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<h1><a name="ch24.html_1"></a>24<br>
Integrating Medical and Psychological Treatments for Cancer Pain </h1>

<address>Karen L. Syrjala, Pain and Toxicity Research Program, Division of


Clinical Research, Fred Hutchinson Cancer Research Center, Seattle,
Washington
98104 and Department of Psychiatry and Behavioral Sciences, University of
Washington School of Medicine, Seattle, Washington 98195</address>

<p>Where do psychological treatments belong in the management of cancer


pain?
Most clinicians and researchers now acknowledge the importance of
emotional,
cognitive, sociocultural, and behavioral factors in the experience of pain and
the success of treatment for the cancer patient. But after we acknowledge
the
importance of these psychosocial factors, there are few examples to guide us
in
how to integrate these recognitions into a medical practice with busy nurses
and physicians, limited financial resources, varying ages and sociocultural
norms of the patient environment, fatigued and ill patients, and protective,
worried families.</p>
<p>Certainly, psychological treatments never take the place of medical
treatment; they are not alternative pain management methods, but they are
always, in some form, an adjunct to pharmacologic or other medical
interventions. The question is not whether we ``should'' use these
techniques,
but rather how we can use them with clear intent, not arbitrarily or by
coincidence, or even to the patient's disadvantage.</p>

<p>In this chapter, I will review the psychological methods all health care
providers can use in management of cancer pain. I want to focus particularly
on
communication and educational methods that can be integrated into any
medical
practice by any professional treating the cancer patient with pain. Then I will
provide more detail on specific cognitive-behavioral approaches
psychologists and
other behavioral medicine specialists use.</p>

<h2><a name="ch24.html_1_1"></a>OVERVIEW</h2>

<p>The role of psychology in cancer pain treatment is not only to eradicate


pain. In a sense, the role of psychology is as an observer: to notice what has
not been fully or consistently addressed; to remind the physician, the nurse,
sometimes the family and even the patient, that there is more to the patient
than the disease or the pain, more to the treatment than the drugs.</p>

<p>Other chapters in this book describe in detail the theoretical,


physiologic,
and observable relationships among the constructs of sensation, emotion,
cognition, and behavior in the experience of pain and suffering. We can
demonstrate the empirical validity of these constructs. Based on research
results, we can prescribe effective models of psychological treatment,
incorporating cognitive-behavioral methods as adjuncts to pharmacology for
the
management of cancer pain. To some extent I will do this. But prescribing an
optimal model for psychological treatment will not change day-to-day
practice
or improve comfort for the majority of patients who are followed by
physicians
and nurses but do not have access to psychological specialists trained in
cancer pain. Thus it is necessary to think not only about what works given all
the resources possible, but what can be accomplished given the resources
most
settings have accessible.</p>
<p>What can be accomplished when the physician or nurse understands
basic
tenets of communication about pain management? What can be
accomplished by a
psychologist or social worker who knows about cancer patient issues but
may not
be a pain expert or know cognitive-behavioral skills like hypnosis, imagery,
or
cognitive restructuring? And in those situations where pain experts are
available or cognitive-behavioral skills are known, what is effective for
psychological specialists to provide? This chapter will review interventions at
several levels of expertise and training. The goal is that these will be useful
to you at the level of resources and skills available in your setting or in
those settings where you teach others.</p>

<p>There are two important additional issues to address in discussing these


interventions. First, since all patients will not have access to all resources,
we need to define the most important interventions that can be provided in
the
course of ``standard'' medical practice. Second, not everyone benefits from
the
same psychological intervention any more than everyone benefits from the
same
pharmacologic intervention. We need to know more about who benefits from
what;
and we need to define adequate evaluation of the patient and the patient's
needs.</p>

<h3><a name="ch24.html_1_1_1"></a>Goals of Treatment</h3>

<p>What do we attempt to do in most cancer pain treatment and where do


psychological methodologies apply? In optimal situations, our
treatments:</p>

<ul type=disc>
<li class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-
alt:auto;
mso-list:l2 level1 lfo1;tab-stops:list 36.0pt'>make the patient free of
pain, </li>
<li class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-
alt:auto;
mso-list:l2 level1 lfo1;tab-stops:list 36.0pt'>add no side effects from
treatment (especially constipation, sedation, and mental confusion), </li>
<li class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-
alt:auto;
mso-list:l2 level1 lfo1;tab-stops:list 36.0pt'>enable the patient to
function physically and socially, </li>
<li class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-
alt:auto;
mso-list:l2 level1 lfo1;tab-stops:list 36.0pt'>free the patient from fear
of future suffering, </li>
<li class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-
alt:auto;
mso-list:l2 level1 lfo1;tab-stops:list 36.0pt'>maintain high quality of
emotional and social life (without depression, anxiety, withdrawal, or
alienation from family). </li>
</ul>

<p>When these optimal goals are not met, we strive to select treatments
that
provide the greatest physical comfort possible while causing the fewest
possible side effects and least disruption of function. We try to provide
treatments that allow patients<!--[fj --> to meet their expectations for
quality of life at their present point in the course<!--[fj --> of the disease.
We assure patients that suffering can be treated and that they can<!--[fj -->
have some control over discomforts. Thus our practical goal is to help
patients<!--[fj -->
believe that their symptoms are manageable while they maintain the best
possible<!--[fj -->
quality of life.</p>

<h3><a name="ch24.html_1_1_2"></a>Standard Medical Practice</h3>

<p>Pain treatment usually proceeds in the following stages:</p>

<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-


alt:auto;
margin-left:36.0pt;text-indent:-18.0pt;mso-list:l1 level1 lfo2;tab-stops:list
36.0pt'><![if !supportLists]>1.<span
style='font:7.0pt "Times New Roman"'>&nbsp;&nbsp;&nbsp;&nbsp;
</span><![endif]>Evaluation
indicates a pain problem. </p>

<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-


alt:auto;
margin-left:36.0pt;text-indent:-18.0pt;mso-list:l1 level1 lfo2;tab-stops:list
36.0pt'><![if !supportLists]>2.<span
style='font:7.0pt "Times New Roman"'>&nbsp;&nbsp;&nbsp;&nbsp;
</span><![endif]>The
first line of treatment after assessment is medical: radiation; chemotherapy;
surgery; medication by various routes, beginning orally; neuroinvasive
procedures. </p>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-
alt:auto;
margin-left:36.0pt;text-indent:-18.0pt;mso-list:l1 level1 lfo2;tab-stops:list
36.0pt'><![if !supportLists]>3.<span
style='font:7.0pt "Times New Roman"'>&nbsp;&nbsp;&nbsp;&nbsp;
</span><![endif]>Nurses,
physicians, physical therapists, patients, and family members may add some
physical treatment methods of their own: ice or heat; massage; positioning;
movement. </p>

<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-


alt:auto;
margin-left:36.0pt;text-indent:-18.0pt;mso-list:l1 level1 lfo2;tab-stops:list
36.0pt'><![if !supportLists]>4.<span
style='font:7.0pt "Times New Roman"'>&nbsp;&nbsp;&nbsp;&nbsp;
</span><![endif]>If
assessment identifies problems of anxiety, depression, sedation, delirium, or
other mental status change, psychotropic medications may be considered.
</p>

<p>In many cases, antidepressants, antianxiety agents, antipsychotics, or


stimulants are prescribed by the treating physician. Evaluation by a
psychiatrist is underused in most settings. Consequently, an inadequate
number
of psychiatrists are trained in the unique medical problems and psychological
issues of cancer patients. At the same time, oncologists or cancer pain
specialists often are not entirely familiar with psychotropic medications or
their proper indications, thus these drugs may not be given optimal
trials.</p>

<h2><a name="ch24.html_1_2"></a>INTERVENTIONS TO INTEGRATE INTO


STANDARD
MEDICAL PRACTICE</h2>

<p>Having recognized the role of standard medical practice, the following


communication tools should be understood by all practitioners:</p>

<p class=MsoNormal><span style='font-family:Symbol;mso-ascii-font-


family:"Times New Roman"'></span><span
style="mso-spacerun: yes"> </span>Multidimensional assessment </p>

<p class=MsoNormal><span style='font-family:Symbol;mso-ascii-font-


family:"Times New Roman"'></span><span
style="mso-spacerun: yes"> </span>Information provision </p>
<p class=MsoNormal><span style='font-family:Symbol;mso-ascii-font-
family:"Times New Roman"'></span><span
style="mso-spacerun: yes"> </span>Education about pain management
</p>

<p class=MsoNormal><span style='font-family:Symbol;mso-ascii-font-


family:"Times New Roman"'></span><span
style="mso-spacerun: yes"> </span>Reframing </p>

<p class=MsoNormal>These tools must be learned because they will be


used in the
course of standard treatment-related communication. Without understanding
their
use, practitioners are more likely to assess, inform, or educate inadequately
or in forms that enhance anxiety or helplessness. Nurses and physicians
convey
information at the bedside, they listen, they reassure patients and family
members, and they actively educate patients about both the pain and
potential
treatments. Each of these interactions can enhance patients' beliefs in their
ability to cope with the symptoms they have, can foster adherence to the
medical plan, or can escalate patient anxiety or helplessness. </p>

<h3><a name="ch24.html_1_2_1"></a>Assessment</h3>

<p>Regular assessment is the cornerstone for determining when


pharmacologic and
nonpharmacologic treatments should be introduced. Far from feeling
burdened by
reporting pain and other symptoms, patients are often relieved that staff ask
specific questions. Cancer patients are reluctant to complain and do not
know
what experiences are ``normal'' or what should be reported. They will often
answer ``fine'' or ``OK'' if asked only ``How are you doing?'' A pain score,
rated on a scale from 0 to<!--[fj --> <!-- -->10, can be used as an objective
quality-assurance tool to determine the need for further evaluation or
change
in treatment. Pain above a score of 3 indicates a need to assess more
dimensions of the pain experience than just pain severity. These moderate or
severe pain reports above 3 suggest the need to use higher doses or a
different
medication or, alternatively, a different intervention. Even temporary pain
should not exceed 6 on a scale from 0 to 10 without mandating further
evaluation
or additional pain treatment methods <a
href="http://www.talaria.org/ch24.html#references">(7)</a>.</p>
<p>In addition to identifying the level of unrelieved pain, assessment must
evaluate patient functioning. When patients do not require further treatment,
the following factors apply:</p>

<p class=MsoNormal><span style='font-family:Symbol;mso-ascii-font-


family:"Times New Roman"'></span><span
style="mso-spacerun: yes"> </span>Sleep includes uninterrupted hours
adequate
to feel rested; </p>

<p class=MsoNormal><span style='font-family:Symbol;mso-ascii-font-


family:"Times New Roman"'></span><span
style="mso-spacerun: yes"> </span>Basic self-care is adequate to maintain
necessary health, self-esteem, and adherence to medical treatment; </p>

<p class=MsoNormal><span style='font-family:Symbol;mso-ascii-font-


family:"Times New Roman"'></span><span
style="mso-spacerun: yes"> </span>Daily activity maintains lung and
cardiac
function and muscle flexibility and strength. </p>

<p class=MsoNormal><span style='font-family:Symbol;mso-ascii-font-


family:"Times New Roman"'></span><span
style="mso-spacerun: yes"> </span>Interactions with family and medical
staff
meet needs for assistance, information, and emotional support; </p>

<p class=MsoNormal><span style='font-family:Symbol;mso-ascii-font-


family:"Times New Roman"'></span><span
style="mso-spacerun: yes"> </span>Mood is mostly hopeful or neutral, with
manageable fear or discouragement. </p>

<p class=MsoNormal><span style='font-family:Symbol;mso-ascii-font-


family:"Times New Roman"'></span><span
style="mso-spacerun: yes"> </span>Thoughts are overall neutral or
positive
regarding ability to handle pain and the demands of treatment; </p>

<p class=MsoNormal><span style='font-family:Symbol;mso-ascii-font-


family:"Times New Roman"'></span><span
style="mso-spacerun: yes"> </span>Attitude is accepting of treatments as
needed to maintain comfort and health care; opioids, if needed, are not
rejected out of fear of addiction, tolerance, side effects, or sense of
personal weakness. </p>
<h3><a name="ch24.html_1_2_2"></a>Concepts Related to Psychological
Interventions</h3>

<p>Thoughts, emotions, and behaviors are the observable targets of


psychological interventions for managing cancer pain. Interactions with
medical
staff provide options for <i>cognitions</i><!-- --> or thoughts about
symptoms
or sensations. Illness-related concerns become the focus of a patient and
family's thinking. Interactions with the medical staff are given enormous
significance. Words and behaviors are repeated,<!--[fj --> <!--
-->overinterpreted,
and scrutinized for covert messages. Most often, the family models their
unspoken and spoken rules, beliefs, and behaviors on the medical team <a
href="http://www.talaria.org/ch24.html#references">(27)</a>. One of the
valuable contributions a physician, nurse, or social worker can make<!--[fj
-->
to the long-term mental health of the family is to model, by example, the
acceptability of talking about and planning for pain management, disease
progression, and<!--[fj --> dying.</p>

<p>Patients turn the words of the medical team into internal cognitions that
can increase fear or provide reassurance when they have pain or unfamiliar
experiences. Properly provided information assists patients in maintaining
adaptive thoughts and reducing or eliminating maladaptive thoughts.
Maladaptive
thoughts increase patients' beliefs that an experience is out of control.</p>

<p>As noted above, emotions are closely tied to and influenced by


thoughts.
Cognitive-behavioral methodologies are built on the recognition that how
people
think affects how they feel and, if you change how they think and behave,
their
feelings, and even their experience of sensations, will change also <a
href="http://www.talaria.org/ch24.html#references">(2)</a>. Originally
developed for treating depression, these methods have been adapted for the
treatment of chronic pain and of cancer pain <a
href="http://www.talaria.org/ch24.html#references">(35,38,39)</a>. Over
time,
unrelieved pain can engender feelings of helplessness and hopelessness. At
the
extreme of hopelessness, cancer patients with severe, unrelieved pain are
more
likely to commit suicide <a
href="http://www.talaria.org/ch24.html#references">(5)</a>.
The recognition of helpless feelings and the introduction of alternative
experiences of self-control or joy counter these helpless feelings. For
example, a patient may be tired and uncomfortable, with very limited
activity
possible. A family member may help the patient to bathe, reassure her of the
success of the effort she is making, no matter how small the result may
seem,
and then talk with her about an activity she has done before or one she
would
like to do when she is better. These behaviors and discussion remind the
patient that she is not totally helpless. Acknowledging the effort involved in
small accomplishments can bring a sense of control back to the patient.
Remembering positive events evokes feelings of pleasure. In addition, the
memories of the past and anticipation of the future remind the patient that
there is more to her existence than the present pain.</p>

<p><i>Coping behaviors</i><!-- --> are all of those actions (or inactions)


patients take to try to manage their pain. These might be helpful or
counterproductive. In the broadest sense, these include verbal and
nonverbal
communications about pain such as reporting pain, withdrawing, and other
behaviors that indicate suffering or might initiate efforts to help from
others. These certainly include taking medications to relieve pain as the
most
common coping strategy used by cancer patients. Other behaviors are used
by
nurses or experimented with by patients or families, including physical
methods
such as the use of ice or heat, rest, and physical positioning (for details,<!--
[fj -->
<!-- -->see ref. 22). Additional coping methods that influence cognitive and
emotional responses to pain can be incorporated into treatment. These
include
the use of cognitive modifications, active distractions such as hobbies,
massage, exercise, physical activity, and relaxation, imagery, or
hypnosis.</p>

<h2><a name="ch24.html_1_3"></a>SPECIFIC COPING


INTERVENTIONS</h2>

<p>Table 1 lists the coping interventions all medical professionals use in


regular practice that will either help or hinder patient and family coping
efforts.</p>

<h3><a name="ch24.html_1_3_1"></a>Information</h3>
<p><b><span style='font-size:13.5pt'>Chapter 24 Table 1:</span>Coping
interventions used by all health care providers</b> </p>

<table border=0 cellpadding=0 align=left width="50%" bgcolor="#e0ffe6"


style='width:50.0%;mso-cellspacing:1.5pt;background:#E0FFE6;mso-table-
anchor-vertical:
paragraph;mso-table-anchor-horizontal:column;mso-table-left:left'>
<tr>
<td style='padding:.75pt .75pt .75pt .75pt'>
<p class=MsoNormal align=center style='text-
align:center'><b>Intervention<o:p></o:p></b></p>
</td>
<td style='padding:.75pt .75pt .75pt .75pt'>
<p class=MsoNormal align=center style='text-align:center'><b>Assists
with<o:p></o:p></b></p>
</td>
</tr>
<tr>
<td style='padding:.75pt .75pt .75pt .75pt'>
<p class=MsoNormal>&nbsp;Information</p>
</td>
<td style='padding:.75pt .75pt .75pt .75pt'>
<p class=MsoNormal>&nbsp;Cognitions</p>
</td>
</tr>
<tr>
<td style='padding:.75pt .75pt .75pt .75pt'>
<p class=MsoNormal>&nbsp;&nbsp;Temporal</p>
</td>
<td style='padding:.75pt .75pt .75pt .75pt'>
<p class=MsoNormal>&nbsp;&nbsp;Remember it's not forever</p>
</td>
</tr>
<tr>
<td style='padding:.75pt .75pt .75pt .75pt'>
<p class=MsoNormal>&nbsp;&nbsp;Procedural</p>
</td>
<td style='padding:.75pt .75pt .75pt .75pt'>
<p class=MsoNormal>&nbsp;&nbsp;Reframing</p>
</td>
</tr>
<tr>
<td style='padding:.75pt .75pt .75pt .75pt'>
<p class=MsoNormal>&nbsp;&nbsp;Sensory</p>
</td>
<td style='padding:.75pt .75pt .75pt .75pt'>
<p class=MsoNormal>&nbsp;&nbsp;Labeling</p>
</td>
</tr>
<tr>
<td style='padding:.75pt .75pt .75pt .75pt'>
<p class=MsoNormal>&nbsp;Education</p>
</td>
<td style='padding:.75pt .75pt .75pt .75pt'>
<p class=MsoNormal>&nbsp;Adherence<br>
Reducing helplessness</p>
</td>
</tr>
<tr>
<td style='padding:.75pt .75pt .75pt .75pt'>
<p class=MsoNormal>&nbsp;Reframing</p>
</td>
<td style='padding:.75pt .75pt .75pt .75pt'>
<p class=MsoNormal>&nbsp;Neutral or positive coping perspective<br>
Reducing helplessness</p>
</td>
</tr>
</table>

<p>To the extent possible, we make the unfamiliar more predictable by


informing
patients of what is going to happen. This in itself is reassuring, since
uncertainty is known to increase distress and threaten perceptions of ability
to cope <a href="http://www.talaria.org/ch24.html#references">(25)</a>.
The in<!-- -->
formed consent process used in many hospitals emphasizes provision of
medical
information that patients often cannot fully comprehend <a
href="http://www.talaria.org/ch24.html#references">(26)</a>. The process
forces
patients to recognize the limits of their own (or the medical staff's) control
over the outcome of treatment. Although this process is necessary, it
emphasizes the negative and makes it more difficult for patients to maintain
positive or hopeful cognitions.</p>

<p>Some of the effects of this informed consent process and the overall
uncertainty about what will happen can be countered by providing specific
information about what is known. Information helps patients to ``label'' their
sensations with familiar, less frightening terms. Information also gives
patients a way of ``reframing,'' or thinking about their situation from a less
threatening or less helpless perspective.</p>
<p>There are three kinds of information that can be helpful to patients'
labeling and reframing efforts. The most important is <i>temporal
information.</i><!-- -->
Telling patients when something is likely to happen and, even approximately,
how long it will last is the most useful information we can provide <a
href="http://www.talaria.org/ch24.html#references">(19)</a>. For all of us,
if
we know something will end, we can tolerate much more than if we think it
might
go on forever. To facilitate coping, it is helpful to break the timing of
events into the smallest time frames possible. So, for instance, we do not
talk
about a bone marrow aspiration as taking ``only 20 minutes.'' We break the
aspiration down into sections. The local anesthetic numbing section might
take
30 sec; the pressure of the needle going into the bone marrow might take 5
sec;
the pull might take another 10 sec. Although the overall procedure might
take
20 min including preparation, we help patients recognize that the painful
sections last about 2 min, and most of the procedure is not painful at all. For
any of us, our belief that we can tolerate 2 min of intense discomfort is much
greater than our belief that we can tolerate 20 min of physical
discomfort.</p>

<p><i>Sensory information</i><!-- --> is helpful to patients because it tells


them exactly how they will feel. Using descriptors other than
<i>pain</i><!-- -->
or <i>hurt</i><!-- --> helps patients to label what they feel with familiar,
known terms. Vague terms are uninformative and can only leave patients
worrying
about what an experience will be like and whether they will be able to stand
it.
Anything familiar is less threatening than the unfamiliar, even when it is
unpleasant. Thus we would describe sensations as <i>stinging</i><!-- -->
or <i>hot</i><!-- -->
or <i>pressure.</i><!-- --> These terms do not deny discomfort, but they
also
allow patients to prepare themselves for specific sensations and reassure
themselves when sensations fit those predicted. Use of a simile can be very
helpful when describing a sensation and reminding the patient that the
experience is tolerable.</p>

<p><i>Procedural information</i><!-- --> informs the patient of specifically


what
will happen or is happening. This gives the patient an overview of what the
nurse or doctor is doing. The patient can then remind himself that what is
happening is expected. This reduces uncertainty, which in turn maintains the
belief that the situation is under control. As a general rule, procedural
information is the most frequently provided form of information, but it is less
useful for assisting positive appraisals than temporal or sensory information
<a
href="http://www.talaria.org/ch24.html#references">(20,37)</a>. For most
patients, once the procedure has been reviewed, the focus can turn to other
forms of information provision.</p>

<p>The exception to this guideline is the patient who is extremely anxious


and needs
a great deal of control; otherwise he or she will feel totally out of control.
For these patients, procedural information is equally as important as
temporal
and sensory information. At its extreme, these patients may be terrified to
the
point of phobia or refusal to continue care. For the small number of patients
who are phobic of procedures and cannot tolerate distraction away from the
procedure, we recommend systematic desensitization and/or anxiolytics <a
href="http://www.talaria.org/ch24.html#references">(13)</a>. These
patients
need to receive constant feedback from the person doing the procedure and
need
opportunities to be in control where possible.</p>

<p>Ideally, patients receive all three types of information. Procedural and


sensory information are provided prior to beginning any new process, and
then
the focus moves to temporal information and active distraction so thoughts
focus away from discomforts that cannot be alleviated. When changes in
treatment are required, new procedural and sensory information may be
needed.
But, as a rule of thumb, when medical treatment cannot further reduce
discomforts, rather than focus on the pain, it is more helpful to remind
patients that they are coping well, that this phase will not last forever, and
then move attention to areas where control is an option.</p>

<h3><a name="ch24.html_1_3_2"></a>Education</h3>

<h4><a name="ch24.html_1_3_2_1"></a>Barriers to Adequate Pain and


Symptom
Control-Targets for Education</h4>

<p>Barriers to effective pain management have been identified for both


physicians
and patients. In a recent survey of 1,177 oncologists who had cared for more
than 70,000 cancer patients in the previous 6 months, inadequate pain
assessment was identified most frequently as the number-one reason
patients are
undertreated <a
href="http://www.talaria.org/ch24.html#references">(41)</a>.
Patient reluctance to report pain, patient reluctance to take opioid
medications, and physician reluctance to prescribe opioids were other key
factors identified as barriers to adequate treatment.</p>

<p>Mounting evidence supports the observation that patients and their


families
not only fear cancer pain but believe that pain cannot be effectively
controlled without unacceptable consequences. A recent survey in Wisconsin
<a
href="http://www.talaria.org/ch24.html#references">(9)</a> found 72% of
the
respondents agreeing that cancer pain can get so bad that a person might
consider suicide; 39% agreed that strong painkillers are an indication that a
patient is close to death. In cancer patients with metastatic disease who
were
on opioids for pain, 63% said they would wait until pain was moderate to
severe
before asking for analgesics, rather than taking them ``before the pain
returns'' <a href="http://www.talaria.org/ch24.html#references">(8)</a>.
Nearly
70% endorsed the statement ``I feel I should not take narcotic medications
on a
regular basis but only when the pain is extreme.'' In relation to effects of
opioids, 70% expressed concerns about tolerance; 70% expressed concerns
about
mental confusion; 63% identified addiction as a concern. Spouses were more
often concerned about tolerance (80%) and less often concerned about
addiction
(58%).</p>

<p>In research on cancer patients' beliefs about cancer pain, Ward and
colleagues <a
href="http://www.talaria.org/ch24.html#references">(42)</a>
reported that 79% endorsed beliefs that addiction is a danger with pain
medication; various side effects were concerns for 61% to 85% of the
patients;
60% endorsed beliefs that a choice might be needed between treating the
disease
or treating the pain; 59% agreed that pain medication should be ``saved'' for
when pain is severe, otherwise it might be ineffective; 50% expressed
concern
that complaining about pain might annoy their doctor. These data indicate
that
a majority of cancer patients do have concerns that their pain will not be
controlled during the course of their disease. Furthermore, the majority have
misperceptions about tolerance, side effects, and addiction and, perhaps
because of these concerns, believe that they should postpone taking pain
medications until pain is extreme. When patients who return home to treat
themselves believe that opioids are dangerous, they will not adhere to their
physicians' prescriptions of oral medications no matter how proper these
prescriptions are.</p>

<h4><a name="ch24.html_1_3_2_2"></a>Education Methods</h4>

<p>Information presents facts; it provides patients with labels for sensations


and helps reframe a situation from a less threatening perspective. Education
provides information that patients can then use to modify their own coping
behaviors. This implies not only being told facts, but also having the
opportunity to adapt the facts to fit their own situation and to plan their own
responses. Beliefs about which patients need to be educated related to
medication use are listed in <a
href="http://www.talaria.org/ch24.html#table2">Table
2</a>.</p>

<p>General medical care research has noted that patients who desire
information
about their medical care nonetheless do not engage in information-seeking
behaviors with their doctors or nurses <a
href="http://www.talaria.org/ch24.html#references">(3,4)</a>. Patients
tend to
regard their doctors as the appropriate decision makers, even about what to
discuss, and do not initiate communication about problems <a
href="http://www.talaria.org/ch24.html#references">(3)</a>. Patients and
their
family members are unlikely to raise questions addressing beliefs and fears
about pain.</p>

<p>Messerli and colleagues <a


href="http://www.talaria.org/ch24.html#references">(24)</a>
surveyed postmastectomy patients and surgeons regarding education
needed and
sources of education important to these patients. While surgeons identified
talking with a sensitive, understanding doctor as the most important
resource,
with written materials as second most valuable, patients identified written
pamphlets as most important in both first- and second-place rankings.
Discussion with other patients ranked third; counseling with a nurse or other
health care provider ranked fourth; videotapes ranked fifth. Patients
identified talking with a sensitive, understanding doctor as eighth in
ranking.</p>

<p class=MsoNormal><a name=table2><b><span style='font-


size:13.5pt'>Chapter 24
table 2: </span>Barriers to patient use of appropriate pain
medication</b></a> </p>

<table border=0 cellpadding=0 align=left width="50%" bgcolor="#ffff80"


style='width:50.0%;mso-cellspacing:1.5pt;background:#FFFF80;mso-table-
anchor-vertical:
paragraph;mso-table-anchor-horizontal:column;mso-table-left:left'>
<tr>
<td style='padding:.75pt .75pt .75pt .75pt'>
<p class=MsoNormal>Belief that pain with cancer is intolerable and
inevitable<br>
Belief that medication should be taken only when pain is intolerable, not on
a regular basis to keep pain in control<br>
Fear of addiction (psychological dependence)<br>
Need to be a ``good'' patient and not complain unless specifically asked
about pain<br>
Fear of side effects such as mental confusion, sedation, or constipation<br>
Concern about tolerance and loss of effectiveness of medication</p>
</td>
</tr>
</table>

<p>These results suggest that physicians will have to specifically ask about
symptoms
and request questions if they wish to communicate with and educate
patients.
With time demands on practice, it is equally important to note that written
materials and communication with nurses and other patients can be more
than
adequate substitutes for education directly from the physician as long as the
information is reinforced by the physicians' communications.</p>

<p align=right style='text-align:right'><a name=table3><b><span


style='font-size:13.5pt'>Chapter 24 table 3: </span>Topics of
medication-related education needs of patients and family
members</b></a></p>

<span style='mso-bookmark:table3'></span>
<table border=0 cellpadding=0 align=right width="50%" bgcolor="#ff80ff"
style='width:50.0%;mso-cellspacing:1.5pt;background:#FF80FF;mso-table-
anchor-vertical:
paragraph;mso-table-anchor-horizontal:column;mso-table-left:right;mso-
table-top:
middle'>
<tr>
<td style='padding:.75pt .75pt .75pt .75pt'>
<p class=MsoNormal>What the medication and nonpharmacologic
treatments are<br>
When to use them<br>
Whether and when to give more medication<br>
What to be concerned about (symptoms, side effects)<br>
What not to be concerned about (symptoms, side effects)<br>
Addiction and tolerance are not problems to worry about<br>
To be a ``good'' patient, symptoms must be reported promptly because pain
can
be treated; to not treat pain will have serious negative effects on the
patient's health<br>
Calling in: for what problems; who to call at what times of day</p>
</td>
</tr>
</table>

<p>Rimmer and colleagues <a


href="http://www.talaria.org/ch24.html#references">(29)</a>
found that cancer patients who received medication-related education
demonstrated higher compliance with analgesic prescriptions and had
reduced
concerns about taking opioid analgesics. These patients who received
training
also had a tendency to report lower pain levels compared to the untrained
control group.</p>

<p>Concerns about negative effects of educating patients sometimes arise


from
fears that discussing possible side effects will oversensitize patients to
symptoms. Available research indicates that informing patients about
possible
side effects of therapy does not increase the occurrence of side effects or
have other adverse effects <a
href="http://www.talaria.org/ch24.html#references">(17,43)</a>.</p>

<p>Specific medication education needs of patients and their family


members are
listed in <a href="http://www.talaria.org/ch24.html#table3">Table 3</a>.
These
targets for education of patients and their families should be addressed
when
pain is mild and when opioids are first needed. We also educate patients in
an
abbreviated form about the gate-control theory so they understand that
nonpharmacologic methods may be effective and that this does not mean
that the
pain is ``not real.''</p>

<h3><a name="ch24.html_1_3_3"></a>Reframing by Health Care


Providers</h3>

<p>Physicians and other health care providers can assist patients and
families
by remembering that these listeners will retain and repeat exact words over
and
over to themselves and one another. These include both negative and
positive
information, but most people look for statements that offer hope. When
providing day-to-day feedback about the patient's condition, including
statements about what is going well, that are not misleading, can be very
helpful. It is always possible to find positive points, even if the point is
that the patient is doing a good job of managing a very difficult situation. We
first address the symptoms, problems, and patient concerns. Next we ask
what
the patient has been doing and ask about symptoms we believe they do not
have.
Finally, we comment on those areas of functioning that are not problems and
on
the many accomplishments of the patient and family. Thus we acknowledge
the
problems and then recognize that, no matter how difficult, there are things
that are not problems and the patient and family are doing a good job of
managing the situation. This simple, positive perspective can make a large
impact on feelings of control, self-efficacy, and overall good feelings within
and among family members.</p>

<h2><a name="ch24.html_1_4"></a>COPING STRATEGIES REQUIRING


SPECIALIZED
TRAINING</h2>

<p><a name=table4><b><span style='font-size:13.5pt'>Chapter 24 table


4: </span>Coping
interventions used after specialized training</b></a> </p>
<table border=0 cellpadding=0 align=left width="60%" bgcolor="#ffffa0"
style='width:60.0%;mso-cellspacing:1.5pt;background:#FFFFA0;mso-table-
anchor-vertical:
paragraph;mso-table-anchor-horizontal:column;mso-table-left:left'>
<tr>
<td style='background:#90FFA0;padding:.75pt .75pt .75pt .75pt'>
<p class=MsoNormal align=center style='text-
align:center'><b>Intervention<o:p></o:p></b></p>
</td>
<td style='background:#90FFA0;padding:.75pt .75pt .75pt .75pt'>
<p class=MsoNormal align=center style='text-align:center'><b>Assists
with<o:p></o:p></b></p>
</td>
</tr>
<tr>
<td style='padding:.75pt .75pt .75pt .75pt'>
<p class=MsoNormal>Self-statements</p>
</td>
<td style='padding:.75pt .75pt .75pt .75pt'>
<p class=MsoNormal>Belief the situation is manageable</p>
</td>
</tr>
<tr>
<td style='padding:.75pt .75pt .75pt .75pt'>
<p class=MsoNormal>Reframing</p>
</td>
<td style='padding:.75pt .75pt .75pt .75pt'>
<p class=MsoNormal>Neutral or positive perspective, belief in self-
competence</p>
</td>
</tr>
<tr>
<td style='padding:.75pt .75pt .75pt .75pt'>
<p class=MsoNormal>Active coping and distraction</p>
</td>
<td style='padding:.75pt .75pt .75pt .75pt'>
<p class=MsoNormal>Stimulation that competes with or blocks pain
sensations</p>
</td>
</tr>
<tr>
<td style='padding:.75pt .75pt .75pt .75pt'>
<p class=MsoNormal>&nbsp;&nbsp;Focus on mental activity</p>
</td>
<td style='padding:.75pt .75pt .75pt .75pt'>
<p class=MsoNormal>Blocks attention to pain</p>
</td>
</tr>
<tr>
<td style='padding:.75pt .75pt .75pt .75pt'>
<p class=MsoNormal>&nbsp;Focus on active behaviors</p>
</td>
<td style='padding:.75pt .75pt .75pt .75pt'>
<p class=MsoNormal>Reminders of competence</p>
</td>
</tr>
<tr>
<td style='padding:.75pt .75pt .75pt .75pt'>
<p class=MsoNormal>&nbsp;Goal setting</p>
</td>
<td style='padding:.75pt .75pt .75pt .75pt'>
<p class=MsoNormal>Addition of pleasure to daily experience</p>
</td>
</tr>
<tr>
<td valign=top style='padding:.75pt .75pt .75pt .75pt'>
<p class=MsoNormal>Relaxation and imagery (hypnosis)</p>
</td>
<td style='padding:.75pt .75pt .75pt .75pt'>
<p class=MsoNormal>Reduction of autonomic arousal and tension, possible
neuroendocrine changes</p>
</td>
</tr>
<tr>
<td style='padding:.75pt .75pt .75pt .75pt'>
<p class=MsoNormal>Relaxation<br>
&nbsp;Progressive muscle relaxation<br>
&nbsp;Deep breathing</p>
</td>
<td valign=top style='padding:.75pt .75pt .75pt .75pt'>
<p class=MsoNormal>Reduction of tension components contributing to
pain</p>
</td>
</tr>
<tr>
<td style='padding:.75pt .75pt .75pt .75pt'>
<p class=MsoNormal>Imagery</p>
</td>
<td style='padding:.75pt .75pt .75pt .75pt'>
<p class=MsoNormal>Mental activity that competes with pain</p>
</td>
</tr>
<tr>
<td style='padding:.75pt .75pt .75pt .75pt'>
<p class=MsoNormal>&nbsp;&nbsp;Pleasant places</p>
</td>
<td style='padding:.75pt .75pt .75pt .75pt'>
<p class=MsoNormal>Introduces feelings of pleasure</p>
</td>
</tr>
<tr>
<td style='padding:.75pt .75pt .75pt .75pt'>
<p class=MsoNormal>&nbsp;&nbsp;Analgesic images</p>
</td>
<td style='padding:.75pt .75pt .75pt .75pt'>
<p class=MsoNormal>Blocks pain sensations</p>
</td>
</tr>
<tr>
<td style='padding:.75pt .75pt .75pt .75pt'>
<p class=MsoNormal>&nbsp;&nbsp;Brief images</p>
</td>
<td style='padding:.75pt .75pt .75pt .75pt'>
<p class=MsoNormal>Blocks pain sensations</p>
</td>
</tr>
<tr>
<td valign=top style='padding:.75pt .75pt .75pt .75pt'>
<p class=MsoNormal>&nbsp;&nbsp;Storytelling</p>
</td>
<td style='padding:.75pt .75pt .75pt .75pt'>
<p class=MsoNormal>Reminders of past pleasures</p>
</td>
</tr>
<tr>
<td valign=top style='padding:.75pt .75pt .75pt .75pt'>
<p class=MsoNormal>Structured support</p>
</td>
<td style='padding:.75pt .75pt .75pt .75pt'>
<p class=MsoNormal>Sense of not being alone, alternative perspectives
(reframing), education that may enhance adherence, expression of feelings,
increased sense of competence</p>
</td>
</tr>
</table>

<p>Many cognitive-behavioral and psychological interventions can be used


to
treat cancer patients with pain <a
href="http://www.talaria.org/ch24.html#references">(13)</a>. <a
href="http://www.talaria.org/ch24.html#table4">Table 4</a> lists coping
strategies used most often by psychologists, social workers, nurses, or
psychiatrists after specialized training. These are skills that can be taught
to the patient so that a method can be used when the therapist is not
present.</p>

<h3><a name="ch24.html_1_4_1"></a>Self-Statements</h3>

<p>When patients receive information and education, they are as prepared


as
possible to cope with threats to health or well-being. They can then use this
information in self-statements or affirmations to remind themselves that the
experience is expected and temporary and that they can cope. We help
patients
prepare ``I can cope'' statements prior to a major stressor, specifically to
address the fears of the individual patient.</p>

<p>We prepare these statements by first exploring the conversations a


person
has with himself or herself. Many patients initially deny any helpless or
self-defeating thoughts. With an accepting approach, exploration, and some
provision of examples from other patients, most people acknowledge specific
fears or concerns that sometimes enter their minds about what might go
wrong.
Patients then develop alternative phrases to remind themselves of areas
where
they have control. Finally, we work out statements to reinforce that they are
doing as well as possible in this exceptional experience. It is important to
emphasize that this approach is only effective when it is adapted to, and
developed with, the individual patient.</p>

<p>In discussing any cognitive modifications, it is essential to assure both


patients and families that they will not kill themselves or cure themselves by
having the ``right'' thoughts or by maintaining only positive thoughts. Fears
and helpless thoughts are normal and should be understood and tolerated as
normal; at the<!--[fj --> same time, we encourage patients not to stay in
these
thoughts. At times, awareness of these thoughts can help patients identify
when
they need more information<!--[fj --> or when they need reassurance from
someone else whose knowledge or support<!--[fj --> they value.</p>

<h3><a name="ch24.html_1_4_2"></a>Reframing</h3>
<p>In addition to providing reframes to the patient as a part of regular
communication, we teach patients to learn to reframe for themselves. After
teaching them to identify negative self-talk, times when they expect the
worst,
or situations that really bother them, we teach four forms of reframing:</p>

<p class=MsoNormal><span style='font-family:Symbol;mso-ascii-font-


family:"Times New Roman"'></span><span
style="mso-spacerun: yes"> </span>Focus on what they have done or can
do
instead of what they cannot do or have not done; </p>

<p class=MsoNormal><span style='font-family:Symbol;mso-ascii-font-


family:"Times New Roman"'></span><span
style="mso-spacerun: yes"> </span>Find something positive that they will
gain
from the situation and focus on that; </p>

<p class=MsoNormal><span style='font-family:Symbol;mso-ascii-font-


family:"Times New Roman"'></span><span
style="mso-spacerun: yes"> </span>Look at the situation from the
perspective
of an uninvolved observer to try to find a more balanced, neutral view; </p>

<p class=MsoNormal><span style='font-family:Symbol;mso-ascii-font-


family:"Times New Roman"'></span><span
style="mso-spacerun: yes"> </span>Focus on the temporary nature of what
is
difficult. </p>

<h3><a name="ch24.html_1_4_3"></a>Active Coping and


Distraction</h3>

<p>Distraction is a normal part of coping when we have exhausted our


abilities
to solve problems or simply want a break from problems or preoccupations.
Distraction is not the same as denial, which implies an inability to recognize
reality, or avoidance, which implies an unwillingness or inability to cope with
reality. Denial can be beneficial in situations where nothing can be done to
change
the circumstances and focusing on fears may just increase anxiety <a
href="http://www.talaria.org/ch24.html#references">(21)</a>. Avoidance,
on the
other hand, seems unhelpful as a coping strategy and is related to greater
levels of distress <a
href="http://www.talaria.org/ch24.html#references">(40)</a>.
When coping with cancer pain, getting through the day comfortably is often
the
greatest problem and one that may be hard to totally solve. In this case,
focusing attention away from discomforts can be one of the better coping
strategies. Individuals each have their own preferred distractions. We work
with patients to plan when, where, and how they will use specific
distractions.</p>

<p>Some distractions involve focusing on thoughts or <i>mental


activity.</i><!-- -->
Imagery is one such focus. Others include self-statements, prayers, reading,
listening to someone read, and listening to music. Other activities focus on
<i>active
behaviors</i><!-- --> such as working on a hobby, using deep breathing,
and
relaxation. Many patients report talking with family and friends as the most
effective distractor. Often the best way to focus attention away from
discomfort is to create more pleasant sensations. Massage and exercise such
as
walking are commonly used. We encourage patients to set a goal each day
for one
thing they want to do for their own comfort or pleasure, regardless of how
small or what else has to be done. This then becomes a focus and provides a
sense of achievement that reminds patients of their control over their own
experience.</p>

<h3><a name="ch24.html_1_4_4"></a>Relaxation and


Imagery/Hypnosis</h3>

<p>Relaxation with imagery is one of the most easily accepted, most useful
noninvasive methods for managing cancer pain. Progressive muscle
relaxation can
be provided either by tensing and relaxing each muscle in turn <a
href="http://www.talaria.org/ch24.html#references">(4)</a> or by deep
breathing
and relaxing muscles without first tensing <a
href="http://www.talaria.org/ch24.html#references">(33)</a>. Knowledge
of the
physical sensations of tension and relaxation in the various parts of the body
can be helpful to patients so that they can easily notice tension and relax
muscles when stressed. Once patients understand relaxation and deep
breathing,
we explore goals or wishes for the future. We develop images of places
where
they felt relaxed, healthy, strong, and capable. Nearly all patients enjoy and
respond to these ``pleasant place'' images. With some patients we
incorporate
suggestions for increased general comfort or for numbness in the painful
area. An
understanding of the use of suggestion is one of the primary distinctions
between relaxation and hypnosis <a
href="http://www.talaria.org/ch24.html#references">(1,16)</a>. For the
purposes
of pain management, research does not yet allow us to clearly distinguish
effects of hypnosis from those of relaxation and imagery. Because of the
negative connotations of hypnosis for some patients, we usually use the
term
relaxation with imagery <a
href="http://www.talaria.org/ch24.html#references">(15)</a>.</p>

<p>Brief imagery can be used to counteract the sensory qualities of pain.


When
in-depth imagery is not possible because the patient is not interested or does
not have the needed attention span, brief images can still provide a time-out
from pain and illness. We take the patient's description of sensation and
create an image to match.<!--[fj --> <!-- -->In cases such as severe,
paroxysmal pains, we use a brief image that counteracts the sensory quality
of
the pain. For burning, stabbing pain we might have the patient focus on deep
breaths while imagining blowing arctic air through the sensation; for extreme
pressure in the abdomen, we might use an image of a heavy weight lifting off
the painful area, lifting higher with each exhalation.</p>

<p>For less excruciating pains, but where patient attention or participation


in
receptive imagery is impaired, we simply have patients tell us a story about
a
place they have been. With questions, we help them to expand on the story
in
the same way we would do with imagery. Storytelling is nearly always more
effective with children than formal relaxation and imagery. The nurse or
family
member can tell a story or have the child tell the story. When possible,
having
the patient tell the story will be more absorbing and distracting than
listening to a story.</p>

<h3><a name="ch24.html_1_4_5"></a>Structured Support</h3>

<p>Support is clearly one of the essential needs for patients and family
members. Most people actively seek support as the most frequent coping
strategy
of cancer patients <a
href="http://www.talaria.org/ch24.html#references">(10)</a>.
Men tend to be more reluctant than women to seek out supports and to
provide
emotional support rather than problem-solving. Including education in
support
efforts can be an effective enticement for men who otherwise might resist
supports.</p>

<p>The value of support is being increasingly recognized in numerous


studies.
Recent research demonstrates that cancer patients who receive active
psychological support, with or without skills training, from groups or
individuals, report less pain and live longer <a
href="http://www.talaria.org/ch24.html#references">(11,31,32,35)</a>.
These
supports are not alternatives to traditional medicine, but the expression of
feelings and the sharing of experiences may help patients to participate
more
fully in medical treatment. Researchers are exploring whether these support
interventions have neuroendocrine or immunologic effects <a
href="http://www.talaria.org/ch24.html#references">(12,28,31)</a>.</p>

<h3><a name="ch24.html_1_4_6"></a>Controlled Clinical Trials of


Psychological
Interventions for Cancer Pain Relief</h3>

<p>Although there has been considerable interest in the use of


psychological
interventions for cancer pain management, few controlled clinical trials have
examined the utility of these techniques. Spiegel and Bloom <a
href="http://www.talaria.org/ch24.html#references">(32)</a> randomly
assigned
breast cancer patients to three groups: a support group, a support group plus
hypnosis training, and a no-treatment group. Support groups for the two
treatment
conditions lasted more than 1 year, but outcome assessment was completed
at 1
year. Both support groups reported significantly less pain and suffering than
the untreated group, with the hypnosis group reporting lowest pain levels
after
1 year. A recent study by Fawzy and colleagues <a
href="http://www.talaria.org/ch24.html#references">(11)</a> did not look
specifically at pain, but did randomly assign cancer patients to an untreated
control group or a group that received coping skills training consisting of
four components: brief education, support, training in problem-solving, and
relaxation with imagery. The advantage of this study was its short duration,
six weekly sessions. These researchers found that the intervention
significantly reduced patient reports of fatigue and distress while increasing
patient use of active cognitive and behavioral coping methods. Results
remained
at 6-month follow-up. Even though this study did not look directly at pain,
the
methodology indicates that relatively brief, cost-effective (e.g., group)
interventions can have long-lasting results.</p>

<p>We have completed two studies testing the efficacy of cognitive-


behavioral
skills training for pain related to bone marrow transplantation for cancer. In
both clinical trials, we found that patients can learn these skills with brief
training and can use the methods to reduce severe pain even when opioids
are
used concurrently, as long as the training occurs before treatment begins. In
a
pilot study, we randomly assigned patients to four groups: a no-treatment
control; an untreated attention control where patients spent time with a
therapist but no psychotherapeutic support was provided; a group that
received
hypnosis training; and a group that received cognitive-behavioral training
without imagery or hypnosis <a
href="http://www.talaria.org/ch24.html#references">(34)</a>. Patients
received
two sessions of training and had two half-hour ``booster'' sessions per week
in
the hospital to help them use the skills. The hypnosis group reported
significantly less pain than all other groups, without using more opioids.
Results suggested that hypnosis or imagery may be the most potent of the
interventions. In our second study, we modified the interventions somewhat:
(a)
the untreated control group remained the same; (b) the cognitive-behavioral
group included relaxation with imagery and simplified cognitive skills; (c) we
called the hypnosis group ``relaxation with imagery''; and (d) we changed
the
attention control to an active psychotherapeutic support group that also
received education and reframing from the therapist, although no coping
skills
were taught <a
href="http://www.talaria.org/ch24.html#references">(35)</a>. All
patients were treated individually in the same format as in the pilot study.
Consistent with the Spiegel and Bloom study <a
href="http://www.talaria.org/ch24.html#references">(32)</a>, we found
that
patients in all three treatment groups reported less pain than the untreated
group.</p>

<p>Results of these four studies indicate that psychological intervention


from
trained therapists helps cancer patients to manage disease-related pain and
treatment-related pain. Structured support is effective, but there may be an
additive effect from the inclusion of coping skills in the intervention.
Further research is needed to more clearly define the effective components
of
these interventions. Possibly the specific content is less important than
providing the patient with some skills for self-management of symptoms and
conveying that the patient has the ability to cope with the pain. Our research
and that of Fawzy and colleagues clearly indicate that long-term treatment is
not needed, that brief, focused interventions can be effective <a
href="http://www.talaria.org/ch24.html#references">(11,34,35)</a>.</p>

<h3><a name="ch24.html_1_4_7"></a>Pediatric Considerations</h3>

<p>Most of these methods need little adaptation for use with children.
Information is important for children, but of course must be phrased with
words
the child will understand. Otherwise the child may be frightened by
unfamiliar
terms. As with adults, education should be oriented to reinforce areas where
the child has some control, such as asking for medication or understanding
rewards for self-care activities. Children can plan for their own active
distractions and can be engaged in play even when quite ill. Active
storytelling play can be even more engaging than storytelling imagery while
lying in bed. Children frequently enjoy art projects and drawing, whereas
adults may be intimidated by perceived performance expectations with
art.</p>

<p>Assessing children's pain is as feasible as with adults and should be the


cornerstone of any pain treatment. In most cases, children as young as 7
years
old are able to report pain on a 0-to-10 scale if the scale is explained and
practiced briefly <a
href="http://www.talaria.org/ch24.html#references">(23,36)</a>.
Children between age 3 or 4 and 7 can use scales of faces where ``no pain''
is
indicated by a smiling face and ``extreme pain'' is indicated by a tearful
face. Under age 3 we rely on observation to inform us of pain intensity,
although pain cannot be distinguished from general distress by the
observation
measures available <a
href="http://www.talaria.org/ch24.html#references">(18,30)</a>.
Other areas of assessment should be included as described above.</p>

<h3><a name="ch24.html_1_4_8"></a>Who Benefits When?</h3>

<p>Prior to moderate or severe pain, patients are most open to


opportunities to
enhance their control over symptoms. Once pain is moderate, patients may
benefit from imagery done by a therapist but are less likely to be able to use
any new cognitive-behavioral skills on their own. Attention span,
concentration, and energy are necessary for learning new coping skills. When
patients are sedated or confused from medical treatments or the disease, or
when patients are exhausted and frustrated because all other treatments
have
been inadequate, we have a very difficult time teaching cognitive techniques
for relieving pain. Information and education are always useful, but again are
best provided when the pain problem is in early, mild stages. Physical
methods
such as massage or active distraction can be introduced at any point.</p>

<p>Although we do not have strong data yet on which patients benefit most
from psychological
methods of cancer pain control, clinical experience with patients in pain is
quite similar to reports of cancer patients who have chemotherapy-related
nausea and vomiting. Thus we can extract some general principles. Patients
who
are most anxious, or who expect the physicians and nurses to be in control,
have difficulty learning cognitive coping skills. These patients may initially
need supportive listening and identification of specific areas where they have
some control <a
href="http://www.talaria.org/ch24.html#references">(6)</a>.
Cognitive-behavioral skills may be introduced after anxiety has decreased
and
after patients believe they have the ability to participate in managing their
symptoms. At the other extreme, for patients who cope actively and manage
anxiety well, it may be hard to tell whether the skills benefit them. Patients
with moderate anxiety and those who have not evaluated their coping plans
may
benefit the most from cognitive-behavioral methods <a
href="http://www.talaria.org/ch24.html#references">(6)</a>. These
patients are
often motivated to learn skills that help them to feel like participants in
their care. They feel more in control of their physical reactions when they
learn the skills, and they respond well to the additional support provided by
the trainer.</p>
<p>For several categories of patients, it is particularly useful to have
psychiatric or psychological evaluation in advance of a crisis to permit a
baseline assessment and to plan for management if pain becomes a
problem.
Patients with difficult personality styles may respond very well to the
structure of a medical setting if the treatment team understands the
patient's
needs and is consistent in their approach. These patients may use
cognitive-behavioral methods appropriately as long as their other
psychological
needs are recognized.</p>

<p>Patients with histories of alcohol, long-term opioid, benzodiazepine, or


other substance abuse may have greater difficulty with opioid management
and
achieving acceptable pain control. Anxious staff may raise questions as to
whether medication is being used to treat pain or emotional needs. We have
seen
patients use opioids very appropriately when their history of substance
abuse
is more than 1 year old, although these patients may still need higher doses
of
drug to achieve pain relief. Patients with active histories of drug misuse are
more difficult to evaluate for adequacy of pain treatment. In these cases, we
work with medical staff to set external criteria for assessing pain control.
With some of these patients, we establish contracts for minimum behaviors
that
must be adhered to if medication is maintained or increased. Again, these
patients may respond well to cognitive-behavioral methods as long as the
treatment plan also incorporates recognition of their unique psychological
and
medical needs.</p>

<h2><a name="ch24.html_1_5"></a>CONCLUSIONS</h2>

<h1><a name="ch24.html_2"></a>Integrating Psychological Methods with


Medical
Treatments </h1>

<p>Standard medical practice in cancer pain management can easily


integrate
cognitive and behavioral skills. All health care professionals can
provide:</p>

<p class=MsoNormal><span style='font-family:Symbol;mso-ascii-font-


family:"Times New Roman"'></span><span
style="mso-spacerun: yes"> </span>Assessment of pain and related quality
of
life; </p>

<p class=MsoNormal><span style='font-family:Symbol;mso-ascii-font-


family:"Times New Roman"'></span><span
style="mso-spacerun: yes"> </span>Information in a manner that uses
familiar
descriptions of expected sensations and indicates the situation is
manageable; </p>

<p class=MsoNormal><span style='font-family:Symbol;mso-ascii-font-


family:"Times New Roman"'></span><span
style="mso-spacerun: yes"> </span>Education that (a) responds to
common beliefs
about cancer pain and opioid use; (b) conveys that cancer pain can be
controlled; and (c) provides specific behaviors, including taking medication,
that the patient can use to manage his or her own pain; </p>

<p class=MsoNormal><span style='font-family:Symbol;mso-ascii-font-


family:"Times New Roman"'></span><span
style="mso-spacerun: yes"> </span>Reframing that reminds the patient of
what is
going well and acknowledges the beneficial coping efforts the patient is
making; </p>

<p class=MsoNormal><span style='font-family:Symbol;mso-ascii-font-


family:"Times New Roman"'></span><span
style="mso-spacerun: yes"> </span>Support for expression of emotions
such as
fearful or helpless thoughts about the disease or pain experience. </p>

<p>Psychological specialists may be needed in two roles:</p>

<p class=MsoNormal><span style='font-family:Symbol;mso-ascii-font-


family:"Times New Roman"'></span><span
style="mso-spacerun: yes"> </span>To train other cancer pain specialists in
methods of information provision, patient and family education, support, and
cognitive reframing; </p>

<p class=MsoNormal><span style='font-family:Symbol;mso-ascii-font-


family:"Times New Roman"'></span><span
style="mso-spacerun: yes"> </span>To provide structured support or
patient
skill training in self-statements, reframing, active coping and distraction,
relaxation with imagery or hypnosis, and ways to communicate with medical
staff
or gather needed information. </p>

<h3><a name="ch24.html_2_0_1"></a>What Works?</h3>

<p>Research indicates that psychological interventions, when integrated


with
standard medical care, do reduce cancer pain. Data support the efficacy of
the
following methods: education, information, support, imagery, and coping
skills
packages that include active cognitive and behavioral coping.</p>

<h3><a name="ch24.html_2_0_2"></a>Feasibility</h3>

<p>These interventions need to be made available to more patients.


Widening
availability requires developing methods that take less time and do not
depend
only on professional resources. The following modes of delivery would
expand
the availability and efficacy of these methods:</p>

<p class=MsoNormal><span style='font-family:Symbol;mso-ascii-font-


family:"Times New Roman"'></span><span
style="mso-spacerun: yes"> </span>Early information, education, and
coping
skills training prior to severe pain; </p>

<p class=MsoNormal><span style='font-family:Symbol;mso-ascii-font-


family:"Times New Roman"'></span><span
style="mso-spacerun: yes"> </span>Multimodal training using videotapes,
written materials, audiotapes, and brief one-to-one contact with follow-up;
</p>

<p class=MsoNormal><span style='font-family:Symbol;mso-ascii-font-


family:"Times New Roman"'></span><span
style="mso-spacerun: yes"> </span>Including a family member as a coach
when
providing information, education, or training in coping skills; </p>

<p class=MsoNormal><span style='font-family:Symbol;mso-ascii-font-


family:"Times New Roman"'></span><span
style="mso-spacerun: yes"> </span>Use of group rather than individual
formats
for training or support. </p>
<p>Cancer pain experts all acknowledge that physical mechanisms interact
with
thoughts, behaviors, emotions, and environment to determine how patients
respond to cancer pain and pain treatments. Yet many nurses, physicians,
social
workers, psychologists, and psychiatrists do not know what psychology can
offer
or how to integrate this area of expertise into the medical management of
the
cancer pain patient. At the same time, many nurses and physicians believe
they
can meet the psychological needs of patients themselves. Results of
research
available today inform us of how to improve patient pain relief both by
expanding the knowledge of nurses and physicians and by including more
social
workers, psychologists, and psychiatrists in active treatment of cancer pain
problems.</p>

<h2><a name="ch24.html_2_1"></a>ACKNOWLEDGMENTS</h2>

<p>This work was supported by grants from the National Cancer Institute
(CA38552 and CA57807-01). The author thanks Dr. Janet Abrams for her
editorial
contributions.</p>

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