Managing pain is one of the hardest things to do in healthcare. As nurses, it seems that we have a bipolar relationship with pain management. We are either extremely empathetic with our patients and try to achieve optimum pain control (which is what we should always do), or we are cynical about our frequent-flyer patients, who may have long and intimate histories with pain medication and drug abuse.
Whatever the scenario is, pain management is usually a complex issue, and if we are not careful, we can fall into the habit of failing to distinguishing among different kinds of pain. This may seem like a very basic part of nursing and medical care in general, but it can be very easy to lump pain into one big, ambiguous category.
Take the new medical resident who is fed up with addicts coming into the ER for pain medication, especially hydromorphone. On this particular day, this resident also has a patient who was admitted with metastatic lung cancer with rib and spinal column involvement. The first thought might be to load the patient up with opioids, but the resident might be forgetting that a variety of adjuvant classes of medications can be helpful in bone metastases, including nonsteroidal anti-inflammatory drugs, steroids, bisphosphonates, and cannabinoids.1 Not to mention the fact that our patients would like to be alert to interact with their family and friends.
Opioids like hydromorphone, fentanyl, and morphine may be adequate for controlling visceral, muscular, and incisional pains, but they are often not enough for bone pain. Medications such as dexamethasone and tramadol should be used in conjunction with an opioid. In most cases, a patient experiencing debilitating bone pain will be open to trying different therapies.
Pharmacologic therapy is usually the standard of pain management, but several other options are available. Radiation therapy, for example, is often used to shrink tumor size and minimize bone pain.
Percutaneous interventions are also starting to emerge in the medical community. Though these procedures are not as commonly used as radiation therapy, they have shown some evidence of being effective in controlling or minimizing pain. Cryoablation, for example, uses a probe that is inserted into the skin while utilizing a bone biopsy set to access the lesions within the bone. Extremely cold gas is delivered directly to the tumor through an opening at the end of the probe. Once the gas is delivered, the tumor is frozen, and the dead cells are destroyed.2 In one study, patients reported pain relief four weeks after cryoablation that ranged from 50 to 100 percent.
Similar percutaneous approaches utilize heat (thermal ablation), radio frequencies (percutaneous radio frequency), and the injection of ethanol and bone cement (osteoplasty). Osteoplasty is probably the most common of these kinds of procedures. We most often see patients with spinal metastases undergoing a vertebroplasty, which involves injecting medical grade bone cement into the vertebra. This procedure restores mobility while providing long-term pain relief.3
With so many options to manage metastatic bone pain, there only remains the task of educating nurses and even our frustrated medical residents about the different approaches to metastatic bone pain management.
How has your facility utilized percutaneous interventions in managing bone metastases? What are the different processes in place for educating personnel about different kinds of pain management?
- US National Library of Medicine: Management of bone metastasis.
- Society of Interventional Radiology: Nonsurgical Treatments for Metastatic Cancer in Bones.
- Radiology: Painful Metastases Involving Bone: Percutaneous Image-guided Cryoablation—Prospective Trial Interim Analysis.