Question: Which of the following is true regarding Ms. Jackson’s presentation?
1. She is experiencing a rare complication of her treatment.
2. Her age is a risk factor for the complications she is experiencing.
3. Her pain experience post-operatively is unrelated to her current issues.
4. Her cancer is gone; her pain is likely to be factitious drug seeking behavior.
Discussion
1. Incorrect. Approximately 200,000 women in the United States diagnosed annually with breast cancer, and more than 40% of those women undergo mastectomy as part of their treatment regimen. As many as 50 – 60% of women experience significant chronic pain after mastectomy, radiation, and chemotherapy treatments, indicating that PPMP is an important public health issue. Most women with PPMP experience dramatic declines in health-related quality of life, and many women also face loss of function to the point of disability, suggesting that most front line care providers should be prepared to treat PPMP skillfully and aggressively. A multidisciplinary approach to the treatment of PPMP, including interventions by primary care, neurology and/or pain medicine, psychology/psychiatry, nursing, physical and/or occupational therapies, and spirituality, is likely to produce the best functional outcome for women with PPMP syndromes. Other common pain syndromes that persist after cancer treatment include neuropathy from chemotherapy, neck and shoulder pain syndromes in head and neck cancer survivors, and post-thoracotomy syndromes. Pain is a common late effect of cancer treatment.
2. Correct. Factors that are predictive of transitioning from acute pain to chronic pains are varied and poorly defined. Some studies indicate that demographic and medical factors may be related to having PPMP. The demographic features found to be predictive of PPMP in some studies are being of younger vs. older age and of non-Caucasian race.
3. Incorrect. The medical factors that have been related to PPMP are having reconstructive procedures performed at the same time as the mastectomy, experiencing severe, uncontrolled post-operative pain, undergoing extensive invasive breast surgery, quantitative sensory testing indicating reactivity to pain sensations, and having radiation therapy for breast cancer. Predominant psychological factors that are consistently predictive of the development of chronic pain with associated poor functional outcomes include generalized anxiety, experiencing insomnia the night before the surgery, somatization, social support (e.g., marital status, support of friends and family), and the dysfunctional coping strategy of catastrophizing (i.e., an exaggerated negative mental response to pain consisting of rumination, magnification, and helplessness. An example of pain catastrophizing would be “This pain is killing me.”).
4. Incorrect. There are a number of well-recognized pain syndromes that are associated with cancer and cancer treatment. PPMP is one example of a pain syndrome that presents diagnostic and management challenges for care providers. Other common pain syndromes include post-chemotherapy neuropathic pain, post-thoracotomy pain, shoulder-girdle pain and dysfunction, and perineal pain in gynecologic cancer survivors. One common challenge for persons experiencing persistent pain after completion of cancer therapy is access to adequate pain management. The misconception that pain should resolve when cancer is “cured” places this group at risk for mismanagement.
Further recommended reading: Levy MH, et al. Management of Chronic Pain in Cancer Survivors. Cancer J, 2008
How to Begin an Evaluation
Evaluation of a complaint of pain begins with a complete history and physical. A pain history should include the “what, where, when, how much, what makes it better, what makes it worse” you need to understand the pain. Clarify if the patient is experiencing multiple types of pain. Ask the patient to describe the quality of each type of pain. You will need to know what medications the patient has tried for pain, and how helpful they were.
The PQRST pneumonic is helpful for remembering elements related to pain assessment:
- P - Provoking and palliating
- What makes it better or worse?
- Q - Quality
- What are pain characteristics?
- R - Region, radiation, referral
- Where is pain located?
- S - Severity - intensity, disruption
- Use pain scale.
- T - Temporality - when
- When does pain happen?
You also want to explore factors that help you understand the patient’s personal risk/benefit ratio for use of opioid pain medication. You should include mental health history, substance abuse history, family history of substance abuse, history of sexual abuse, and coping strategies. Did you identify four elements to help fill in the picture?
Diagnostics
“Routine bloodwork” is not helpful in evaluating chronic pain. Tests should be directed to the causes suggested by history. In this case, for example, a full work up for rheumatologic disease is unlikely to yield helpful information.
A urine drug screen will be helpful to let you know if your patient is compliant with her current pain regimen or at greater risk for opiate misuse because of other substance abuse issues.
Imaging is essential in evaluating pain complaints in cancer survivors, particularly in the context of a change in an otherwise stable pain syndrome. This is especially true for patients who have disease that is high risk for metastatic spread (advanced stage at diagnosis or aggressive tissue type).
Lab Results
Hematology
White blood cell 6.2, hematocrit 31.4, platelets 172
Chemistry
Sodium 145, potassium 3.2, chloride 109, bicarbonate 29, blood urea nitrogen 33, creatinine 1.5
Liver enzymes
Total bilirubin 0.8, aspartate aminotransferase (AST) 82, Alanine aminotransferase (ALT) 39, Alkaline Phosphatase 135
Urine toxicology
Positive for oxymorphone
Imaging
MRI of the chest and reconstructed breast mounds does not reveal any abnormality
Evaluation by Acute Pain Service
Mrs Jackson was evaluated by the Acute Pain Service during her surgical hospitalizations, and efforts were made to control her pain with hydromorphone PCA at conservative dosing. Ms Jackson remembers that her doctors refused to increase her dose. She states these efforts were not successful and describes severe pain through both hospitalizations and on discharge.
She was followed by the outpatient palliative care clinic during her treatment, and was gradually titrated to 60 mg oxycontin twice daily and 4 mg hydromorphone every 4 hours as needed. She also takes gabapentin 300mg three times daily for her neuropathic pain. This regimen has allowed her to resume work, but she still rates her pain as 7/10, and is requesting an increase in her oxycontin from her palliative medicine physician.
Question: Which of the following is true regarding Ms Jackson’s experience with the health care system?
1. As an African American, she has a higher risk of receiving excessive doses of opioid pain medications.
2. As an African American, she is likely to under-report pain.
3. As an African American, she is less likely to receive opioid pain medication than a white person with a similar presentation.
4. As an African American, she has a higher risk of aberrant medication use than a white person with a similar presentation.
Discussion
1. Incorrect. The evidence that ethnic minority patients receive lower analgesic dosing as compared to white counterparts with similar presentation has been demonstrated in many healthcare settings, and in many populations, including cancer patients.
2. Incorrect. There is no evidence to support that African American women underreport pain as compared to white counterparts. Data from experimental pain models indicates that African Americans may have greater pain sensitivity than their white counterparts. Many factors, including cultural factors, may influence how individuals experience and communicate about pain.
3. Correct. African Americans are less likely to be prescribed opioid medications for pain than white Americans.
4. Incorrect. African Americans do not have a higher risk of aberrant medicine related behaviors than their white counterparts. Studies indicate that the risk of aberrant medication use for African Americans is similar to or lower than the same risk in white Americans. Despite this, African Americans are more likely to experience opioid risk reduction strategies, such as urine drug screening, than their white counterparts.
Further Recommended Reading: J Health Care Poor Underserved. 2010 Feb;21(1):177-220. Race, ethnicity, and pain among the US adult population
