured treatments include rofecoxib and celecoxib, which function as COX-2 inhibitors, and are preferred due to their fewer side effects (Elder et al., 2016). Nevertheless, the overarching recommendation by the present paper is that dosages for pharmacologic therapy for somatic pain in cancer patients should be tailored according to the medical history of the patient, as well as the patient’s renal function.

In the event that one type of NSAID is not effective in alleviating of pain symptoms due to metastasis, transitioning to another type of NSAIDs may be beneficial before considering the termination of therapy. As shown by Mercadante et al. (2013), in a situation where a patient has no had significant relief from somatic cancer pain with NSAID therapy, the physician should consider starting a trial of corticosteroid treatment. Evidence also shows that corticosteroids can be employed as adjuvant therapy, especially if the patient has known hypersensitivity to NSAIDs. However, corticosteroids are not without their side effects as they have been associated with some incidences of diabetes, and gastrointestinal bleeding. For patients with somatic pain resulting from bone metastasis, who fail to show significant improvements despite the use of NSAIDs, opioids, and corticosteroids, referral should be made for evaluation by a radiation oncologist (Schneider, Voltz & Gaertner, 2012). Generally, radiation therapy is advocated for in all patients presenting with bone metastasis, though for frail and homebound patients in end-of-life care, such therapy is only recommended after other treatment modalities have proven to be ineffective.

Nonpharmacologic Approaches

While the pharmacologic therapies have been the mainstay of somatic pain management in palliative care, the biopsychosocial approach to pain management recognises the need to address the various social and psychological aspects of pain, which necessitate the involvement of other specialists in an interprofessional approach to care. In such care, nonpharmacologic therapies support the efficacy of standard pharmacologic modalities in holistic pain management (Williams, Eccleston & Morley, 2012). In other words, while the pharmacologic therapies treat somatic physiological and emotional aspects of the pain, non-pharmacologic approaches aim to address the behavioural, cognitive, affective, and socio-cultural aspects of the pain. As noted by Williams, Eccleston and Morley (2012), such therapies can be used as complimentary or adjuvant treatments for moderate or severe pain. They contribute by increasing the individuals’ sense of control over the pain and decreasing the feeling of weakness, by improving functional capacity of the patient, reducing stress and anxiety, and lowering the needed dosage of pain-relief medication (Schneider, Voltz & Gaertner, 2012). Some of the widely used non-pharmacologic complimentary therapies include acupuncture, relaxation techniques, support groups, imagery, family counselling, biofeedback, patient education, and psychotherapy.

Professional and Ethical Considerations

Ranging from policy and law, to which healthcare professional subscribe, to personal attitudes and responsibility related to pain and suffering, ethical and legal issues in decision-making are crucial elements of the complex picture of interprofessional pain management. In clinical settings views relating to pain and pain care can, especially in palliative care, can sometimes be laden with a lifetime of subjective perceptions and views founded on education level, family, religious and cultural beliefs (Schatman & Darnall, 2013). Such beliefs can be further made more difficult by varying views among healthcare professionals, communities, and family members (McGee et al., 2011). The understanding here is that, while healthcare professionals and regulators remain critical in the safe use of pain medication and non-pharmacologic interventions, it is those at the centre of pain care (patients), who are live through the pain, and who have a primary human right to have the pain managed.

It is important to note that, while the incidence of pain does not discriminate, its care can. Providers of health care, persons who live with chronic pain, and families need to be cognizant of the biases and factors in the personal background when approaching a pain care strategy. Evidence shows that inequalities in pain care exist, founded on race, gender, income level, and age (McGee et al., 2011; Johnson, Todd & Moulton, 2007). Furthermore, McGee et al. (2011) note that there are noteworthy concerns with the management of chronic cancer pain in emergency clinical settings since such patients have nowhere else to go. Withholding pain treatment leads to unnecessary suffering, which is not only wrong ethically, but could also be grounds for future litigation. Based on the principles of autonomy, justice, beneficence, and non-maleficence, and recognising the intrinsic dignity of all individuals, and the profound wrongness in withholding pain treatment, the present paper declares that the all individuals, irrespective of their beliefs, gender or orientation have the right to access pain care without bias or discrimination, as well as their right to be informed on the assessment and management approaches available by appropriately trained  healthcare professionals, are fundamental to effective interprofessional pain management.

The Role of the MDT

In the context of chronic somatic cancer pain, following an initial diagnosis, the primary physician may offer prescriptive treatments that may control the pain. The primary care physician, therefore, performs the critical role of gatekeeper or coordinator of the pain management strategy. In addition, referrals to an occupational counsellor, physiotherapist, or rehabilitation specialist may also be useful to understanding the underlying physical causes of the pain. On the other hand, referral to a behavioural therapist or a psychologist may also make important contributions by offering psychological approach to the pain management (Fishman et al., 2013). In essence, therefore, the core members of in the interprofessional team may vary accordingly, though they typically comprise members from three or more medical specialities such as neurology, anaesthesiology, neurosurgery, rheumatology, clinical psychology, orthopaedics, nursing, and physiotherapy. It should be reiterated that some treatments can be performed by one of several professionals, as long as proper training is provided.

Another important professional in the multidisciplinary team is the anaesthesiologist, who uses their expertise to implement and recommend pain management procedure, varying from central or peripheral nerve blocks to device implantation, radiofrequency procedures, and neurodestruction techniques. In general, anaesthesiologists are equipped with crucial experience in using strong analgesic drugs, as well as neural or surgical blockade (Hadzic, 2016). They, therefore, play an important role in the formulation of interprofessional pain management plans.

            In relation to somatic pain caused by bone metastasis, rheumatologists may be needed as they have significant experience in managing patients with chronic pain linked to inflammatory disease of the musculoskeletal system and soft tissue disorders (Elder et al., 2016). In addition, a neurologist may be needed to recommend appropriate therapeutic pain management alternatives.

Of these roles, one of the most critical is that provided by the clinical nurse specialist. According to Angeles et al. (2013), the clinical specialist nurse not only performs ongoing assessment of the client’s pain, but also assists in establishing treatment plans and in conducting interventional procedures. The nurse also maintains a therapeutic relationship with the patient and responds to the patients concerns, offering ongoing patient education.

Another important member of the multidisciplinary team is the clinical psychologist, who offers day-to-day psychosocial care to the patient. As previously noted, the psychosocial aspect of pain is important to the differential manifestations and experiences of pain. In the same respect, the patient may also exhibit significant psychosocial barriers to recovery, and the psychologist contributes to identifying such barriers (Fishman et al., 2013), as well as the psychosocial weaknesses and strengths. The psychologist can also use cognitive behavioural therapy and other strategies like hypnosis, biofeedback techniques, and autosuggestion to facilitate the management of the patient’s negative feelings related to pain in urologic cancer.

Implications for Practice

The present discussion has revealed the various roles that various professionals can play in the holistic management of pain, which considers the biopsychosocial aspects of pain and pain management. Based on the evidence presented, it is apparent that the successful management of somatic pain in a patient with urologic cancer is dependent on effective communication between all the parties involved. Such information must involve adequate and timely information exchange between nurses, primary care physicians, patients, and specialists. Nurses training ought to cover such communication, as well as considerations of patient expectations of therapeutic relationships.

Nursing professionals must also understand the causes of poor communication during the referral process in pain management. One such cause is the inadequate and delayed information transfer. Nurses and other care professionals must learn to use standardised referral procedures and forms to help ease the communication process (Angeles et al., 2013). Such standardised communication can be facilitated by computer-generated letters, thereby eliminating incomplete information. The paper also highlights the need to use language that is understood by the various professionals involved in the care team as well as the patient. The use of complex language in interprofessional settings not only creates social distance and barriers between the care provider and the patient, but can also deter effective communication between the various professionals involved. Another important consideration for practice arising from the present debate is the need for interdisciplinary structures for facilitate collaboration and referrals among the various professionals.

Conclusion

One of the key challenges facing palliative healthcare providers today is the provision of effective pain management. Given that biological, social, and psychological factors interact in a complex way to influence the variabilities in the way individuals experience pain, there is need for the consideration of these factors in designing treatment plans. Based on a consideration of the various components involved in the pathophysiology of pain, the current paper recognises the roles of various professionals involved in the provision of holistic interprofessional care, which includes both pharmacologic and non-pharmacologic interventions. Besides each member understanding their roles in pain management for the patient, collaborative communication is critical to prevent duplication of roles and possible negligence, as well as to enhance information exchange critical to decision-making.

 

 

 

 

References

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