PSYCHO-ONCOLOGY, VOL. 3: 103-108 (1994)

CANCER PAIN MANAGEMENT GUIDELINES: IMPLICATIONS FOR PSYCHO-ONCOLOGY

Associate Attending Psychiatrist, Memorial Sloan-Kettering Cancer Center, 1275 York A venue, Box 421, New York, NY 10021, USA

WILLIAM BREITBART

INTRODUCTION

On March 2nd, the Agency for Health Care Policy and Research (AHCPR) held a press con- ference in Washington, D.C., to present the newest AHCPR Clinical Practice Guideline (No. 9): Management of Cancer Pain. The guideline, produced by the AHCPR and the Public Health Service of the U.S. Department of Health and Human Services, was developed by a multi- disciplinary panel co-chaired by Richard Payne, M.D., Ada Jacox, Ph.D., R.N. and Daniel B. Carr, M.D. International Psycho-oncology Society (IPOS) and American Society of Psychia- tric Oncology/AIDS (ASPOA) member William Breitbart, M.D. served as a panel member along with other prominent mental health professionals (Charles Cleeland, Ph.D., and Richard Chapman, Ph.D.) who contributed greatly to the emphasis on psychosocial issues related to cancer pain man- agement so evident in the cancer pain guidelines. Many ASPOA and IPOS members in the United States served as peer reviewers of the cancer pain guidelines, thus influencing greatly the content of the guidelines. Importantly, ASPOA was one of twenty-five national organizations which endorsed the ‘Management of Cancer Pain Guidelines’.

The AHCPR Cancer Pain Guideline is an important resource as an educational tool and as a tool for improving the quality of cancer pain management. Organized psycho-oncology should examine the recent activities in the cancer pain field and learn from their successes. The American Pain Society established a set of stan- dards of care for acute and cancer pain manage- ment in 1991. With the addition of the 1992

* Author to whom correspondence should be addressed.

AHCPR Acute Pain Guideline and the new 1994 AHCPR Cancer Pain Guideline, both pro- fessional and governmental organizations have agreed on a set of principles which form the basis of a standard of care for pain. The AHCPR guideline can serve as a resource and foundation from which individual institutions can then outline a standard of care and an institutional commitment to quality improvement consistent with that standard. An institutional standard of care should include acknowledgement of the accepted practice of pain assessment, education of staff, and patient education.

The State Cancer Pain Initiative movement (ap- proximately 30 states have initiatives) has taken the AHCPR Cancer Pain Guideline and is using it not only as a tool for professional as well as con- sumer education, but also in its fight to remove state regulatory barriers (controlled substance prescribing) to adequate cancer pain manage- ment. On April 21, 1994, concurrent with the state cancer pain initiatives national meeting, the American Pain Society sponsored a national satelite video-conference titled ‘An Imperative to Improve Cancer Pain Treatment: the AHCPR Guideline.’ Over 4OOO professionals in 10 cities around the U.S. participated in this conference. Among the featured speakers was Frank Brescia, M.D., a member of ASPOA, who spoke about assisted suicide and inadequately treated pain.

These events and activities must not go unnoticed by the psycho-oncology community. There are many parallels between the issues of pain in cancer patients and distressing psycho- logical symptoms (i.e. anxiety, depression, delirium) in cancer patients. Some steps have been taken. ASPOA and IPOS members, including Dr Holland were panel members of an AHCPR Depression Guideline which included a section on

CCC 1057-9249/94/020l03-06 0 1994 by John Wiley & Sons, Ltd.

Received 28 April 1994

BREITBART 104 WILLAIM

cancer and depression. ASPOA sponsored a sym- posium of standards of care for delirium manage- ment at the Academy of Psychosomatic Medicine in 1993. But obviously there is so much more that can be done. The example has been set and it is up to us to meet the challenge.

For the interested reader, what follows is a concise overview of the AHCPR Cancer Pain Management Guideline:

GUIDELINE OVERVIEW

Background Over eight million Americans have cancer or a

history of cancer, and its prevalence is increasing. More than one million new cases of cancer are diagnosed annually in the United States; it is esti- mated that in 1994, 8,200 of these diagnoses will occur in children.

Most people with cancer experience pain at some time, and many experience pain that is un- relieved by conventional pain relief practices. Cancer pain varies with the individual, and with the type and stage of the disease. Among patients with newly diagnosed or intermediate-stage cancer, 60% report moderate to severe pain. Nearly 75% of those with advanced cancer have pain.

Although cancer pain may resolve when a patient is cured, it may also continue indefinitely or recur for many reasons, including (1) tumor progression and related pathology (e.g., nerve damage), (2) surgery and other invasive diagnostic or therapeutic procedures, (3) chemotherapy or radiation toxicity, (4) infection, or ( 5 ) limited physical activity. In addition, people with cancer pain experience everyday aches and pains, such as headaches, and pain from arthritis or other concurrent diseases.

Unrelieved pain causes unnecessary suffering. Diminished activity, decreased appetite, and loss of sleep can further weaken an already debilitated patient. Even when the disease is under control and life expectancy is long, uncontrolled pain associated with cancer can prevent a person from working productively, enjoying recreation, and maintaining family and societal roles.

Psychologically, cancer pain can be devastating: Believing that pain heralds the inex- orable progress of a feared, destructive, fatal disease, people with cancer often lose hope. The

inability to cope or to understand pain treatment options may lead to impaired self-image, anxiety, and depression.

Fain associated with cancer is frequently under- treated in both adults and children. Despite recent advances that enable pain to be controlled by relatively simple means in approximately 90% of cancer patients, experts agree that undertreatment of pain constitutes a serious public health problem.

Addressing the problem Because of the number of people who have or

will have cancer, pain associated with cancer has great potential to have a negative effect on pro- ductivity and quality of life, as well as to increase health care costs, Decisions regarding the assess- ment, treatment, and follow up of pain in people with cancer are critical.

In 1991, the Agency for Health Care Policy and Research (AHCPR), a part of the Public Health Service of the U.S. Department of Health and Human Services, convened a panel of private- sector experts, including consumers, to study the problem and develop clinical practice guidelines. AHCPR had several reasons for studying the management of cancer pain:

Prevalence of the problem in the U.S. popula- tion. Concern for the quality of life for persons with cancer, Variation in cancer pain management practices. Lack of information for both health care pro- fessionals and the public on appropriate assess- ment and management of cancer pain. Cost/reimbursement issues in cancer pain control.

Objectives

pain, the guideline Panel had these objectives: To ensure quality care for people with cancer

Aid decision making in the management of cancer pain in adults and children, including infants and adolescents. Reduce variations in clinical practice. Educate health professionals and consumers about managing cancer pain. Encourage further biomedical, clinical, and cost research on managing cancer pain.

CANCER PAIN MANAGEMENT GUIDELINES 105

Findings and recommendations: approaches to pain management

Learning about cancer pain and pain manage- ment options is a responsibility shared by the patient, herlhis family, and a health care team that may include one or more physicians (such as the patient’s family physician, internist, oncolo- gist, surgeon, anesthesiologist, neurologist, or other specialists), nurses, physical therapists, psychologists, and social workers.

When a bond of trust develops between patients and health professionals, it enables patients to maintain active participation in their care. Sensi- tive communication concerning pain, treatment alternatives, costs, benefits, and risks is needed to attain this bond.

Effective pain management involves assess- ment, treatment, reassessment of results, and sometimes referral. It entails continuity of pro- fessional care, including patient instruction and use of community resources.

Pain management: principles and procedures Extensive study of the anatomy, physiology,

and pharmacology of pain analgesia has shown

Table 1. Key points about cancer pain

how neural pathways descending from the brain to the spinal cord control activity in certain spinal pathways. Analgesic drugs and other stimuli can activate these systems to control pain. However, the perception of pain is complex: It involves psychological and emotional processes in ascending neural pathways in addition to descending pain-inhibiting systems.

Involvement in pain assessment and treatment helps the patient maintain a sense of psychological well-being. Together the health care team and the patient can seek the most eifective methods of managing pain, changes in pain, and any new pain that may occur throughout the illness (see Table 1).

Because of the recurring nature of cancer pain, the Guideline presents both principles and pro- cedures of pain management-assessment, treat- ment, and followup.

Assessment Health professionals should ask about pain

often and use the patient’s self report as the primary source of information. Clinicians should assess pain with easy-to-use rating scales and

For the practitioner For the consumer

Reassure patients and families that most pain can be relieved safely and effectively. Involve the patient in decision making.

Assess pain often and systematically. Use the patient’s report of pain and what relieves it and your knowledge of common cancer pain syndromes.

Individualize multimodal treatment plans. Begin with the least invasive interventions. Explore similar drugs before considering another class of drug or more invasive treatment.

Find out more about managing cancer pain. Read the Clinical Practice Guideline and use the Quick Reference Guides. Give the Patient Guide to your patients to help them understand how to be an active participant in their treatment.

Report new pain promptly. Use drawings or rating scales to help describe the location, intensity, and what triggers or relieves pain.

Take medication exactly as prescribed. Regular doses help maintain an effective level of the drug in your body. Report side effects immediately.

Remain active to preserve strength, flexibility, and range of motion. Ask your health care team about other methods of coping with pain.

Read Managing Cancer Pain: Patient Guide. It provides the names of national support groups. AHCPR also has a Guideline and a Quick Reference Guide for your health care practitioner.

106 WlLLAIM BREITBART

document the efficacy of pain relief regularly after starting or changing treatment. Using these pain assessment tools at home can help patients ensure the continuity of effective pain control.

Pain evaluation includes use of a detailed history, physical examination, and psychosocial assessment. Prompt recognition of common cancer pain syndromes hastens therapy and minimizes the negative effects of unrelieved pain. Changes in pain patterns or development of new pain should trigger diagnostic evaluation and modification of treatment.

The patient should receive a written pain management plan. Communication about pain management should occur when a patient is transferred from one setting to another.

Drug therapy: the cornerstone of cancer pain management

The use of medications should be based on the needs of the individual patient. The simplest dosage schedules and least invasive pain manage- ment modalities should be used first. When a drug is ineffective or side effects occur, other similar drugs should be tried before that category of drug is abandoned. Convenient, cost-effective oral administration is preferred. Alternative routes include transdermal, rectal, and injection or infusion (parenteral). A variety of adjuvant drugs may be used to counteract side effects.

Nonsteroidal anti-injlammatory drugs (NSAIDs), including aspirin and acetaminophen, should form the basis of pharmacologic manage- ment of mild to moderate cancer pain, unless contraindicated by the risk of bleeding.

Opioids, such as morphine, should be added when pain persists or increases. For persistent or moderate to severe pain, higher doses or an opioid of greater potency can be given. Doses can be given around the clock, with additional ‘rescue’ doses as needed. Regular dosing maintains a con- stant level of drug in the body and helps to prevent the recurrence of pain.

Contraindications include giving a mixed opioid agonist-antagonist to the patient already receiving a full agonist (e.g., morphine) because to do so may precipitate withdrawal and increase pain. Due to potential toxicity, meperidine (Demerol) should not be used for long-term opioid therapy.

Tolerance and physical dependence are expected with long-term opioid treatment; there- fore, the patient’s need for increasing doses of opioids should not be confused with addiction. The Guideline contains special precautions for treating substance-abusing patients.

Physical modalities Patients should remain active and participate in

self-care when possible. Exercises (active and pas- sive) help maintain strength in the patient who is confined to bed. However, when a patient is in acute pain, physical activity should be limited to self-administered range-of-motion exercises. Repositioning often enhances comfort. Prolonged immobilization generally should be avoided.

Stimulation such as heat, cold, massage, pressure, or vibration can help alleviate pain associated with muscle tension or spasm. Before choosing acupuncture, the patient should report any new pain to the health care team.

Psychosocial interventions As part of a multimodel approach to pain man-

agement, psychosocial interventions should be introduced early in the course of illness, but they should not be substituted for analgesics. Patients can learn techniques such as relaxation, imagery, cognitive distraction, and reframing. Education helps patients and caregivers understand how pain can be prevented by regular, scheduled use of analgesics, including opioids.

To help meet patient and family needs, clini- cians should help patients contact peer support groups. Pastoral care members of the health care team should take part in planning and provide spiritual care and information on community resources.

Invasive interventions With rare exception, noninvasive treatments

should precede invasive palliation. However, when pain cannot be controlled and proper expertise is available, several options may be considered. Patient comfort during invasive pro- cedures should be a priority, and clinicians should be familiar with chemotherapy, radiation therapy, and surgical interactions to reduce the risk for iatrogenic complication.

CANCER PAIN MANAGEMENT GUIDELINES 107

Both surgery and radiation can be palliative as well as therapeutic when tumors or their metastases cause pain, obstruction, bleeding, or compression. Beta particle emitting radio pharmaceuticals can be effective for metastatic bone pain but should be used only when scinti- graphy shows a lesion.

Neurolytic blockage should be used only when other options (e.g., drug therapy, radiation) are ineffective, poorly tolerated, or clinically inappro- priate. Selective destruction of nerves to achieve pain relief requires expertise in the anatomy of cancer pain syndromes as well as the skill to perform the procedures and manage possible side effects. Key considerations are coexistent medical conditions, the patient’s understanding of the risks, and herlhis ability to cooperate during a procedure. When a patient becomes pain free as a result of neurolysis, opioids should be stopped gradually to avoid a withdrawal syndrome.

The Guideline discusses the advantages and dis- advantages of these and other methods, such as intraspinal drug delivery, in detail.

Special topics In addressing the needs of the individual patient

with cancer, the Guideline emphasizes pain man- agement in special populations: pediatric and elderly patients, those with concurrent medical or substance abuse problems (including HIVIAIDS), cognitively impaired patients, and members of minority and ethnic groups. The unique needs of persons with language or educational deficits are considered.

Ways to reduce procedure-related pain are the subject of one section of the Guideline. Strategies for managing distress as well as pain must be tai- lored to individual procedures and the patient’s emotional and physical condition. Sedation is an option when painless procedures require patient cooperation in remaining still, particularly for very young or cognitively impaired patients. Con- scious sedation should be used only in a setting that ensures safety and adequate monitoring.

To ensure optimal pain management for all patients, the Guideline concludes by recom- mending the incorporation of patient feedback into formal evaluation of pain management prac- tices in all settings where patients with cancer receive care.

Guideline development The Cancer Pain Guideline Panel, comprised of

physicians, nurses, allied health professionals, and consumers active in the health care field, con- ducted an exhaustive review of the published literature on pain control in patients ranging in age from neonates to the elderly. Of approxi- mately 9600 citations found in searches of 19 data bases, 625 studies were critiqued for scientific merit and 550 were included in tables of evidence on various interventions. After best-evidence synthesis of scientific evidence, including meta- analysis when the numbers of experimental studies were sufficient, the Panel considered health policy issues such as health care resources, patients’ and practitioners’ concerns, ethical and legal questions, and insurance, A public hearing allowed the Panel to receive oral and written testi- mony from groups and individuals not repre- sented on the Panel.

The results of both the literature review and the public hearing were incorporated in a draft guide- line. A group of clinicians and other health pro- fessionals carefully chosen on behalf of the users who would benefit from the guideline evaluated the draft guideline for its validity, clarity, flexi- bility, and applicability in practice settings. The final recommendations combine the Panel’s guideline with the comments of reviewers rep- resenting professionals and patients around the country.

For further information The Guideline is available in several forms:

Quick Reference Guides for Clinicians. Prepared for the health practitioner, these two documents highlight principles and procedures of managing pain in patients of different ages. They are Man- agement of Cancer Pain: Adults and Management of Cancer Pain: Infants, Children, and Adolescents. Clinical Practice Guideline: Management of Cancer Pain. Prepared for the health practitioner, it includes a more detailed discussion of the issue and the Panel’s findings and recommendations, plus fully referenced supporting evidence, and flowchart. Patient Guide: Managing Cancer Pain. (Pub- lished in English and Spanish), is a brochure for consumers that summarizes information on managing cancer pain.

108 WILLAIM BR

To order these publications, call the National Cancer Institute’s Cancer Information Service toll free number 800-4-CANCER, or write:

Cancer Pain Guideline P.O. Box 8547 Silver Spring, MD 20907, USA

Cancer Pain Guideline Panel

Ada Jacob, RN, PhD, (Co-Chair) Johns Hopkins University; Daniel Carr, MD, (Co- Chair) Massachusetts General Hospital; Richard Payne, MD, (Co-Chair) MD Anderson Cancer Center, Houston, TX; Charles Berde, MD, PhD, Children’s Hospital, Boston, MA, William Breit- bart, MD, Memorial Sloan Kettering Cancer Center, New York, NY, Joanna M. Cain, MD, University of Washington Hospital; C. Richard Chapman, PhD, University of Washington, Charles S. Cleeland, PhD, University of Wis- consin Medical Center, Betty Ferrell, RN, PhD, City of Hope Medical Center, Duane, CA; Rebecca S. Finley, PharmD, MS, University of Maryland Cancer Center; Nancy 0. Hester, RN, PhD, University of Colorado Health Sciences Center; C. Stratton Hill, Jr., MD, MD Anderson Cancer Center; W. David Leak, MD, Cleveland Clinic Foundation; Arthur Lipman, University of Utah; Catherine L. Logan, Living Through Cancer, Inc., Albuquerque, NM; Charles L McGarvey, MS, National Institutes of Health; Christine Miaskowski, RN, PhD, University of California, San Francisco; David Stevenson Mulder, MD, McGill University, Montreal, Canada; Judith Paice, RN, PhD, Rush- Presbyterian-St. Luke’s Medical Center, Chicago, IL; Barbara Shapiro, MD, Children’s Hospital of Philadelphia; Edward B. Silberstein MD, Univer-

LEITBART

sity of Cincinnati Medical Center; Rev. Robert Smith, PhD, State Medical Center, Stony Brook, NY; Jeanne Stover (deceased); Carole V. Tsou, MD, University of Hawaii; Loretta Vecchiarelli, Action Care Management Services, West Springfield, MA; David Weissman, MD, Medical College of Wisconsin.

REFERENCES

Agency for Health Care Policy and Research, Acute Pain Management Guideline Panel. (1992) Acute pain management: Operative or medical procedures and trauma. Clinical Practice Guideline (AHCPR Pub. No. 924032). Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services.

American Pain Society, Committee on Quality Assur- ance Standards (1991) American Pain Society quality assurance standards for relief of acute pain and cancer pain. In M. R. Bond, J. E. Charlton and C. W. Woolf (eds), Proceedings of the 6th World Congress on Pain. Elsevier Science Publications, New York.

Max, M. B. (1990) Improving outcomes of analgesic treatment: Is education enough? Annals of Internal Medicine 113(1 l), 885-889.

Miaskowski, C., Jacox, A., Hester, N. 0. and Ferrell, B. R. (1992) Interdisciplinary guidelines for the man- agement of acute pain: Implications for quality improvement. Journal of Nursing Care Quality,

Agency for Health Care Policy and Research, Depres- sion Guideline Panel (1993) Depression in Primary Care: Volume 1: Detection and Diagnosis. Clinical Practice Guideline (AHCPR Pub. No. 93-0550). Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services.

7(1), 1-6.