The Case of the Pain Paradox: Follow-Up and Clinical Trial
The January 2018 case study (https://voice.ons.org/news-and-views/the-case-of-the-pain-paradox) introduced Vince, a 55-year-old man receiving chemotherapy and radiation for recurrent bladder cancer. He suffers from chronic back pain because of spinal stenosis and has been on opioid therapy for nearly two years.
Although Vince quit smoking after being diagnosed with bladder cancer, he continues to drink a bottle of wine each evening. He served in Iraq as a member of the National Guard and has a brother who suffers from opioid addiction.
When Vince is diagnosed with recurrent cancer, his primary care physician who originally prescribed hydromorphone refers him to a pain management clinic. Vince is disgruntled about having to sign a pain contract and discusses his frustration with Jenny, an oncology nurse in the radiation department.
When Jenny reviews Vince’s social history, she recognizes that he has several risk factors for opioid abuse and addiction (see sidebar).
What Would You Do?
Opioid abuse has reached epidemic proportions in the United States, resulting in strict prescribing regulations and an increase in public awareness campaigns. In 2015, an estimated 12.5 million people abused prescribed opioids (https://www.drugabuse.gov/drugs-abuse/opioids/opioid-overdose-crisis).
Physical dependence and addiction are potential unwanted side effects of opioid pain medications. Addiction is characterized by the inability to stop using a drug despite its negative consequences on health and livelihood. Physical dependence includes tolerance (needing higher doses to deliver the same effect) and withdrawal (producing physical and mental symptoms when the drug is stopped). Physical dependence can be present without addiction (https://www.drugabuse.gov/publications/drugfacts/genetics-epigenetics-addiction), but the two concepts are most often found together.
Pharmacogenomics is the study of how genes (https://voice.ons.org/news-and-views/what-oncology-nurses-need-to-know-about-pharmacogenomics) affect the individual response to medications and how matching medications to a person’s genes could result in a near-perfect fit. Up to 50% of the risk for addiction to medications is attributed to a person’s genes (https://www.drugabuse.gov/drugs-abuse/opioids/opioid-overdose-crisis). By understanding genetic variations, healthcare providers can prescribe medications that may be highly effective and produce minimal side effects.
Jenny tells Vince about a clinical trial offered at the cancer center that includes genomic profiling for pain management (https://clinicaltrials.gov/ct2/showNCT02542397?term=pharmacogenomics%20OR%20pharmaco). She encourages him to see if he qualifies for the study and follows up with him two weeks later. Vince reports that both he and his brother are participating in the clinical trial.
Jenny exemplifies oncology nurses’ responsibility to develop and maintain current knowledge of pain management strategies and current clinical trials. As described in the first part of this case study (https://voice.ons.org/news-and-views/the-case-of-the-pain-paradox), Jenny holistically addressed Vince’s pain issues by providing him with nonpharmacologic pain management interventions.