1 . Which of the following is the key to overcoming barriers to adequate management of pain at the end of life?
| A) | | Education |
| B) | | Open communication |
| C) | | Withholding pain medications |
| D) | | Both A and B |
ISSUES IN EFFECTIVE PAIN MANAGEMENT
Education and open communication are the keys to overcoming
these barriers. Every member of the healthcare team should reinforce accurate information
about pain management with patients and families. The clinician should initiate conversations
about pain management, especially regarding the use of opioids, as few patients will raise the
issue themselves or even express their concerns unless they are specifically asked [12]. It is important to acknowledge patients'
fears individually and provide information to help them differentiate fact from fiction. For
example, when discussing opioids with a patient who fears addiction, the clinician should
explain that the risk of addiction is low [1].
It is also helpful to note the difference between addiction and physical dependence.
2 . Which of the following represents a way that a clinician can allay a patient's fears about pain medication?
| A) | | Explain that pain and severity of disease are not necessarily related. |
| B) | | Assure patients that the availability of pain relievers cannot be exhausted. |
| C) | | Acknowledge that side effects may occur but emphasize that they can be managed promptly and safely. |
| D) | | All of the above |
ISSUES IN EFFECTIVE PAIN MANAGEMENT
There are several other ways clinicians can allay patients'
fears about pain medication:
Assure patients that the availability of pain relievers cannot be exhausted; there
will always be medications if pain becomes more severe.
Acknowledge that side effects may occur but emphasize that they can be managed
promptly and safely and that some side effects will abate over time.
Explain that pain and severity of disease are not necessarily related.
3 . Which of the following is a cultural or demographic factor that may contribute to lack of effective pain management?
| A) | | Expression of pain and the use of pain medication is generally the same across cultures. |
| B) | | Inadequate supplies of opioids are more likely in pharmacies in primarily white neighborhoods. |
| C) | | Communication with patients regarding level of pain may be complicated by language barriers if an interpreter is not used. |
| D) | | Some racial/ethnic minority patients have been shown to be more likely to report pain because they lack fear of side effects or addiction. |
ISSUES IN EFFECTIVE PAIN MANAGEMENT
Cultural and demographic factors may also contribute to lack
of effective pain management. Expression of pain and the use of pain medication differ across
cultures. For example, Hispanic and Filipino patients have been shown to be reluctant to
report pain because of fear of side effects or addiction [17]. Even when effective opioids have been prescribed, access may be
difficult, as inadequate supplies of opioids are more likely in pharmacies in primarily
nonwhite neighborhoods [18]. Communication
with patients regarding level of pain is a vital aspect of caring for patients in the end of
life. When there is an obvious disconnect in the communication process between the
practitioner and patient due to the patient's lack of proficiency in the English language, an
interpreter is required.
4 . The reported prevalence of pain at the end of life is greatest among adults with
| A) | | cancer. |
| B) | | COPD. |
| C) | | diabetes. |
| D) | | heart failure. |
The prevalence of pain at the end of life has been reported
to range from 8% to 96%, occurring at higher rates among people with cancer than among adults
with other life-limiting diseases [19,20]. Pain can be caused by a multitude of factors
and is usually multidimensional, with pain frequently being exacerbated by other physical
symptoms and by psychosocial factors, such as anxiety or depression [8].
5 . Which of the following is the most reliable indicator of pain?
| A) | | Patients' self-report |
| B) | | Results of physical examination |
| C) | | Results of functional assessment |
| D) | | Results of multidimensional assessment |
Pain should be assessed routinely, and frequent assessment
has become the standard of care [8]. Pain is a
subjective experience, and as such, the patient's self-report of pain is the most reliable
indicator. Research has shown that pain is underestimated by healthcare professionals and
overestimated by family members [8,21]. Therefore, it is essential to obtain a pain
history directly from the patient, when possible, as a first step toward determining the cause
of the pain and selecting appropriate treatment strategies. When the patient is unable to
communicate verbally, other strategies must be used to determine the characteristics of the
pain, as will be discussed.
6 . Research has shown that pain is
| A) | | overestimated by patients. |
| B) | | overestimated by healthcare professionals. |
| C) | | underestimated by healthcare professionals. |
| D) | | underestimated by patients' family members. |
Pain should be assessed routinely, and frequent assessment
has become the standard of care [8]. Pain is a
subjective experience, and as such, the patient's self-report of pain is the most reliable
indicator. Research has shown that pain is underestimated by healthcare professionals and
overestimated by family members [8,21]. Therefore, it is essential to obtain a pain
history directly from the patient, when possible, as a first step toward determining the cause
of the pain and selecting appropriate treatment strategies. When the patient is unable to
communicate verbally, other strategies must be used to determine the characteristics of the
pain, as will be discussed.
7 . Generalized pain is usually indicative of
| A) | | tissue lesions. |
| B) | | underlying tissue injury. |
| C) | | central nervous system damage. |
| D) | | All of the above |
Questions should be asked to elicit descriptions of the pain
characteristics, including its location, distribution, quality, temporal aspect, and
intensity. In addition, the patient should be asked about aggravating or alleviating factors.
Pain is often felt in more than one area, and physicians should attempt to discern if the pain
is focal, multifocal, or generalized. Focal or multifocal pain usually indicates an underlying
tissue injury or lesion, whereas generalized pain could be associated with damage to the
central nervous system. Pain can also be referred, usually an indicator of visceral
pain.
8 . Chronic pain is defined as
| A) | | acute pain that develops over several days with increasing intensity. |
| B) | | transitory exacerbations of severe pain over a baseline of moderate pain. |
| C) | | pain that occurs during defined periods of time, on a regular or irregular basis. |
| D) | | pain that persists for at least three months beyond the usual course of an acute illness or injury. |
Temporal aspects of pain refer to its onset: acute, chronic,
or "breakthrough." A recent onset characterizes acute pain, and there are accompanying signs
of generalized hyperactivity of the sympathetic nervous system (diaphoresis and increased
blood pressure and heart rate). Acute pain usually has an identifiable, precipitating cause,
and appropriate treatment with analgesic agents will relieve the pain. When acute pain
develops over several days with increasing intensity, it is said to be subacute. Episodic, or
intermittent, pain occurs during defined periods of time, on a regular or irregular basis.
Chronic pain is defined as pain that persists for at least three months beyond the usual
course of an acute illness or injury. Such pain is not accompanied by overt pain behaviors
(grimacing, moaning) or evidence of sympathetic hyperactivity.
9 . According to the World Health Organization (WHO) ladder, pain should be managed
| A) | | with only nonopioids for steps 1 and 2. |
| B) | | in a stepwise progression from step 1 to step 3. |
| C) | | in a manner according to the severity of the pain. |
| D) | | with opioids given around the clock and nonopioids given on an as-needed basis. |
The WHO analgesic ladder, introduced in 1986 and
disseminated worldwide, remains recognized as a useful educational tool but not as a strict
protocol for the treatment of pain. It is intended to be used only as a general guide to
pain management [31]. The three-step
analgesic ladder designates the type of analgesic agent based on the severity of pain
(Figure 1) [31]. Step 1 of the WHO ladder involves the use of nonopioid analgesics, with
or without an adjuvant (co-analgesic) agent, for mild pain (pain that is rated 1 to 3 on a
10-point scale). Step 2 treatment, recommended for moderate pain (score of 4 to 6), calls
for a weak opioid, which may be used in combination with a step 1 nonopioid analgesic for
unrelieved pain. Step 3 treatment is reserved for severe pain (score of 7 to 10) or pain
that persists after Step 2 treatment. Strong opioids are the optimum choice of drug at Step
3. At any step, nonopioids and/or adjuvant drugs may be helpful. Some consider this model to
be outdated and/or simplistic, but most agree that it remains foundational. It can be
modified or revised, as needed, to apply more accurately to different patient
populations.
10 . The maximum recommended dose of acetaminophen is
| A) | | 1–1.5 g per day. |
| B) | | 3–4 g per day. |
| C) | | 5–7 g per day. |
| D) | | 8– 10 g per day. |
Nonopioid analgesics, such as aspirin, acetaminophen
(Tylenol), and nonsteroidal anti-inflammatory drugs (NSAIDs), are primarily used for mild
pain (Step 1 of the WHO ladder) and may also be helpful as coanalgesics at Steps 2 and 3.
Acetaminophen is among the safest of analgesic agents, but it has essentially no
anti-inflammatory effect. Toxicity is a concern at high doses, and the maximum recommended
dose is 3–4 g per day [8]. Acetaminophen
should be avoided or given at lower doses in people with a history of alcohol abuse or renal
or hepatic insufficiency [8].
11 . The onset of action of fentanyl transdermal patch is
| A) | | 5 to 10 minutes. |
| B) | | 30 to 60 minutes. |
| C) | | 8 to 12 hours. |
| D) | | 12 to 18 hours. |
OPIOIDS FOR THE MANAGEMENT OF PAIN IN ADULTSa
| Drug | Typical Starting Doseb | Onset of Action | Duration of Action |
|---|
| Codeine | 15–60 mg | 30 to 60 minutes | 4 to 6 hours |
| Hydrocodone | 2.5–10 mg | 10 to 20 minutes | 4 to 8 hours |
| Morphine, immediate release | 15–30 mg |
| 15 to 30 minutes (oral) | | 5 to 10 minutes (IV) |
| 3 to 6 hours |
| Oxycodone, immediate release | 5–10 mg | 10 to 30 minutes | 3 to 4 hours |
| Oxymorphone, sustained release | 10 mg | 5 to 10 minutes | 8 to 12 hours |
| Hydromorphone | 2–4 mg | 15 to 30 minutes | 4 to 5 hours |
| Methadone | 5–10 mg | 30 to 60 minutes | 4 to 6 hours |
| Tapentadol | 50–100 mg | <60 minutes | 4 to 6 hours |
| Tapentadol, extended release | 50–100 mg | — | — |
| Fentanyl (buccal tablet) | 100–200 mcg | 5 to 15 minutes | 2 to 4 hours |
| Fentanyl (transdermal patch) | 25 mcg/hour (worn for 3 days) | 12 to 18 hours | 48 to 72 hours |
| Buprenorphine (transdermal patch) | 5–10 mcg/hour (worn for 7 days) | — | — |
| aAll information is given for oral formulations
unless otherwise specified. | | bDoses given are guidelines for opioid-naïve
patients; actual doses should be determined on an individual basis. |
|
12 . According to the WHO ladder, which of the following is the opioid considered to be the first- line treatment for Step 3 pain management?
| A) | | Fentanyl |
| B) | | Morphine |
| C) | | Methadone |
| D) | | Oxycodone |
Morphine is considered to be the first-line treatment for
a Step 3 opioid [34]. Morphine is available
in both immediate-release and sustained-release forms, and the latter form can enhance
patient compliance. The sustained-release tablets should not be cut, crushed, or chewed, as
this counteracts the sustained-release properties. Morphine should be avoided in patients
with severe renal failure [28].
13 . What is the most common side effect of opioid use?
| A) | | Allergy |
| B) | | Nausea |
| C) | | Sedation |
| D) | | Constipation |
Opioids are associated with many side effects, the most
notable of which is constipation, occurring in nearly 100% of patients. The universality of
this side effect mandates that once extended treatment with an opioid begins, prophylactic
treatment with laxatives must also be initiated. Tolerance to other side effects, such as
nausea and sedation, usually develops within three to seven days. Some patients may state
that they are "allergic" to an opioid. It is important for the physician to explore what the
patient experienced when the drug was taken in the past, as many patients misinterpret side
effects as an allergy. True allergy to an opioid is rare [8]. Opioid rotation may also be done to reduce adverse events.
14 . Which of the following is NOT a barrier to the use of palliative radiotherapy?
| A) | | Transportation issues |
| B) | | Patient inconvenience |
| C) | | Longer life expectancy |
| D) | | Lack of knowledge in the primary care community |
However, palliative radiotherapy has become a
controversial issue. Although the benefits of palliative radiotherapy are well documented
and most hospice and oncology professionals believe that palliative radiotherapy is
important, this treatment approach is offered at approximately 24% of Medicare-certified
freestanding hospices, with less than 3% of hospice patients being treated [56,57,58]. As previously
noted, reimbursement issues present a primary barrier to the use of palliative radiotherapy
[56,57,58]. Among other
barriers are short life expectancy, transportation issues, patient inconvenience, and lack
of knowledge about the benefits of palliative radiotherapy in the primary care community
[55,56,57,59].
15 . Focused relaxation and breathing can help decrease pain by easing muscle tension.
Focused relaxation and breathing can help decrease pain by
easing muscle tension. Progressive muscle relaxation, in which patients follow a sequence of
tensing and relaxing muscle groups, has enabled patients to feel more in control and to
experience less pain and can also help provide distraction from pain [12]. This technique should be avoided if the
muscle tensing will be too painful.
