Page 51 Complete Your CE Test Online - Click Here Vomiting occurs in about one-third of patients who take opioids; twice as many have nausea. Antiemetics, such as metoclopramide, may be used preventively; prochlorperazine, promethazine, and olanzapine can be used as well. Constipation is common and a scheduled stimulant laxative is typically started along with opioid treatment unless there is a problem with bowel obstruction or diarrhea, along with encouragement to exercise and take in sufficient fiber. The goal is one bowel movement per day, and the regimen may need to be changed to meet that. Significant respiratory depression can usually be avoided through careful titration of doses. Delirium is linked to opioids but is usually multifactorial and not caused by the opioid. In the event of uncontrolled pain at maximal doses, or neurotoxicity such as myoclonus, hallucinations, vivid dreams, confusion, or tolerance (i.e. less pain relief with the same dose over time), opioid rotation (switching) may be helpful. Adjuvant drugs may be given along with opioids to optimize pain relief. These drugs can potentiate opioids, help with symptoms or relieve certain types of pain [145,203,146]: ● ● Antidepressants (such as venlafaxine, duloxetine, desipramine, nortriptylene) for neuropathic pain. ● ● Anticonvulsants may also help neuropathic pain. ● ● Gabapentin and pregabalin, for neuropathic pain. ● ● Local anesthetics for procedural pain. ● ● Corticosteroids in conjunction with opioids (although evidence is weak). ● ● Stimulants during the day, to help with opioid-induced sedation. ● ● Bisphosphonates and denosumab for bone metastases. There are big differences in how patients respond to these drugs, and side effects are common. Some patients have too many side effects from drugs or have pain that needs to be treated in a different way. Other treatments in these cases include [146]: ● ● Nerve block is a procedure in which either a local anesthetic or a drug is injected into or around a nerve to block pain that cannot be controlled in other ways. Nerve blocks may also be used to find where the pain is coming from, to predict how the pain will respond to long-term treatments, and to prevent pain after certain procedures. ● ● Surgical neurologic treatments can be done by inserting a device that delivers drugs or stimulates the nerves with mild electric current. In rare cases, surgery may be done to destroy a nerve or nerves that are part of the pain pathway. ● ● Cordotomy is a less common surgical procedure that is used to relieve pain by cutting nerves in the spinal cord. This blocks pain and other sensation. This procedure may be used for patients who are near the end of life and have severe pain that cannot be relieved in other ways. ● ● Palliative care team consultation: These providers typically work in teams that include doctors, nurses, mental health specialists, social workers, chaplains, pharmacists, and dietitians. Some of their goals are to: ○ ○ Improve quality of life for patients and their families. ○ ○ Manage pain and non-pain symptoms. ○ ○ Support patients who need higher doses of opioids, have a history of substance abuse, or are coping with emotional and social problems. Radiation therapy Radiation therapy is used to relieve pain in patients with skin lesions, other tumors, or bone metastases. Palliative radiation therapy may be given as local therapy directly to the tumor or to larger areas of the body. Radiation therapy can help shrink tumors that are causing pain and may help patients with bone pain move more freely and with less pain [146]: ● ● External radiation therapy may be given in a single dose or divided into several smaller doses given over a period of time. The decision as to whether to have single or divided dose may depend on how easy it is to get the treatments and their cost. ● ● Radiopharmaceuticals may be used to relieve pain from bone metastases. A single dose of a radioactive agent given IV may relieve bone pain when there are too many areas to treat with external radiation therapy. Physical medicine and rehabilitation Patients with cancer and pain may lose their strength, freedom of movement, and ability to manage their daily activities. Physical therapy or occupational therapy may help. Physical medicine uses physical methods, such as exercise and machines to prevent and treat disease or injury. Physical methods to treat weakness, muscle wasting, and muscle and bone pain include: ● ● Exercise to strengthen and stretch weak muscles, loosen stiff joints, help coordination and balance, and strengthen the heart. ● ● Changing position (for patients who are unable to move on their own). ● ● Limiting movement of painful areas or broken bones. Some patients may be referred to a physiatrist (a doctor who specializes in physical medicine) who can develop a personal plan for them. Some physiatrists are also trained in procedures to treat and manage pain [146]. Complementary therapies Complementary and alternative therapies combined with standard treatment may be used to help treat pain. Acupuncture, support groups, and hypnosis are a few integrative therapies that have been used to help pain [146]. ● ● Acupuncture is an integrative therapy that applies needles, heat, pressure, and other treatments to one or more places on the skin. Acupuncture may be used as an adjunct to try and help control pain, including pain related to cancer. ● ● Hypnosis may help patients relax and is often combined with other thinking and behavioral methods. Hypnosis to relieve pain works best in people who are able to concentrate, use imagery, and who are willing to practice the technique. ● ● Support groups help many patients. Patients with religious affiliations may be helped by religious counseling. Pastoral counseling (non-denominational) may also help by offering spiritual care and social support. Cancer pain in older patients is managed more cautiously Elders must be started on lower doses of opioids and titrated slowly to allow for differences in pain thresholds and responses to the drugs. There are some recommendations against using NSAIDs and tricyclic antidepressants in geriatric patients [145]. Meperidine is contraindicated in chronic pain management. It can be especially harmful in patients with decreased renal function or dehydration, and can cause delirium in older patients [203]. After pain control medications and other measures are started, and especially after each modification or addition, the nurse and the cancer treatment team must continue to assess how well it is working, monitor for side effects, and make changes if needed. Mucositis (Stomatitis) and mouth pain Ulcerative mucositis occurs in about 40% of patients receiving chemotherapy, and typically starts seven to ten days after treatment starts, remaining for about two weeks after it is finished. Chemotherapy often damages healthy cells in the mouth and gut, causing problems with eating and drinking liquids. Pain and inflammation can also be caused by fungal infections (thrush), viral infections, radiation to the head and neck. Susceptibility to these infections can be caused by direct toxicity to the mucosa as well as neutropenia and dysfunction of the salivary glands. There are no agents that prevent this toxicity, although dental and periodontal infections can be treated. Some infections can be prevented by oral rinses with 0.12% chlorhexidine gluconate and gentle brushing and