J. T. is a 50-year-old patient with a 3-year history of lung cancer with metastasis to the bone. For several months, she has been experiencing pain that until recently has been well controlled with morphine sulfate sustained release (MSSR) (for example, MS Contin®) 90 mg PO every 12 hours and occasional morphine sulfate immediate release (MSIR) 20 mg q 2 hours PRN.

Two days ago, J. T. began to have more frequent pain in her right shoulder, which she rated a “7” on a scale of 0 to 10. Throughout the day she took six doses of MSIR 20 mg with good effect. The home health nurse contacted J. T.’s physician to request an increase in her MSSR to provide better pain control. The doctor ordered an increase in J. T.’s MSSR to 150 mg every 12 hours, and an increase in the morphine sulfate immediate release (MSIR) to 40 mg every 2 hours as needed. He also instructed the client to contact him if the pain continued or got worse.

One day after increasing her MSSR to 150 mg every 12 hours, J. T. rates her pain as “2” at rest. But the following day, J. T.’s pain rating increases to a “10” despite the increase in MSSR and increased use of MSIR. Today’s assessment of pain indicates that the pain in J. T.’s shoulder is now associated with painful sensations shooting down to her thumb and index finger. The nurse recognizes that J. T.’s pain is out of control, that it meets the definition for pain crisis as defined by National Comprehensive Cancer Network (NCCN) guidelines, that it is likely neuropathic, and that J. T. needs more aggressive treatment to control her pain. The nurse instructs J. T. to take a dose of MSIR 40 mg, and she contacts the physician, who agrees to have J. T. admitted directly to the oncology unit with a diagnosis of uncontrolled pain related to metastatic lung cancer.

Surveys in the early 1990s indicated that pain was experienced by approximately one-third of individuals treated for cancer and more than two-thirds with advanced cancer. At that time is was estimated that in
almost all cases (98% and 99%, respectively), clients should have had their pain adequately relieved. Instead, 40% to 50% of these clients failed to achieve adequate pain relief.

Since that time, there have been advances in the scientific understanding of pain, therapeutic options, and training of healthcare providers. Despite this, current estimates suggest that worldwide, as many as 50% of patients with cancer pain are inadequately treated. Table 6-1 addresses the steps required to improve cancer pain management.

The purpose of this chapter is to educate current and future healthcare providers about clinical problems in the management of pain that they may not encounter in traditional curricula. Hopefully it will enlighten providers in such a way that improvements in the management of cancer pain occur and more relief is achieved.

The intensity of chronic cancer pain varies from mild (1-3) to moderate (4-6) to severe or excruciating (7-10). Most clients describe their cancer pain as mild to moderate (1-6). If an increase in the intensity of chronic cancer pain occurs, prompt medical attention is warranted to fully assess the pain and determine its origin. Increased pain often represents progression of cancer, particularly in advanced disease. However, new pain in a person with cancer may also be a sign of infection, fracture, or a neurological problem. It is essential that client reports of a “new” pain be thoroughly explored to ensure that a reversible complication (such as spinal cord compression) is not overlooked. Reports of pain, especially of increased severity or at a new location, must not automatically be attributed to a pre-existent cause or to opioid tolerance. Opioid tolerance is seldom the cause of increased cancer pain.

Knowledge of relationships that certain cancers have with pain patterns and patterns of metastasis helps determine the etiology of new pain. Multiple myeloma and cancers of the breast, prostate, and lung account for the majority of cancers with bone metastasis that frequently is characterized by pain. Pain in bones is caused by direct tumor involvement of bone with activation of nociceptors or from compression of adjacent nerves, vascular structures, and soft tissue. With multiple sites involved, clients with bone metastasis commonly have multiple areas of pain. Complications of bone metastasis, such as pathological fractures or spinal cord compression, can lead to additional sources for pain and morbidity. Spinal cord or epidural compression commonly occurs with cancers of the breast, prostate, lung, and kidney, as well as with multiple myeloma and melanoma.