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C H A P T E R 91

PAIN MANAGEMENT AND ANTIEMETIC THERAPY

IN HEMATOLOGIC DISORDERS

Shane E. Peterson, Kathy J. Selvaggi, Bridget Fowler Scullion,
and Craig D. Blinderman

Relieving pain in patients with hematologic disorders requires a often exhibit completely different behaviors, becoming mobile,
1,2
multifaceted approach. This chapter will provide the clinician with engaged, and involved with other people. The first component in the
the tools to perform a systematic evaluation of the pain complaint and assessment is to believe the patient’s complaint.
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propose a rational, evidence-based, strategy. After the source and type Patient reports of pain are valid, reliable, and reproducible. A
of the pain has been identified and assessed, appropriate nonpharma- variety of assessment tools that can be completed within 5–10
1,7
cologic and pharmacologic therapies can be initiated. The approach minutes are available. The pain complaint should be characterized
to managing pain in hematologic disorders is largely based on the by a number of descriptors, including the pain location, intensity,
approach for managing cancer-related pain. We do not address the quality, onset, and duration; location and patterns of radiation; and
neurosurgical or anesthetic procedures for managing pain; those what relieves or exacerbates the pain and its functional consequences
1–5
interested in these techniques are referred to several excellent reviews. (including how the pain affects the patient’s ability to sleep or eat and
We will also review the pharmacologic strategies for managing nausea how it affects physical activity, relationships with others, emotions,
in patients with hematologic disorders undergoing treatment. and concentration). Most patients with chronic cancer pain also
7,8
experience periodic flares of pain, or “breakthrough pain.” An
important subtype of breakthrough pain is “incident pain,” which is
TAXONOMY OF PAIN caused by voluntary activity. The initial evaluation should determine
the extent to which the patient has breakthrough pain and if it is
Although there is no one standardized classification system for cancer provoked by movement (nociceptive) or tends to be paroxysmal in
pain, several systems have been proposed. Cancer pain syndromes, nature (neuropathic). This subjective information, combined with
and thus by analogy, pain syndromes in hematologic disorders, may the physical examination and diagnostic studies, may identify a
be classified temporally, pathophysiologically, and etiologically, specific pain syndrome and its implied pathophysiology.
according to distinct clinical–anatomical entities, or any combination In a patient with a hematologic disorder, the cause of pain may
thereof. It is important to determine both the etiology and inferred be the disease itself, the specific therapy for the disease, diagnostic
pathophysiology in the assessment of the pain complaint because this procedures related to the disease, or unrelated disorders (Table 91.1).
may suggest the use of specific therapies. Pain can be categorized as Splenomegaly, bone injury (e.g., infarction, infection, hemarthroses,
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nociceptive (somatic or visceral), neuropathic, or idiopathic. Nocicep- and infiltration), leptomeningeal infiltration, and spinal cord com-
tive pain is pain that is sustained predominantly by tissue injury or pression frequently accompany hematologic diseases. Chemotherapy
inflammation. Nociceptive somatic pain is described as sharp, aching, and radiation therapy can cause mucositis, typhlitis, hemorrhagic
stabbing, throbbing, or pressure-like. Nociceptive visceral pain is cystitis, and peripheral neuropathy; corticosteroid withdrawal may
poorly localized and is usually described as crampy pain (e.g., obstruc- cause myalgias. Immunosuppression, caused by the diseases them-
tion of hollow viscus) or as aching and stabbing (e.g., pain secondary selves or by the therapies used to treat them, may lead to painful
to splenomegaly). Neuropathic pain is sustained by abnormal infections such as perirectal abscesses, herpetic or candidal esophagi-
somatosensory processing in the peripheral or central nervous system tis, and herpes zoster. Patients with sickle cell disease have a number
(CNS). Sensations described as “burning,” “shock-like,” and “electri- of causes for both acute and chronic pain (Table 91.2).
cal” typically suggest neuropathic pain. On physical examination, Distress, however, may arise from nonanatomic sources. The pain
patients may have allodynia (pain induced by nonpainful stimuli) and complaint may represent the patient’s only means of expressing
hyperalgesia (increased perception of painful stimuli). In the absence nonspecific feelings of distress to the physician. Chapman recognized
of evidence sufficient to label pain as either nociceptive or neuro- three categories of this distress: anxiety, arising from fear of disfigure-
pathic, we may use the term idiopathic. However, in patients with ment or of uncontrollable pain, fear of loss of social position or of
hematologic disorders, this term should lead to additional workup self-control, or fear of death; anger at the failure of the physicians to
and a search for an underlying etiology and pathophysiology. provide a cure; and depression from the loss of physical ability, a sense
of helplessness, and the impact of financial problems. In addition to
these psychological, social, and financial contributions, spiritual
EVALUATION OF THE PAIN COMPLAINT concerns may exacerbate any concomitant painful sensations. Alle-
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viating them may significantly reduce distress and decrease the need
Initial Evaluation for pain medications or other interventions.
Sometimes there may be a disparity between the patient’s expres-
Effective pain management requires a comprehensive assessment of sion of pain and the patient’s family or friends’ appreciation of the
the patient’s pain. The clinical presentation of a patient with chronic impact of the pain. The following observation may help to begin a
pain is very different from that of a patient in acute pain. The patient conversation around this issue: “You seem to show a different per-
with chronic pain does not present with the common autonomic spective about the pain from those of your family and friends. Help
manifestations of acute pain (e.g., tachycardia, sweating, elevated me to understand what the pain is like for you and why you think
blood pressure) or facial grimacing, but often is withdrawn, quiet, your family and friends feel differently.” Differences in cultural
depressed, or irritable; moves very little spontaneously; and complains backgrounds may also affect the expression of pain, and thus may
of discomfort when moved. When the pain is relieved, these patients vary within a family, as well as in different families. 9

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