Pain Management Revisited

Now that the SARS-CoV-2 virus and its variants have altered clinical oncology practice as we know it, let’s return to a familiar focus from the Core Curriculum for Oncology Nursing—pain management (Brant et al., 2019). Much has happened during the past two years that influences the effective management of pain in patients with cancer—not the least of which is a clinical environment that has been changed by the COVID-19 pandemic.

In the meantime, the opioid crisis has worsened. This is not surprising because of treatment services affected by the pandemic, increased poverty and homelessness, and more ubiquitous mental illness in our communities. According to the U.S. Department of Health and Human Services (2021), 1.6 million people misused prescription pain relievers for the first time in 2020, a significant increase over pre-pandemic levels.

Then, there are the situations with Purdue Pharma and Johnson & Johnson, the parent company of Janssen Pharmaceuticals. Court cases in the United States sought accountability from these companies, citing their policies that downplayed addiction risks and pushed physicians to increase opioid dosages, which crippled communities struggling with the opioid epidemic. In October 2020, Purdue Pharma reached a landmark $8.3 billion settlement with the U.S. Justice Department, curbing the manufacture and marketing of Oxycontin^® and other highly addictive opioid medications (Kornfield et al., 2020). In June 2021, Johnson & Johnson agreed to pay New York state more than $230 million in a settlement that will keep the company out of the opioid business in the United States (Nir, 2021).

These settlements—the first of many cases crawling through the courts—affect how our patients perceive the use of pain medication. Therefore, oncology nurses will need to be even more thorough and strategic when educating patients and their caregivers on ways to relieve cancer pain.

To provide context going forward about pain management for patients with cancer, here are some perspectives from clinical colleagues.

According to Gretchen A. McNally, PhD, ANP-BC, AOCNP®, a nurse practitioner in hematology in the Arthur G. James Cancer Hospital and Richard J. Solove Research Institute at the Ohio State University in Columbus, “The opioid epidemic presents an opportunity to explore non-opioid and integrative medicine options to provide more comprehensive, patient-centered, and ultimately, more effective pain management to our patients.”

Latoya Spencer Lindsey, DNP, RN, NE-BC, a nurse manager in the Department of Supportive Oncology at Levine Cancer Institute in Charlotte, North Carolina, stated:

In the height of the pandemic, oncology services, like most ambulatory medical services, initiated or enhanced virtual [or] telemedicine services. However, when managing oncology pain, most often patients are receiving multiple opioids to effectively manage their pain. During the peak of the pandemic, the DEA [U.S. Drug Enforcement Administration] guidelines requiring in-person pill counts and periodic random urine toxicology screens were relaxed, which provided physicians and advanced practice practitioners flexibility in prescribing opioid medications. Oncology nurses need to continue to serve as patient advocates, with the understanding that pain is subjective; [therefore], it is necessary to report and treat objectively exactly what the patient relays as his/her pain level. It is also necessary for oncology nurses to familiarize themselves with oncology palliative medicine, understanding that the service can assist with pain management in [patients with cancer] regardless of prognosis.

Lastly, Jeannine M. Brant, PhD, APRN, AOCN^®, FAAN, an oncology nurse specialist and the director and lead scientist of Collaborative Science and Innovation at Billings Clinic in Montana said the following:

[Because of the COVID-19 pandemic], patients have been reluctant to come to the hospital, and this has encouraged us to better manage pain in the home setting. We need to better rely on oral analgesics, titrate them effectively, and recognize early on when pain is not under control. The opioid crisis has affected the way we perceive patients’ pain and also provide management. We want to be sure that we are safe in our approach—that we are adequately managing pain, while at the same time, we are preventing misuse, abuse, and diversion. We have to be more thoughtful in our approach, use an interdisciplinary team to discuss patients who are at risk for misuse, abuse, and diversion, and yet strive for patient comfort and alleviation of suffering. It’s a balancing act. To manage cancer pain, oncology nurses have several roles and responsibilities: first, as advocates of optimal pain control, recognizing that relief of pain is our ultimate goal; second, to gain more knowledge and skills in cancer pain management by attending workshops, bootcamps, and courses on opioid titration, rotation, best use of co-analgesics, and use of interventional strategies; and finally, to provide safe care [because] managing pain comes with inherent risks—potential for oversedation, the problem of constipation and other deleterious side effects, and the potential for misuse, abuse, and diversion. So, we need to have our eyes wide open to these risks and manage them accordingly.

There is much to consider when managing pain for patients with cancer. Let’s all apply our pain management expertise so that patients can benefit from appropriate, tailored, and effective care.

About the Author(s)

Ellen Carr, PhD, RN, AOCN^®, is the editor of the Clinical Journal of Oncology Nursing at the Oncology Nursing Society in Pittsburgh, PA. Mention of specific products and opinions related to those products do not indicate or imply endorsement by the Oncology Nursing Society. Carr can be reached at CJONEditor@ons.org.