Assessment Task 1: Topic 3 – Cancer Pain

Introduction

Cancer is a widespread disease in our community that affects many people both directly and
indirectly. Over 110 000 new cases of cancer were diagnosed in Australia in 2010(1) and half of all
Australians will be diagnosed with cancer by the age of 85(2). The patients that have been
diagnosed with cancer have a significant impact on the nation’s health system; 60% of cancer
patients will survive more than five years after diagnosis and it costs $3.8 billion directly(2). After
non-melanoma skin cancer, the most common cancers are prostate, bowel, breast, melanoma and
lung(1).

Cancer is uncontrolled growth of cells due to a disruption of the cell’s DNA. These cells can
proliferate to substantial numbers developing into a tumour. The cells may also spread via blood
vessels or the lymphatic system, making them malignant. Benign cancers are those that do not
spread beyond the immediate area(1). Cancerous cells can arise from almost any tissue cell in the
body(1). Cancer is caused by potential carcinogens which include tobacco, ultraviolet radiation and
asbestos(1).

Pain is the most common symptom of cancer and its intensity increases with disease progression(3).
According to Margo McCaffrey; “Pain is whatever the experiencing person says it is and exists
whenever he says it does.”(4) This means that paramedics can’t assess a person’s pain by observing
them as everyone expresses pain differently and the only reliable way to assess pain is to ask the
sufferer about it. The International Association for the Study of Pain (IASP) went further to say that
pain is “an unpleasant sensory and emotional experience in association with actual or potential
tissue damage, or described in terms of such damage.”(4) This means that pain may occur after
injury or possibly without injury, even phantom pain is real to the person experiencing it and they
should be managed the same. The pain can be classified as acute, sub-acute, chronic or
breakthrough (intermittent)(4, 5). The pain can affect patients physical functioning, daily activity,
psychological and emotional status and social life(6). Paramedics are likely to attend cancer patients
with pain in their breakthrough phase and when it affects their daily functioning to a point where
they need emergency assistance.

Breakthrough pain was first described in 1989 as a “transitory increase in pain to greater than
moderate intensity which occurs on a baseline pain of moderate intensity or less”, this definition

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was later refined, a year later, by the same group, such that breakthrough pain is a “transitory
exacerbation of pain that occurs on a background of otherwise stable pain in a patient receiving
chronic opioid therapy.”(7) The literature wholly agrees with this definition and emphasises the
point that breakthrough pain must be pain that occurs above the level of pharmacologically
managed background pain(4). The repercussions are that the patients paramedics attend with an
exacerbation of their background pain may already be prescribed the opioids that paramedics are
qualified to administer; this reduces the paramedics’ options of management. Breakthrough pain
can last anywhere from seconds to minutes or even hours and may be completely unexpected or
triggered by an event like moving or coughing(4).

The prevalence of cancer pain increases as the disease progresses(3) and 70 to 90% of patients with
advanced disease experience pain(4, 7, 8). While those receiving treatment for their cancer,
experience pain in 30 to 50% of cases(4). It is likely that paramedics then will come across a patient
with cancer pain. However, in 85 to 97% of cases, cancer pain can be controlled(4, 9), this is
consistent with Levy (1996) who found that chronic cancer pain can be treated in 95% of cases(10).
Meanwhile breakthrough pain occurs in 40 to 80% of patients with cancer(7) and this is the case
where paramedic intervention is most likely needed.

The pain associated with cancer is usually caused by the pressure the tumour creates on organs,
bones and especially nerves(4). Neuropathic pain is caused by the dysfunction of the central or
peripheral nerves and can feel like a burning, shooting or aching sensation and may or may not be
accompanied with paraesthesia (tingling, numbness)(5). Pain may also develop if the metastatic
tumour causes obstruction of blood vessels or the bowel(4). Treatment for cancer is also very
painful, chemotherapy can result in mouth sores, peripheral neuropathy (in the limbs), constipation,
diarrhoea or abdominal cramps(4). Treatment can also cause pain in the bones or joints. There is
also significant amounts of pain associated with procedures that are required to be performed either
in the diagnosis or treatment of cancer, these include surgeries, biopsies, blood tests and spinal
taps(4).

Management

The management of pain for those affected with cancer should follow the principles set out by the
World Health Organization (WHO) in their pain ladder(9). The three step approach is inexpensive
and 80 to 90% effective(9). It delineates pain into three categories; mild, moderate and severe. For
mild pain the treatment should be over-the-counter medications such as paracetamol and non-

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steroidal anti-inflammatories (NSAIDs), which include ibuprofen, aspirin (acetylsalicylic acid) and
naproxen sodium(4). For moderate pain, the same medications above should be supplemented with
opioids including; hydrocodone, codeine and oxycodone and appropriate adjuvants (vide infra)(4).
Once the pain has become severe, the medications prescribed should include paracetamol, NSAIDs,
higher doses of the above opioids and additional opioids as needed including morphine, fentanyl and
hydromorphone(4). Paramedics may attend a patient that has pain that has exceeded the pain level
that their prescription is designed for, in this case paramedics should be allowed administer low
dose opioids (morphine or fentanyl) until pain relief is reached. The patient should then be referred
to their oncologist for a discussion surrounding their pain management strategies so that the
prescription can be altered.

Adjuvants are medicines that are designed to treat a different disease but have found to be effective
in another. Adjuvants for cancer pain include antidepressants, anticonvulsants and corticosteroids.
In some cases it has been found that non-opioid or opioid analgesics are ineffective against cancer
pain, but adjuvants were discovered to work(11). Neuropathic pain can be relieved by
antidepressants and/or anticonvulsants. It was found that low doses of gabapentin (an
anticonvulsant) and imipramine (an antidepressant) in combination can significantly decrease the
total pain score and the frequency of breakthrough pain episodes(5), it was also discovered that
gabapentin when administered in conjunction with morphine provided better analgesia at lower
doses of each drug(5). There are also adjuvants to lessen bone pain, these are bisphosphonates,
calcitonin and various radiopharmaceuticals(4).

Breakthrough pain requires a medication that is easily administered, works rapidly and is quickly
excreted(4), this is because the pain may only last momentarily and can come on suddenly. If it is
very easily administered then patients can be taught to self-administer. Actiq is a lozenge on a stick
that is designed to be inserted into the patient’s mouth and they’re able to transfer it across their
mouth and consequently the drug is absorbed transmucousally. The lozenge contains fentanyl
citrate and works within 5 to 10 minutes. For the paramedic that attends a patient suffering from
breakthrough pain they could administer intranasal (IN) fentanyl as its onset is immediate and its
peak effectiveness is at 5 minutes(12).

Pain can be eradicated in the long term by reducing the effects the tumour has on the body. This
can be achieved by reducing the size of the tumour by treatments such as radiation, chemotherapy,
radiofrequency ablation or surgery(4). Radiation can also be used to treat pain that occurs in bones,
the brain, blood vessels, nerves and the spine(4). A more drastic procedure that achieves reduced

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pain is a nerve block, it utilises a local anaesthetic (such as lignocaine) to block the nerve and this
may last between three and six months(4).

Pharmaceuticals and medical procedures are not the only approach that can be taken to reduce or
combat pain. Alternative methods that are used include various cognitive and behavioural
techniques, such as relaxation, distraction and visualisation(4). There are also mind and body
techniques that may decrease pain, these fall under the banners of either hypnosis or
biofeedback(4). Although there may not be much scientific evidence to support their effectiveness
they have almost no associated risks and are generally worth experimenting with to find a particular
technique that suits the patient in question.

An alternative method that has been scientifically justified is acceptance. This is the
acknowledgement of pain without directing all efforts toward controlling it and refocusing efforts
towards living a fulfilling life in spite of chronic pain(3). So although this may not decrease the pain a
person experiences, it allows them to increase their physical functioning, daily activity, psychological
and emotional status and social life. Greater acceptance of pain is related to a better psychological
wellbeing, consequently patients may benefit from psychological interventions designed to enhance
pain acceptance(13). These could be the methods that were mentioned above. These methods are
appropriate for long term management of chronic pain.

Paramedic Management and Assessment

Paramedics may attend a patient with cancer pain if they are experiencing an acute breakthrough
episode or if their base level of pain has exceeded the relief their current drug regime can account
for. Although there are currently clinical practice guidelines (CPGs) for paramedics employed by
Ambulance Victoria (AV) for the management of pain due to trauma, cardiac conditions and
headaches(14) there are no guidelines for the treatment of exacerbated pain due to malignancy;
also known as breakthrough cancer pain. This immediately provides a challenge; if the patient is
indeed in pain, the paramedic has no guidelines to follow and must either act using their own clinical
judgement or request advice from either their colleague or duty team manager (DTM). If the
paramedic does choose to treat, they’re likely to administer an opioid for pain relief. These,
however, have known side effects which may pose a challenge in the ongoing management of this
patient. Nausea and vomiting are quite common in the administration of morphine, fortunately
metoclopramide can be administered in this case, or if it’s contraindicated, prochlorperazine may
also be given(15). Drowsiness and respiratory depression are also side effects of morphine and the

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conscious state and respiratory status should be constantly monitored in a patient following
administration. Another side effect of morphine after regular use, so paramedics are unlikely to
encounter it, is constipation which may cause further pain. This can be counterattacked by drinking
eight to ten glasses of water a day and having a high fibre diet(4). NSAIDs can also cause
gastrointestinal disturbances.

A. Determine the presence of persistent baseline pain

1. Does your pain currently have a component you would describe as “constant” or “almost
constant”, or would it be constant or almost constant if nor for the treatment you are
receiving?
If yes, go to question 2 (patients taking an opioid regimen for >12h/day), or question 3
(patients taking an opioid regimen for <12h/day).
If no, stop. Patient does not have persistent baseline pain.
2. For patients taking an opioid regiment for >12h/day:
i. Have you had any pain during the past week?
If yes, go to question 2ii.
If no, patient has controlled baseline pain. Continue to section B.
ii. How would you judge your baseline pain, on average during the past week?
Mild, moderate, severe or excruciating?
If mild or moderate, patient has controlled baseline pain. Continue to section B.
If severe or excruciating, stop. Patient has uncontrolled baseline pain.
3. For patients taking an opioid regiment for <12h/day
i. Have you had any pain during the past week?
If yes, go to question 3ii.
If no, stop. Patient does not have baseline pain.
ii. Did you feel this pain for more than half the time you were awake?
If yes, continue to question 3iii.
If no, stop. Patient has transient pains.
iii. How would you judge your baseline pain, on average during the past week?
Mild, moderate, severe or excruciating?
If mild or moderate, patient has controlled baseline pain. Continue to section B.
If severe or excruciating, stop. Patient has uncontrolled baseline pain.
B. Assessing the nature of baseline pain.
Further questions about the baseline pain.
C. Determining the presence of breakthrough pain.
1. Do you experience temporary flares of severe or excruciating pain?
If yes, patient has breakthrough pain. Continue with the remainder of this questionnaire to
characterise the breakthrough pain.
If no, stop. Patient has controlled baseline pain without breakthrough pain.
D. Assessing the nature of the breakthrough pain.
Further questions about the breakthrough pain.

Figure 1: Breakthrough pain assessment algorithm(7).

The importance of pain measurement in routine cancer patient assessment is advocated by experts
and scientific associations(16). Currently paramedics use a modified form of the Brief Pain Inventory
(Short Form) which includes the 11-point numerical rating scale (NRS) with the descriptors “no pain”
(which corresponds to a score of zero) and “the worst pain imaginable” (corresponding to a score of

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10)(17). The validity and reliability of the NRS has been extensively documented(18). The NRS has a
discriminatory value that’s higher than the verbal rating scale (VRS) when distinguishing between
background and peak pain intensities(16). It also has higher reproducibility when measuring pain
exacerbation, this is in part due to patients using the NRS more appropriately(16). I suggest that
because of this, paramedics don’t change their pain assessment approach and continue to use the
NRS even when assessing cancer pain. However, to determine the presence of breakthrough pain,
and to possibly distinguish it from uncontrolled background pain, the algorithm shown in figure 1
above should be followed. Although this is not necessary and will not affect the management of the
patient in the pre-hospital setting it is useful information for the doctors at the presenting
Emergency Department.

The inadequacies of Ambulance Victoria’s current Clinical Placement Guidelines means that there is
no guideline for paramedics to treat the exacerbation of chronic pain and if they were to come
across the situation they’d have to consult with the DTM. I suggest that if a patient with
exacerbation of their cancer pain was attended to, after assessing what current medications they
were on you would follow the pain ladder provided by WHO and administer either fentanyl or
morphine. Keeping doses similar to those found in the current pain relief CPGs(14), IN fentanyl
should be given as an initial dose of either 200mcg or 100mg depending on age and weight. If
intravenous (IV) access is available then a 5mg dose of morphine should be given. Additional doses
should be the same as the current guidelines(14). Fentanyl could also be given intravenously, and
morphine can be given intramuscularly. This guideline proposal should comfort paramedics when
providing pain relief to patients with cancer pain.

Conclusion

Cancer is a prominent disease in our community and pain is its most common symptom.
Subsequently, paramedics should be aware that the patients’ pain is as they describe it and it most
likely will affect their daily activities. Breakthrough pain is pain that occurs above the managed
baseline level and may require emergency intervention if it persists. Cancer pain occurs in 70 to 90%
of patients with advanced disease, but in 85 to 97% of cases it can be controlled with medication.
The pain can be caused by the pressure of a tumour on tissues or by treatment used to combat its
spread. The WHO recommends a pain ladder approach to managing cancer pain using a variety of
drugs, including paracetamol, NSAIDs, opioids and adjuvants. Adjuvants were described as
medicines that happen to manage pain despite being primarily used for another condition and can

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include antidepressants and anticonvulsants. Pain can also be managed by reducing the size of the
tumour or by alternative methods including behavioural and mind techniques. Acceptance of pain
has also been shown to improve a person’s ability to continue on with their life. Paramedics face the
challenge of not having a CPG currently developed to deal specifically with the exacerbation of
chronic pain but I proposed one that would suffice. Paramedics also have to deal with the
challenges of side effects of the medications they may administer including vomiting and respiratory
depression. Paramedics currently assess pain using the valid and reliable NRS, and this should not
change. With the addition of the outlined CPG paramedics should be able to improve the
emergency management of patients with cancer pain in the future.

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References

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