Pain is a common side effect of cancer and its treatment, but unfortunately it continues to be undertreated in patients with the disease. Oncology nurses should continually assess for this distressing side effect and take steps to help control pain in patients with unresolved symptoms.

The ONS Putting Evidence Into Practice (PEP) Intervention of Pain Project Team reviewed, critiqued, and summarized the research evidence for nursing interventions for adult patients experiencing nociceptive or neuropathic cancer pain. Their work was reported in the December 2009 issue of the Clinical Journal of Oncology Nursing (Aiello-Laws et al., 2009). See Figure 1 for a summary of the PEP team’s recommendations.

Recommended for Practice

Management of cancer pain depends on the pain’s etiology. For mild to moderate nociceptive pain, the PEP team found that acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) should be used. Both types of drugs have a ceiling dose, however, at which additional analgesic effect is unlikely and side effects are increased.

For moderate to severe nociceptive pain, opioids are recommended. Oral administration is preferred for ease, safety, and minimal invasiveness. These drugs have no ceiling effect but are associated with side effects such as nausea, constipation, and sedation that must be managed to ensure patients’ adherence. Nausea and sedation usually improve as patients adjust to the opioids. The standard of care is to initiate a bowel regimen (e.g., stool softener, laxative) as soon as opioids are introduced to prevent or manage constipation effectively.

Figure 1 (click to enlarge)

Corticosteroids also may be used for nociceptive pain, but side effects from chronic, long-term usage may be significant, including weight gain, osteoporosis, Cushing syndrome, proximal myopathy, euphoria, increased appetite, and psychosis. Patients using corticosteroids along with NSAIDs also are at increased risk for gastrointestinal bleeding.

Topical or local anesthetics may be used to reduce pain from procedures, such as lumbar puncture, bone marrow aspirate, and venous port access.

The ONS PEP team identified that coanalgesics can be recommended for practice in certain neuropathic pain conditions. Coanalgesics should be administered initially as single agents, but some patients may require combinations from different coanalgesic categories.

Tricyclic antidepressants and selective serotonin and norepinephrine reuptake inhibitors are recommended as first-line therapy. Certain anticonvulsants are effective in the treatment of trigeminal neuralgia, postherpetic neuralgia, glossopharyngeal neuralgia, and posttraumatic neuralgia. First-line treatment for severe acute neuropathic pain includes opioids in combination with antidepressants or anticonvulsants. Topical and systemic lidocaine also was found effective for short-term use.

Likely to Be Effective

Although bisphosphonates, radionuclides, and radioisotopes have been shown to be effective for nociceptive pain, not enough strong evidence exists for the ONS PEP team to recommend them as first-line treatment. If analgesics or radiotherapy are not effective, the team recommends using bisphosphonates, although healthcare professionals should be aware of its potential for osteonecrosis of the jaw. Radionuclides and radioisotopes may be used for metastatic bone pain, but a full response may not be seen for two to three weeks, so analgesics may need to be continued in the meantime.

For more information on interventions for nociceptive or neuropathic pain, including the interventions that the ONS PEP team did not find sufficient evidence for, refer to the full article by Aiello-Laws et al. (2009). ✱

• Aiello-Laws, L., Reynolds, J., Delzer, N., Peterson, M., Ameringer, S., & Bakitas, M. (2009). Putting Evidence Into Practice: What are the pharmacologic interventions for nociceptive and neuropathic cancer pain in adults? Clinical Journal of Oncology Nursing, 13, 649–655. Retrieved from http://ons.metapress.com/content/c0174j255v2p0706/fulltext.pdf