Judith A. Paice, PhD, RN
In an interview with Oncology Nursing News, Judith A. Paice, PhD, RN, a co-chair of the ASCO Expert Panel that developed the consensus guideline, explained, “For chronic pain, it’s out-served its usefulness as any kind of warning sign, it’s indeterminate in terms of how long it may persist for some people, yet it can have significant effects on physical function, psychological functioning, and the individual’s social life.”
Paice, a research professor at Northwestern Medicine, added that many clinicians are not trained to recognize or treat long-term pain associated with cancer—a gap this clinical practice guideline hopes to bridge.
The guideline spans the entire trajectory of treatment planning, beginning with patient assessment, and recommends that every interaction with a clinician include at least the most basic of pain screenings. It also addresses barriers that can interfere with treatment, as well as factors that can create health disparities.
Paice underscored the importance of “being ‘hyper-aware’ that some groups are under-assessed and undertreated, and knowing who those folks are—people of color, people that are a different ethnic group than the clinician, people with English as a second language … older adults, people who have limited resources,” as well as the importance of being proactive in fighting treatment barriers, and “trying, in a nonjudgmental way to find out what the barriers are.”
Effective communication will help to create a more accurate and full understanding of a patient’s pain and a better initial treatment plan, the guideline notes, and engaging an interdisciplinary team helps. To facilitate these conversations, Paice suggested that clinicians, “welcome and seek reports of pain, letting the patient know that this really, truly, is important, that they aren’t complaining or weak if they tell us that they’re having pain. That it’s an integral part of cancer care.”
Assessment of chronic pain is merely one facet of the guideline, however; it also includes a broad range of approaches to treatment. Managing chronic pain often requires a multimodal approach, and since no two cancers are alike and no two patients are alike, not every therapy will work for every patient.
Among the nonpharmacologic approaches are physical therapy and rehabilitation, integrative therapies (eg, massage, acupuncture), interventional therapies (nerve blocks), psychological therapies (cognitive behavioral therapy, mindfulness), and neurostimulatory therapies (transcutaneous electronic nerve stimulation, spinal cord stimulation).
Nonopioid pharmacologic treatments listed in the guideline include acetaminophen, adjuvant analgesics, and topical analgesics. As far as cannabis is concerned, the guideline authors note that there is not enough evidence for it to be considered a first-line management of chronic pain; however, it does hold benefits as an adjuvant analgesic.
“I wouldn’t say that opioids are the last resort, but we have to carefully consider the long-term implications,” Paice explained. “What’s new about these guidelines is that we really describe some of the long-term consequences of opioids, which we weren’t really aware of years ago. This is where, as clinicians, we need to weigh the risks and benefits.”
When opioids are used, the guideline calls on clinicians to understand all the terminology surrounding these drugs (eg, tolerance, dependence, abuse, and addiction) and incorporate universal precautions in order to minimize adverse consequences. As a second wall of defense against such impacts, the guideline suggests clinician thoroughly educate patients and caregivers/family members on the risks and benefits of long-term opioid therapy.
Paice stressed that rather than a goal of achieving “no pain” in this population, clinicians should focus on developing a safe, individualized treatment plan for each survivor aimed at improving quality of life and enhancing function.
The full guideline and associated tools, including a summary of the recommendations and educational slides, can be accessed here.
Paice JA, Portenoy R, Lacchetti C et al. Management of Chronic Pain in Survivors of Adult Cancers: American Society of Clinical Oncology Clinical Practice Guideline. [published ahead of print July 25, 2016]. J Clin Oncol.