August 27, 2004

Nursing School, VICC study new tool to evaluate pain management of cancer patients

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Shaun Cole, a new Interdisciplinary Graduate Program student, climbs the swinging pole section of the alpine tower at Camp Widjiwagan during orientation activities for graduate students. Photo by Anne Rayner

Nursing School, VICC study new tool to evaluate pain management of cancer patients

Researchers at the School of Nursing and Vanderbilt-Ingram Cancer Center’s Pain and Symptom Management Program are collaborating on a grant that will evaluate pain management for cancer patients.

Using a new guideline, the study will look at how cancer patients who need round-the-clock medications for their pain are assessed and treated, in hopes of better meeting the needs of people who are suffering.

The study, led by Nancy Wells, who holds a doctorate of nursing science, and Barbara Murphy, M.D., was funded by the National Cancer Institute for $278,338 over a period of four years. The funding will allow the investigators to take a closer look at how cancer patients with moderate to severe pain are being treated.

“We’re going to take the national pain guideline and best practice and put it into a protocol, and basically the protocol calls for prescribing opioids or narcotics based on a patient’s level of pain and side effects,” said Wells, the director of Nursing Research at the Medical Center.

It sounds simple, but Wells said some cancer patients with pain requiring round-the-clock treatment have managed to slip through the cracks, and have been suffering in silence for too long.

“In our previous research, we found that patients are hesitant to even mention they have pain. For the most part, they don’t care to bring it up when they are in pain. They are more worried about having cancer and wondering if there is a clinical trial that might present a cure,” she said.

Currently, if the patient does bring up the issue of pain, it is assessed by their health care provider and a decision is made about changing the dose or medication, Wells said.

“But there isn’t a guideline for increasing a patient’s pain medication, so it’s kind of a guessing game,” she said.

That is what Wells and Murphy, associate professor of Medicine and director of the Vanderbilt-Ingram Cancer Center’s Pain and Symptom Management Program, hope to change.

“Physicians need help. It’s not that they don’t want to control their patients’ pain better, it’s that they don’t know how,” Murphy said.

The researchers have developed a new tool they hope will work as a better guideline for pain management. Based on a scale of one to 10, if a patient is experiencing pain they would rate as a five or six, the health care provider will increase the level of pain medication by 25 percent. If a patient rates his or her level of pain at a seven or higher, their medication would be increased by 50 percent.

“This means that whatever we’re prescribing will match what the patient is experiencing,” Wells said.

Patients involved in the study will receive a phone call from a nurse once a week to assess the changes made in medication and latest levels of pain, and determine whether further adjustments need to be made.

Murphy said care providers at home will also play a key role in helping to assess the patient’s needs.

“We are intervening at the level of the care providers with a novel tool because studies looking at patient and family education have, by and large, failed to improve pain outcomes,” she said.

According to Murphy, their guidelines will help provide the knowledge that care providers need, and also help physicians who may feel time constraints interfere with spending the time it takes to manage their patients’ pain better.

“With this tool, the physician signs the order and gives the nurse a place to start and a clear path to follow,” she said.

The study will look at three main outcomes: pain, distress or how much pain bothers the patient, and side effects. Wells said the pilot study showed each of those outcomes improved based on using the titration guidelines.

“In the pilot, all of those significantly declined once an order sheet was started,” Wells said.

If this primary study can show the same success, Murphy said it could become a standard protocol in managing pain among cancer patients.

“The ultimate goal is to prove the safety and efficacy of this, so that it can be made available more broadly to oncologists and nurses in other settings,” Murphy said.

Results from the pilot study are expected to be published in the September/October issue of the American Journal of Hospice & Palliative Medicine.

The study will be randomized by site and will be conducted through the hospitals and oncology practices that make up the Vanderbilt-Ingram Cancer Center Affiliate Network (VICCAN) as well as at Meharry Medical College.

Co-investigators on the grant include Alan Sander, M.D., professor of Medicine and medical director of VICCAN, Kathy Dwyer, Ph.D., associate professor of Nursing, and Joseph Hepworth, Ph.D., research associate professor of Nursing.