Assessing and treating function, not pain severity
Pain used to be assessed and treated based on intensity scores, with patients rating their pain on a 0-10 scale, and trying to lower the pain to a different number. That is changing. Clinicians are now focused on functionality, what the patient can do after pain management that they couldn’t do before it. Clinicians ask patients about their physical and emotional goals, understanding what improved function and quality of life looks like.
Improved functionality could be performing activities of daily living that they can’t do because of pain, Strand says. “That shift is particularly important in chronic cancer-related pain, where there’s no cure for the underlying problem,” he says.
Multimodal therapy is the preferred approach. While medications work well for some, a medication may be contraindicated due to a patient’s other medical issues. And not all pain can be addressed with pharmacological treatments. Treatments like physical and occupational therapy, and cognitive behavioral therapy (CBT) are often helpful, though CBT sometimes carries a stigma. “I try to reframe it,” Paice says. She tells patients “our psychologist here is not for crazy people. It’s for normal people going through crazy times.” She tells them they are going through a difficult time, but have an inner strength that the therapist will help them find.
The idea behind using multiple interventions is to provide the best outcomes with the fewest side effects and least risk. Not all therapy types are indicated for each patient, but it’s important to consider different treatment modes. In the best scenario, patients have access to various therapies to help them move appropriately and with emotions. “It’s really tough to get all of that paid,” Paice says.
Who should treat pain management?
Five years out from cancer treatment, many patients are no longer seeing their oncologist more than once annually, if at all. Some academic medical centers develop care plans for PCPs to follow, but they mostly recommend screening practices, not pain management. That can leave PCPs in the uncomfortable position of treating cancer-related pain, without the knowledge.
“Clinicians have historically not been well trained to manage cancer pain at all stages of their diagnosis, illness, survivorship, and end of life,” Strand says. With a significant patient population with growing health needs, it’s important for all physicians and advanced practice providers to get pain management training.
Palliative care clinicians tend to see more difficult cases, Strand says, either those with a complicated medication regimen, or patients with coexisting symptoms like mood disorders, or patients with a high risk of relapse.
One concern that cancer patients have is the fear of cancer recurrence. A new pain complaint is stressful to patients, given the uncertainty of the disease returning. A clinician treating a cancer survivor for pain should be aware of that.