- Pain Management (http://dev-voice.ons.org/topic/pain-management)
- Clinical Practice (http://dev-voice.ons.org/topic/clinical-practice)
- Clinical Practice Guidelines (http://dev-voice.ons.org/topic/clinical-practice-guidelines)
- Evidence-Based Practice (http://dev-voice.ons.org/topic/evidence-based-practice)
The Case of the Pain Paradox
Vince was diagnosed with non-muscle invasive, high-grade bladder cancer at age 54 and treated with intravesical Bacille-Calmette Guerin immunotherapy. He stopped smoking and began a consistent walking program.
Ten months later, after working on a home remodeling project, he experienced low back pain, and his primary care provider (PCP) prescribed 5 mg hydrocodone/325 mg acetaminophen every four to six hours after diagnosing spinal stenosis on magnetic resonance imaging. Vince continued to use the hydrocodone at escalating doses with moderate pain control for the next six months.
On routine follow-up with his urologist, he was diagnosed with recurrent bladder cancer. He refused a cystectomy and was referred to the oncology clinic, where he began treatment with concurrent chemotherapy and radiation. Vince tells the radiation oncology nurse, Jenny, that his PCP is no longer willing to prescribe pain medication and has referred him to a pain management clinic. He says, “I have cancer but I still have to sign a pain contract like I’m some sort of criminal.” He asks Jenny why his oncologist can’t manage his back pain.
What Would You Do?
Managing acute and chronic pain stemming from injury to body tissues (nociceptive pain) or central nervous system damage (neuropathic pain) is challenging in the general population and increasingly complicated in patients with cancer (https://www.nccn.org/professionals/physician_gls/pdf/pain.pdf) being concurrently treated for chronic pain issues.
The ONS position statement on cancer pain management (https://www.ons.org/advocacy-policy/positions/practice/pain-management) states, “All professionals caring for patients with cancer have an ethical responsibility to acquire and use current knowledge and skills to assess cancer pain and implement evidence-based pain management guidelines (http://ascopubs.org/doi/10.1200/JCO.2016.68.5206).” The position statement further details essential skills for oncology nurses, including the ability to:
- Perform a holistic pain assessment, considering the physical, psychological, spiritual, and sociocultural aspects of unrelieved pain.
- Educate patients about the use of pharmacologic safeguards and nonpharmacologic methods for pain control (see sidebar).
In talking with Vince, Jenny learns that his brother has a history of drug addiction and has been released from several pain management clinics for breaking his pain contract. She validates Vince’s feelings and discusses the value of having a pain specialist possibly address his back-related pain with nonopioid interventional therapies.
Jenny encourages Vince to keep his pain medication in a lock box and not discuss what medications he is taking with anyone other than his healthcare professionals. She also suggests a referral to the hospital’s oncology wellness program for other nonpharmacological methods to help him manage his back pain.
For evidence-based recommendations on managing various types of cancer pain, refer to the ONS Putting Evidence Into Practice resources (http://www.ons.org/practice-resources/pep/pain).