Pharmacological Management

Drug Therapy

Drug therapy is at the nucleus of cancer pain management, and conventionally, morphine remains the strong opioid of choice as well as the standard in pain management in cancer therapy.(9)

Pharmacological intervention following WHO�s analgesic ladder approach is generally accepted in health care as the foundation for cancer pain treatment guidelines. The analgesic ladder consists of non-opioids as the first step to treat mild pain, a mild opioid combined with an adjuvant non-opioid analgesic as the next step, and use of a strong opioid plus an adjuvant as pain increases or becomes increasingly difficult to control.(10)

Opioids

Although opioids are the front-line pain medications for cancer-related pain, opioids such as morphine may not always provide sufficient relief from some cancer-related pain, and the drugs may cause the client to present with adverse side effects.

Research shows that in recent years, there has been a significant increase in the dose and duration of opioid treatment, which may contribute to the increased incidence of CNS adverse effects such as delirium, cognitive dysfunction, agitation, hallucinations, generalized myoclonus and toxic-chronic seizures.(11) While tolerance and physical dependence are common occurrences in long term opioid therapy, addiction is a rare development.(12)

The onus is on the health care professional to ensure the pain relief plan is individualized for each client, and that clients are aware and understand the differences between tolerance, dependency, and true addiction.(13)

Methadone

Methadone, a synthetic opioid agonist, is at present, viewed as a second-line opioid for chronic cancer pain. Traditionally well received as a maintenance drug for opioid addiction, methadone is gradually being recognized as a favorable alternative in clients whose pain is poorly managed by the customary opioid medications.

Although methadone appears to achieve better analgesia than other opioids when neuropathic pain is present, the literature regarding the safety of methadone for pain relief remains controversial. Recommendations for further clinical studies to determine the pharmacokinetics, toxicity, and knowledge of correct administration intervals of methadone as an analgesic are warrented.(6)

Finally, even those physicians who are willing to adopt the use of methadone as a pain management strategy may face difficulties accessing such drugs. There is an overregulation based on bias of methadone�s traditional pharmacological use, and a lack of education regarding the analgesic benefits of methadone in the general healthcare community.(14)

This may result in methadone in treating cancer-related pain remaining relatively unknown or unavailable to healthcare professionals involved in providing cancer-related pain relief for clients whose options are becoming limited. Therefore, as the literature has shown, even with significant research into pain medication administration and cancer pain relief, the benefits of fixed dosing schedules and individualization of dosage and treatment plans, there continues to be healthcare professional-driven barriers to adequate cancer pain relief.

Barriers to Cancer-Related Pain Relief

Adequate relief is theoretically thought to be obtainable in approximately 90% of patients with relatively simple drug therapies. Unfortunately, this outcome is not achieved in most traditional case settings, as evidence suggests that pain is frequently under-treated in the oncology setting. (15)

Barriers to effective pain management emanate from sources both internal and external to the client. External to the client, finances, poor communication between client-healthcare provider, agency-organizational influences, and family caregiver attitudes are named as potential stumbling blocks to pain management.(16)

One of the main reasons for poor pain management is the result of health care professionals who prescribe analgesics as needed as opposed to around the clock, inadequate dose administration, inappropriate selection of analgesics, and failure to promptly treat breakthrough pain. This may be due to physician attitudes to cancer treatment, where the tendency is to give lower priority to symptom control than to disease management.(17)

A primary barrier noted to be prevalent among both health care professionals and clients is the concern regarding opioid tolerance and addiction. It is argued that too often clients are under-treated due to their own preconceived misconceptions regarding opioid tolerance, addiction, or fear of adverse effects, such as respiratory depression. Consequently, client non-adherence to a prescribed treatment regimen may interfere with cancer-related pain management. The literature suggests that pharmacological treatment should be approached from a more holistic point of view, incorporating the clients needs and personal treatment goals, rather than a blanket treatment plan.

(10) Lesage, P. & Portenoy, R.K.(1999). Cancer control. Journal of the Moffitt Cancer Center, 6(2), 136-145

(11) Coyne, P.J. (2003). When the World Health Organization analgesic therapies ladder fails: The role of invasive analgesic therapies.Oncology Nursing Forum, 30(5), 777-783.; Ripamonti, C. & Dickerson, E.D. (2001). Strategies for the treatment of cancer pain in the new millennium. Drugs, 61.
Zorn, M., Rowland, J.H. & Varricchio C.G.(2002). Symptom Management in cancer: Pain, depression, and fatigue. Bethesda, MD: National Library of Medicine

(12) Ersek, M. (1999). Enhancing effective pain management by addressing patient barriers to anagesic use. Journal of Hospice and Palliative Nursing, 1(3), 87-96.;
Ripamonti, C. & Dickerson, E.D. (2001). Strategies for the treatment of cancer pain in the new millennium. Drugs, 61.

(13) Lesage, P. & Portenoy, R.K.(1999). Cancer control. Journal of the Moffitt Cancer Center, 6(2), 136-145. Cancer control. Journal of the Moffitt Cancer Center, 6(2), 136-145.;
Ersek, M. (1999). Enhancing effective pain management by addressing patient barriers to anagesic use. Journal of Hospice and Palliative Nursing, 1(3), 87-96.

(14) Ersek, M. (1999). Enhancing effective pain management by addressing patient barriers to anagesic use. Journal of Hospice and Palliative Nursing, 1(3), 87-96.
; Ripamonti, C. & Dickerson, E.D. (2001). Strategies for the treatment of cancer pain in the new millennium. Drugs, 61,

(15) Lesage & Portenoy 1999; Coyne, P.J. (2003). When the World Health Organization analgesic therapies ladder fails: The role of invasive analgesic therapies.Oncology Nursing Forum, 30(5), 777-783.; Woodgate & Degner, 2003; Ripamonti, C. & Dickerson, E.D. (2001). Strategies for the treatment of cancer pain in the new millennium. Drugs, 61.

(16) Ersek, M. (1999). Enhancing effective pain management by addressing patient barriers to anagesic use. Journal of Hospice and Palliative Nursing, 1(3), 87-96.
; Mazanec, P. & Bartel, J. (2002). Family caregiver perspectives of pain management. Cancer Practice, 10(S-1). S66-S69.:
Coyne, P.J. (2003). When the World Health Organization analgesic therapies ladder fails: The role of invasive analgesic therapies.Oncology Nursing Forum, 30(5), 777-783

(17) Lesage, P. & Portenoy, R.K.(1999). Cancer control. Journal of the Moffitt Cancer Center, 6(2), 136-145.