The IAHPC Manual of Palliative Care
2nd Edition
III. PAIN
Table of Contents
Pain is a more terrible lord of mankind than even death itself.
Albert Schwieitzer (1875-1965)
Abbreviations
References
Internet Resources
CONTENTS
INTRODUCTION
Pain is one of the most common symptoms in palliative care. The aim of palliative care is to allow patients to be pain-free or for their pain to be sufficiently
controlled that it does not interfere with their ability to function or detract from their quality of life.
In palliative care, the treatment of pain needs to be part of a holistic and multidisciplinary approach to patient care.
- Pain can cause or aggravate problems related to other causes of suffering and the pain has to be controlled before the other problems can be addressed
and treated. It is not possible to have meaningful discussions about psychosocial concerns if a patient has uncontrolled pain.
- Pain can be caused or aggravated by psychosocial concerns, which must be addressed before good pain control can be achieved. Where psychosocial
or spiritual problems are causing or aggravating pain, no amount of well-prescribed analgesia will relieve the pain until the responsible psychosocial issues are identified and addressed.
Good pain control requires
- accurate and detailed assessment of each pain
- knowledge of the different types of pains
- a different therapeutic approach to chronic pain
- knowledge of which treatment modalities to use
- knowledge of the actions, adverse effects and pharmacology of analgesics
- assessment and treatment of other aspects of suffering that may aggravate pain
- physical, psychological, social, cultural, spiritual
- assessment tools for different populations (paediatric, illiterate, etc)
- availability of opioid analgesics
TYPES OF PAIN
Definitions
- Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. Pain
is always subjective. (International Association for the Study of Pain).
- Pain is what the patient says hurts. It is what the patient describes and not what others think it ought to be.
Acute and chronic pain (persistent pain)
- Acute pain
- is usually due to a definable acute injury or illness
- it has a definite onset and its duration is limited and predictable
- it is accompanied by anxiety and clinical signs of sympathetic over-activity
- treatment is directed at the acute illness or injury causing pain, with or without the short term use of analgesics
- Chronic pain (Persistent pain)
- results from a chronic pathological process
- it has a gradual or ill-defined onset, continues unabated and may become progressively more severe
- is said to exist if the pain persists longer than the expected healing time for the injury or illness in question
- the patient appears depressed and withdrawn
- there may be no sympathetic over- activity and patients are frequently labeled as "not looking like somebody in pain"
- requires treatment of the underlying disease where possible, regular use of analgesics to relieve pain and prevent recurrence, as well as psychosocial supportive
care
- Incident pain
- occurs only in certain circumstances, such as after a particular movement or on standing
- should be regarded as chronic pain but, as it is intermittent, it is better managed with local measures where possible
- Breakthrough pain
- is a transitory exacerbation of pain that occurs on a background of otherwise stable and controlled pain
Nociceptive, neuropathic and psychogenic pain
- Nociceptive pain
- nociceptive or physiological pain is produced by stimulation of specific sensory receptors or nociceptors in the tissues
- the neural pathways involved are normal and intact
- somatic pain from the skin and superficial structures is usually well localised
- visceral pain is less well localised and there is often referred pain to cutaneous sites
- Neuropathic pain
- is caused by peripheral or central nervous system injury
- pain occurs because the injured nerves react abnormally to stimuli or discharge spontaneously
- neuropathic pain is described as
- a burning stinging feeling (dysaesthesia)
- a shooting pain like an electric shock (lancinating)
- an aching sensation often relieved by firmly squeezing or gripping the affected area
- is less responsive to non-opioid and opioid analgesics and may respond better to an adjuvant analgesics
- Sympathetic pain
- is caused by damage to sympathetic nerves
- is characterised by burning pain and increased sensitivity
- there are signs of sympathetic dysfunction in the affected area
- vasomotor instability (erythema, pallor, oedema)
- sudomotor (sweating) abnormalities
- trophic changes (thinning of the skin and atrophy of the subcutaneous tissue)
- is less sensitive to non-opioid and opioid analgesics
- often responds well to a regional sympathetic nerve block
- Psychogenic pain
- is pain for which there is no physical basis in a patient who has other evidence of psychopathology
- in palliative care, patients are occasionally seen with psychosocial or existential distress in whom psychological factors and not the medical condition
are judged to play the major role in the onset and maintenance of the pain, and for whom primarily psychological therapies may be appropriate
- however, all chronic physical pain is associated with some degree of psychological distress, for which the treatment should be primarily directed at the
cause of the physical pain
Determination of the type of pain is an important part of assessment, as different types of pain respond to different treatments
see Principles of Treatment
CAUSES OF PAIN
In palliative care, there are many different possible causes of pain
Examples of the causes of pain in palliative care patients include pain
- due to the primary disease e.g.
- tumour infiltration
- nerve compression
- associated with treatment e.g.
- diagnostic and staging procedures
- surgery
- due to general debilitating disease e.g.
- pressure sores
- constipation
- unrelated to the primary disease or treatment e.g.
- arthritis
- ischaemic heart disease
Determination of the cause of pain is an important part of assessment, as therapy directed at the cause may greatly improve pain control
see Assessment and Principles of Treatment
FACTORS THAT MODIFY THE PERCEPTION OF PAIN
Pain is always subjective and the perception of pain may be modified by problems or influences related to other physical or psychosocial causes
of suffering
Pain caused by the disease or treatment is modified by these influences, making it either better or worse, resulting in the final clinical pain, which
is what the patient says it is, and what has to be treated
Examples of factors that might aggravate pain
| Pain |
severe or progressive pain |
| pain at multiple or an increasing number of sites |
| pain that causes significant limitation at activity |
| poor prior pain management |
| Other Symptoms |
insomnia or fatigue secondary to unrelieved pain |
| persistent cough or vomiting |
| other distressing symptoms |
| Psychological |
depression |
| anxiety |
| anger |
| Social Difficulties |
problems with interpersonal relationships |
| family problems |
| financial and legal problems |
| Cultural Issues |
culturally insensitive management |
| language barriers |
| Spiritual/Existential |
feelings of meaningless, guilt, regret |
| unresolved religious questions |
Interaction of Pain and the Other Causes of Suffering
- pain has to be controlled before other problems can be addressed and treated
- it is not possible to have meaningful discussions about psychosocial concerns if a patient has uncontrolled pain
- pain can be caused or aggravated by psychosocial concerns, which must be addressed before good pain control can be achieved
- where psychosocial or spiritual problems are causing or aggravating pain, no amount of well-prescribed analgesia will relieve the pain until the responsible
psychosocial issues are identified and addressed
PAIN ASSESSMENT
Clinical Assessment
Comprehensive clinical assessment is fundamental to successful treatment
- accept the patient's description
- pain is always subjective and patients' pain is what they say it is and not what others think it ought to be
- thorough assessment of the pain
- patients should be asked to describe their pain, in their own words
- this information is supplemented by specific questions to define the exact nature of the pain
- the site and radiation of the pain
- the type of pain
- the duration of the pain and whether it has changed
- whether there are precipitating, aggravating or relieving factors
- its impact on functional ability, mood and sleep
- the effect of previous medications
- what the pain means to the patient
- physical examination, including neurological assessment, should be recorded both in writing and pictorially
- further investigations should be limited to those likely to have a significant bearing on treatment decisions
- assess each pain
- many patients have more than one pain and each pain requires assessment
- evaluate the extent of the patient's disease
- the underlying disease is the most frequent cause of pain, new or worsening pain requires the extent of the patient's disease be re-evaluated
- assess other factors that may influence the pain
- physical, psychological, social, cultural, spiritual/existential
- reassess
- repeated reviews are necessary to both assess the effect of treatment and because the underlying disease is usually progressive
Pain measurement
- Pain is a subjective phenomenon and objective measurement does not always reflect the experience
- Pain rating scales may be useful
- to follow the course of a patient's pain
- to assess the effect of treatment
- may be seen by the patient as indicating concern about their pain
Simple techniques should be used. Complex questionnaires may be too demanding for palliative care patients and should be reserved for research.
Visual Analogue Scale
Mark on the line below how strong your pain is
No pain <__________________________> Worst possible pain
Numerical Rating Scale
On a scale of 0 to 10, how strong is your pain?
No pain = 0 1 2 3 4 5 6 7 8 9 10 = Worst possible pain
Verbal Descriptor Scale
Which word best describes your pain?
None Mild Moderate Severe Excruciating
NEXT- PAIN CON'T
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©2008 Published by IAHPC Press |
