Abstracts

REVIEW ARTICLE

Role of the pharmacist on the pharmacotherapeutic follow-up for cancer pain control^*

Mari Lisa Rabelo^I; Márcio Luis Lima Borella^II

^IStudent of Pharmacy, University of Caxias do Sul (UCS). Caxias do Sul, RS, Brazil

^IIProfessor of the Pharmacy Course, University of Caxias do Sul (UCS). Caxias do Sul, RS, Brazil

Correspondence to

ABSTRACT

BACKGROUND AND OBJECTIVES: Pain is a frequent cancer symptom, however most of the times pharmacists of the hospital pharmacy, due to the huge bureaucratic tasks that depart them from patients, have not significantly contributed in assisting cancer pain patients. This study aimed at proposing the insertion of pharmacists in the cancer pain control team aiming at the rational use of drugs at and monitoring patients' adverse reactions.

CONTENTS: For effective pain control, implementation of analgesic measures and assessment of therapeutic efficacy, it is critical to adequately use the "Guide to Cancer Pain Management" of the World Health Organization (WHO), which establishes guidelines for controlling pain of most advanced cancer patients; it is also fundamental to report patients' painful experience to health professionals.

CONCLUSION: Pain measurement scales added to WHO's recommended protocol have been shown to be a critical tool for the rational use of drugs. Pharmacists, in addition to performing their daily activities, are qualified to interact in multidisciplinary teams helping controlling cancer patients' pain, by evaluating the compliance with this WHO protocol to control pain.

Keywords: Analgesic ladder, Cancer pain, Palliative care, Pain measurement, Pharmacist.

INTRODUCTION

Pain is currently a major cause of incapacity and distress for patients with progressive cancer. Approximately 80% of them will experience some type of pain¹. An important aspect to be considered is that chronic pain affects approximately 50% of cancer patients in all stages of the disease, and 70% of those with advanced cancers². In approximately 20% of cancer patients, pain may result from surgical, chemotherapy and radiotherapy treatment³; however, it may also be directly induced by the tumor or by reasons unrelated to the oncologic disease, such as metabolic, infectious, nutritional and degenerative changes¹.

Helping individuals with advanced and potentially lethal diseases, the so-called terminal diseases, and their relatives in one of the most critical moments of their lives is an activity or health care model called "palliative care"⁴. The palliative assistance is aimed at controlling symptoms, without curative function, aiming at preserving quality of life (QL) till the end. Care aims at promoting comfort and is basically focused on hygiene, diet, ostomy dressings and care, and attention to analgesia, thus observing the needs to decrease distress and improve comfort⁵.

Effective cancer pain control in palliative care requires a multidisciplinary team that should follow the protocol proposed by the World Health Organization (WHO), and use oral drugs according to the Analgesic Ladder. This analgesic ladder may provide pain relief for 70% to 90% of patients and interventionist procedures should be reserved for special situations6. However, most of the times pharmacists of the hospital pharmacy have a wide range of bureaucratic tasks which depart them from patients.

Without a pain measurement routine or the integral participation of the health team, it is impossible to obtain satisfactory comfort, thus improving QL of these patients.

So, our study aimed at proposing the insertion of pharmacists in the palliative care of cancer patients, through the analysis of painful patients' prescriptions, aiming at a rational use and the monitoring of drugs adverse reactions (DAR).

CONTENTS

All cancer patients should be daily evaluated for the presence and intensity of pain and currently, due to the proximity between nursing team and patients, nurses are those best suited⁷. However, evaluation and measurement tools are seldom used to monitor such experience⁸.

In this context, in the attempt to objectively document and be successful with pain relief, tools were developed to provide the most adequate therapeutic choice for every patient. In 1986, the WHO has gathered specialists who developed the "Guide to Treat Cancer Pain". This protocol is based on preferably recommending the oral route, the administration of drugs at pre-established times and no longer "if needed" and progressive scaling of analgesics, known as "WHO Analgesic Ladder" (Figure 1)^6,9.

Recently, the addition of a step to the analgesic ladder was proposed to include invasive procedures, such as anesthetic blocks and surgical procedures¹⁰. This cancer pain management protocol is based on three major steps, in ascending order of potency, from non-opioid analgesics and progressing to opioids when pain is moderate or severe. Non-steroid anti-inflammatory drugs (NSAIDs), weak opioids and strong opioids are proposed in this sequence^2,6,11. Adjuvant drugs may be associated to these drugs, such as antidepressants and anticonvulsants, among others. The change from one step to the other is generally due to inadequate analgesia - caused by increased pain - due to disease progression⁶. Acetylsalicylic acid, codeine and morphine are standard analgesics of this proposal². The treatment is considered adequate when there is congruence between the level of reported pain and the potency of the prescribed analgesic^6,9.

According to WHO, this methodology has been tested in several centers of different countries with proven efficacy⁶. However, some authors prefer to be careful with the WHO analgesic ladder, considering that it should not be used for all types of pain, so they stress the importance of identifying the type of patients' pain¹². Due to this and numerous other criticisms, in its 20^th anniversary in 2006 the analgesic ladder was discussed by specialists and afterwards a study was published with evidences supporting each step described in this protocol¹³.

So, it is proposed the use of the WHO analgesic ladder by a multidisciplinary team to evaluate individual patients' needs. For such, it is recommended that pharmacists should better manage their time, decreasing administrative tasks and increasing clinical activities, such as evaluating analgesic prescription, whether it is consistent with WHO protocols and guidelines. Assuring that such drugs are safely used is a critical role of pharmacists, more over that their involvement with patients results in early DAR prevention and detection. So pharmacists' actions should not be limited to bureaucratic tasks. However, these professionals must also assure that prescriptions are as safe as possible, based on the knowledge of relevant factors about drugs and patients.

The proposal of inserting pharmacists also gives them the task of comparing WHO proposed standard to prescription and results obtained from measurements. Pharmacists shall classify prescriptions as compatible, compatible with restrictions or incompatible. Compatible are therapeutic regimens contemplated by the WHO analgesic proposal, compatible with restrictions refers to therapeutic regimens deviating from the analgesic ladder proposal, and incompatible are therapeutic regimens diverging from the WHO proposal. If necessary, the prescribing physician should be warned about the incompatibility of the prescription for painful cancer patients.

In placing pharmacists closer to patients, the posture commonly seen in such environments is changed and pharmacists start seeing patients as the focus of their work. In this sense, with already available resources and working in partnership with patients, physicians, pharmacists and nursing teams may play a very important role in improving patients' QL, by reviewing prescribed analgesic regimens and managing the intervention and interpreting health promotion recommendations.

CONCLUSION

Pain is an individual phenomenon and to characterize it one should adopt a daily pain evaluation pattern for cancer patients. In all cases, treatment should be tailored according to patients' needs, and directed, if possible, toward the pain triggering cause.

Pain management scales, in addition to the WHO protocol, have proven to be essential tools for the rational use of drugs. This way one may define the most adequate drug therapy for patients, assuring that what is evaluated is what patients are living, not what the professional believes is felt. However, with time, there is the need to restore, model or modify it.

Pharmacists' role, through their skills and knowledge, becomes an important tool to analyze the consistence between data collected by the nursing team and physician's prescription. This way, the adequate use of WHO protocols is evaluated, assuring better quality to patients at the end of their lives.

REFERENCES

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