Introduce palliative care for pain at cancer diagnosis

Integrating palliative care into the management of cancer pain can greatly benefit patients, according to a paper presented in The Lancet (2011;377:2236-2247).

As part of the journal's series on pain, Russell K. Portenoy, MD, chairman of the Department of Pain Medicine and Palliative Care at Beth Israel Medical Center, New York, New York, authored a review emphasizing the importance of managing chronic pain as part of a comprehensive strategy for palliative care. Portenoy suggests introducing palliative care interventions from the time of diagnosis as a part of disease management, rather than waiting until the end of life, and to employ specialist palliative care in complex situations.

As Portenoy notes, a recent controlled study found that persons with lung cancer offered support by a specialist palliative-care team from the time of diagnosis experienced less depression, reported improved quality of life, and lived 3 months longer than patients given usual care. However, other research has suggested that an average of 43% of cancer patients receive inappropriate care for pain. “These data affirm the continuing need for professional education in this area,” writes Portenoy.

Portenoy identifies opioid-based pharmacotherapy as the mainstay symptomatic treatment for cancer pain. However, the goal should be optimal positive outcomes from these drugs with minimal risk of both side effects and outcomes related to chemical dependency (misuse, addiction, and diversion). Effective opioid treatment depends on appropriate selection of a drug and a route, individualization of the dose, consideration of “so-called rescue dosing” for breakthrough pain, and treatment of common opioid side effects.

Clinicians should also familiarize themselves with the common indications of such adjuvant analgesic drugs as glucocorticoids, antidepressants, and anticonvulsants, which can be of benefit when opioids are insufficient. Nonsteroidal anti-inflammatory drugs (NSAIDs) can also be useful, says Portenoy, but the gastrointestinal, cardiovascular, and renal risks of these drugs should be weighed against their benefits on a case-by-case basis.

Many nonpharmacologic treatments can be used to improve pain control, coping, adaptation, and self-efficacy in the cancer patient, affirms Portenoy. Mind-body approaches may also be effective pain management techniques for some patients. These techniques can be offered by oncology nurses if access to specially trained health care professionals is restricted.

Portenoy recommends that pain assessment characterize the pain complaint, with clinicians taking into account the status of the underlying disease; clarifying the pain in terms of its cause, syndrome, and pathophysiology; and obtaining details regarding other factors that contribute to the burden of illness.

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