Research1revised
- 1. EFFECTIVE PAIN MANAGEMENT FOR CANCER PATIENTS 1 Effective Pain Management For Cancer Patients Wen-Hsing, Yang Long Island University
- 2. EFFECTIVE PAIN MANAGEMENT FOR CANCER PATIENTS 2 Abstract Ineffective cancer pain management makes patients suffer and severely impacts their daily living. Western medication (morphine, narcotic drugs, analgesia) and combination with complementary alternative medicine (CAT) (acupuncture, massage, herbals) are used to decrease the level of pain. Health professionals evaluate patients’ pain, offering them the treatment or combination of treatments that would be best for them. Professionals must use pain assessment tools and carefully evaluate the patient. Pain medications can be helpful but can produce adverse side effects. Combining treatments can be helpful to manage the pain. The researchers used Prequest, American Cancer Society as databases to understand effective pain management methods and the key words include cancer pain, oxycodone, and CAT. While studies in these two articles lack sufficient methodology, contain shades of bias and contain relatively small sample populations the outcome for the use of combination therapy and oxycodone is promising and recommended but clinically unclear. Do cancer patients obtain more relief from a combination of oxycodone plus CAT compared to the use of oxycodone alone to decrease cancer pain?
- 3. EFFECTIVE PAIN MANAGEMENT FOR CANCER PATIENTS 3 Effective Pain Management for Cancer Patients Clinical Case Study Pain is a common experience for people with cancer, especially if they cannot be cured. Two of my cancer patients do not receive adequate pain reliefs, due to language barriers and cultural beliefs. One of them, Mrs. Chen who has stomach cancer, uses CAT and oxycodone, Mr. Wang who has liver cancer, takes oxycodone instead of morphine to reduce pain. Mrs. Chen uses a CAT to decrease the pain and the medication’s adverse side effects. This helps her to reduce nausea and vomiting caused by the side effects of the oxycodone. Mr. Wang who takes oxycodone was afraid of addiction and refused to take other combination medication which may alleviate more of his pain. Also, the pain assessment by the healthcare professional was not effective due to language barriers and cultural perspective. These tools (the Visual Analogue Scale, the McGill Pain questionnaire, the Numerical Rating Scale and the Face Pain Rating Scale) are used to identify intensity of pain, the location of the pain, the quality of the pain and the duration of the pain. However, the healthcare professional misunderstood these Chinese patients’ cultural values and misinterpreted the pain assessment scales, leading to a poor outcome. Mrs. Chen and Mr. Wang did not know how to use the tools (language barriers). That is the main reason my clients do not receive adequate pain relief. PICO Question: Do cancer patients obtain more relief from a combination of oxycodone plus CAT compared to the use of oxycodone alone to decrease cancer pain? P=Population. Why do cancer patients not receive adequate pain relief? Approximately 50 to 70 percent of cancer clients suffer un-relief cancer pain, due to their stage of illness and at certain point (American Cancer Society, 2013). More than 40 percent of cancer clients receive inadequate pain reliefs from their
- 4. EFFECTIVE PAIN MANAGEMENT FOR CANCER PATIENTS 4 pain medication (American Cancer Society, 2013). This leads to a decrease in the physical and psychological activity of daily living. I=Intervention. What kind of treatment is used in the clinical setting, combination with CAT and medication or simple pharmacology therapy? To treat pain effectively, the caregiver must evaluate a combination of several factors: the clients’ unique symptoms and physical attributes, the stage of his/her particular cancer, the current medical prescriptions and the alternative options such as acupuncture, massage and music, solely or in combination. C=Compare. How does combination CAT and single pharmacology therapy help cancer clients? Pharmacology therapy, CAT or a combination of the two are common intervention to manage cancer pain. Comparing these therapies and finding the best treatment for the cancer client is necessary for optimal pain relief. The acupuncture study explored treating varieties of cancer (liver, stomach, lung) with different combinations of acupuncture and drugs to find the best combination for pain relief. O=Outcome: which one is more successful in treating cancer pain? In the acupuncture article, there was support for addition of acupuncture in therapy but the studies which were done in China, and are predisposed toward the use of acupuncture because of the cultural background of the population. In the oxycodone article, there was no significant clinical difference between the use of oxycodone over morphine and hydromorphone but the researchers recommended the use of oxycodone. Acupuncture Efficacy: Acupuncture is a traditional Chinese medicine which can be used to reduce pain. The question posed by the current survey: "Is acupuncture effective with or without additional
- 5. EFFECTIVE PAIN MANAGEMENT FOR CANCER PATIENTS 5 medication in the treatment of cancer pain?" This survey of Random Clinical Trials (RCT) searched 14 databases to accept 15 trials within its selection criteria. The total number of participants was 1,157 (extremely small), the acupuncture style varied among the studies, but the practitioners’ (those administering the acupuncture) backgrounds were not reported in any of the studies. The survey date was from the inception of the databsaes until April 2011; the paper was published online on March 25, 2012. Ultimately, the review found the individual studies inconclusive due to the limited number of studies and the inadequate methodological quality of the studies themselves. All of the trials were deemed to have a high risk of bias due to the randomization process, insufficient information on dropouts and withdrawals, and the lack of allocation concealment in all but one study. While the reviewers recommended further rigorous exploration of this topic, there were conclusions of individual studies that recommended the use of acupuncture. Several problems exist with this inquiry. The range of cancer types and the differing pains associated with them is too simply broad for this purpose. If there was a focus on a specific type of cancer and its associated pain, there might have been more coherence to the findings, that is, if those more focused studies existed, which they do not in these particular databases. Also, the methods used in the application of the acupuncture were not uniform. There were several variations of the kind of acupuncture practiced so this also must be addressed when trying to reach a consensus on the subject. There must be a focus on one kind of acupuncture. Oxycodone, the Great Reliever: In A Systematic Review of Oxycodone in the management of cancer pain, the authors (King, Reid, Forbes .,& Hanks, 2011) scanned databases (including Medline, EMBASE and
- 6. EFFECTIVE PAIN MANAGEMENT FOR CANCER PATIENTS 6 CINAHL) and current medical literature for studies exploring the efficacy, tolerability and possible adverse effects of replacing morphine and hydromorphone with oxycodone in adult cancer clients who experience moderate to severe pain. The resultant 29 studies included 14 RCTs and were filtered either electronically from the databases up to the date July 31, 2009 or hand searched from recent articles and international conference proceedings. After careful meta- analysis of the material, there were no significant differences, no adverse side effects nor toleration problems reported with the use of oxycodone, and there were some improvements for patients who experience stomach problems with the use of morphine alone. The topic was clearly defined and carefully searched. Included were studies written in English, concerning adults in severe to moderate pain. Excluded were studies in which patients switched from one opioid to another. The conclusion of recommending oxycodone is well supported by the studies used but there were a few problems or omissions of material that must be noted. Some of the studies did not have adequate allocation concealment, but the authors did not find this significant to the conclusions. Concerns over bias were noted several times but also not deemed significant to the conclusions. Side effects of nausea and hallucinations from morphine use were similar, but factors in one study using morphine and sustained release oxycodone and amytriptyline (for sleeping) were too confusing for clear analysis. A total of 3000 patients were included in these studies and the authors have no problem recommending oxycodone as a replacement for morphine and hydromorphone. But the question is why would they? Oxycodone is a blend of acetomenophen and morphine, two proven pain relievers in the medical establishment. Barring possible unforeseen side effects from this unusual combination, logically they should do wonderful things to relieve the pain ridden individual when combined.
- 7. EFFECTIVE PAIN MANAGEMENT FOR CANCER PATIENTS 7 Is it really necessary to check that these two different drugs are still behaving responsively to the individual who needs pain relief? The answer is absolutely for the safety of the patients. My patient Mrs. Chen is taking oxycodone for her cancer and she fits within the age, cancer and pain range the criteria noted above. She also uses acupuncture for pain relief so it is considered combination therapy for pain. It is not necessary for me to devise a protocol or address additional barriers in implementation since my patient is already using oxycodone. Mr. Wang is also clearly fits within the criteria above. But for him, we could easily recommend using combination therapy to ease his pain. If we suggested acupuncture, the recommendations supported extending the numbers of the acupuncture treatments and lengthening the time of the acupuncture sessions (even though the timing of the original sessions was reported as short). This additional expenditure on acupuncture would be well worth it if Mr. Wang’s pain was severe that particular day and the additional relief would be necessary to such a fragile constitution. Summary: To summarize, the purpose of this research is to understand what kind of pain management is better for the cancer clients: using CAT and pain medications or simply using pain medications alone. Cancer patients and my Chinese cancer patients are included. These two articles are systematic reviews which include cancer patients and treatment but do not show significant differences between medication therapy and combination treatment. There are no simple ways to compare the results of the two articles which are both flawed. You cannot recommend one over the other as a clinical finding and therefore, it is not necessary to make any changes in the clinical setting. However CAT is becoming a popular option for pain relief.
- 8. EFFECTIVE PAIN MANAGEMENT FOR CANCER PATIENTS 8 Patients are welcome to open their minds and try something new even if it is not clinically proven and especially if it is not harmful to their bodies. A patient feeling pain-free on oxycodone may find additional relief through CAT. There are many kind of acupuncture with different stages of cancer making research difficult and the results unreliable and unproven. But this does not mean that acupuncture is neither helpful nor effective. If a single treatment is not effective, you can try additional therapy or both of them together until the combination is appropriate for the pain.
- 9. EFFECTIVE PAIN MANAGEMENT FOR CANCER PATIENTS 9 Reference: American Cancer Society.(2013). Pain information for professionals. Retrieved from http://www.cancer.org/myacs/newengland/programsandservices/pain-information-for- professionals. Choi, T.Y., Lee, M. S., Kim, T.H., Zaslawski, C., & Ernst, E. (2012). Acupuncture for the treatment of cancer pain: a systematic review of randomized clinical trials. supportive care in cancer, 21(6),1147-1158. Doi: 10.1007/s00520-012-14329 King, S.J., Reid, C., Forbes, K., & Hanks, G. (2011). A systematic review of oxycodone in the management of cancer pain. Palliative Medicine, 25(5), 454-470. Doi: 10.1177/02692163 11401948