What do we mean by the word pain?
Definition of Pain by International Association for study of Pain (IASP) (2018)
“An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.”
Definition of Pain by McCaffery & Pasero (1999)
Pain is “Whatever the experiencing person says it is, existing whenever he/she says it does person says it is”
The reporting of pain is subjective therefore as health professionals, assessment and management of pain can be challenging. Using pain assessment tools are essential in building up the ‘true picture’ as is observing a person without questioning and looking for changes in behavior and this will be explored further within the module.
Different Types of Pain
The diagram below explains the two main types of pain and the associations of the pain
Common causes of pain in older people
Cicely Saunders first used the term ‘total pain’ in 1964 to describe the intertwined physical, psychological, social, and spiritual dimensions of pain (Clark 1999).
This is an area that health professionals need to build upon incorporating into care planning and documentation.
Examples of Pain Assessment Tools
Brief Pain Inventory
Please press Ctrl and click to display the brief pain inventory tool
Pain is assessed by obtaining a history, performing a physical examination and relevant investigations, and taking into consideration other factors that might influence the experience of pain and/or the ability to communicate
Through Visual Cues
Vital Sign Changes
It is essential to have knowledge of the resident’s disease states, all of which may relate to their pain
Begin with asking a general question e.g. Are you 100% comfortable?
Enquire where the pain is and if there is more than one pain. Then proceed to ask more detailed questions. If a person denies pain or minimizes its severity it may help to ask:
There is frequently more than one major pain. Each painful site should be identified and assessed separately as each pain may involve a different pathology and mechanism. A body chart is especially useful to help monitor the success of treatments for individual pain sites.
There are some characteristic patterns of radiation or referral of pain that may give clues to the cause and type of pain. For example, shoulder tip pain suggests diaphragmatic pathology or liver capsular origin.
What makes the pain better or worse?
Information about what makes the pain better or worse may help in the identification of pain e.g. pain on breathing with pathological rib fracture. Looking at the response to previously tried analgesics also assists with determining the choice and doses of medications.
‘Quality’ refers to the words the person uses to describe their pain:
Pain quality also gives insights into how the person is reacting to their pain – ‘unbearable’, ‘intolerable’ or ‘annoying’ or ‘uncomfortable’.
Pain severity is usually measured using categorical scales (‘none, mild, moderate, severe, worst ever’), numerical scales (0-10 or 0-5), or visual analogue scales.
How does pain severity vary over time? Establish the pattern of each pain at each site, and any fluctuations through the day, especially in relation to movement, sleep, or other events/activities.
Person’s understanding of the pain
Find out what the person knows and feels about their pain.
The physical examination should usually include:
Document pain assessment in the medical record; it can influence decision-making both at the time of the assessment and in the future
As pain is a common symptom, people who are identified as needing palliative care should be assessed for the presence of pain
The components of pain assessment as above should be documented
The response to treatment, such as severity and effects on mobility to keep a track of pain management over time. Any major changes to pain should trigger a more comprehensive assessment
Pain Management for People Living with Dementia
Please press Ctrl and click the link below as an introduction to caring for people living with dementia and some tips on how to manage their pain.
Non- Medication Treatment options include:
Adjust the environment
Apply physical comforts
Medication treatment of pain in advanced dementia
START LOW >>>>>> GO SLOW
Pain assessment & observational tools
Pain tools are commonly used to self-report & for observation. In someone with significant cognitive impairment, we need different pain assessment tools as they are unable to communicate verbally with us.
Tools commonly used in dementia care are:
Pain tool for people living with dementia
Abbey Pain Scale
Caution when using pain assessment tools
Principles of Pain Management
It is important to discuss the person’s expectations and to set both short and long-term treatment goals:
Setting a Treatment Plan
After diagnosing the pathophysiological cause of pain, a systematic approach to developing a management plan is extremely useful. The growing understanding of the importance of the neuropathic component of considerable pain has led to the earlier introduction of co-analgesics, thereby enhancing the effectiveness of the pharmacological treatment.
Non- pharmacological treatments can also be used alongside or instead of pharmacological treatments depending on the person’s wishes such as
The treatment plan should address the ways that pain can be reduced
Questions that can help to clarify a plan of action
Access to pain management as a human right and barriers to the assessment and treatment of pain
Human rights are privileges that all human beings should hold regardless of ethnicity, nationality, gender, or religion. (Brennan et al 2019) The idea of having access to pain management as a human right has gained momentum in more recent years and today the United Nations and regional human rights organizations have accepted the concept and included it into key human rights reports, reviews and standards. Despite the impact that pain has in a person’s quality of life, it continues to be inadequately treated.
Some of the more common barriers to pain management are:
Common misconceptions about opiates
Misconceptions and myths regarding appropriate use of morphine from people in our care, carers, the public and other health professionals create a major barrier to effective pain management. Let us examine some of the misconceptions that are commonly expressed.
As previously discussed, the physical and emotional experience of pain is different for everyone. Therefore, the dose of morphine required will vary from person to person. In palliative care, morphine is usually started at a low dose and slowly titrated up until the pain is relieved with minimal side effects. There is no ceiling dose when using morphine. Additional medication (adjuvant medications) may be required depending on the type of pain.
There is no ceiling dose when using morphine. If the pain is severe enough to use morphine, it should be used.
Drug addiction is associated with people using drugs to get “high” creating a psychological dependence. When opioids are used correctly to relieve pain, addiction is not an issue.
If a person has moderate to severe pain, a strong opioid such as morphine would be considered appropriate.
Not everyone who is dying requires morphine.
The choice of analgesics should be based on the type and severity of the pain. Treatment should reflect the etiology of the pain as well as its severity. (McCaffery & Pasero 1999)
Pharmacological treatment must include early consideration of the use of drugs that treat neuropathic components of pain.
Evaluation of pain relief
Pain reporting to a physician/GP
Reporting should include:
Why is Advocacy with Physicians/GPs important for Pain management?
SPECIFIC DRUGS USED TO MANAGE PAIN
|Simple analgesic Paracetamol/Tylenol
|Available in tablets, sustained release tablets (Panadol Osteo), liquid, suppositories
|Mild pain, bone pain, fever and as an adjuvant to enhance the efficacy of opioids
|NSAIDS ibuprofen, diclofenac, meloxicam, celecoxib
|Oral and rectal suppositories
|Somatic tissue pain
|OPIOIDS –immediate release Tramadol Ordine), Endone, Oxynorm (liquid oxycodone) Hydromorphone (Dilaudid)
|Oral tablets Oral tablets and liquid
|Mild to moderate pain (tramadol is not recommended in older population) Moderate to severe pain both neuropathic and nociceptive
|OPIOIDS –Slow release MS Contin, OxyContin, Targin, Jurnista
|Ongoing moderate to severe pain both neuropathic and nociceptive
|OPIOIDS-slow release buprenorphine (Norspan) fentanyl (Durogesic)
|Transdermal patch Transdermal patch
|Ongoing chronic mild to moderate pain Moderate to severe pain-must already be taking opioids of at least 30-40mg in a 24-hour period to commence on the lowest strength Duragesic 12 patch.
|OPIOIDS-parenteral Morphine Sulphate, Hydromorphone, Oxycodone
|Sub cutaneous Can either be delivered intermittently or via a Syringe Driver
|Moderate to severe pain Usually indicated when a person is unable to take oral medication
|Antiepileptics- sodium valproate pregabalin, gabapentin,
|Tricyclic antidepressants amitriptyline,
|sub lingual drops and sub cutaneous oral, sub cutaneous
|Neuropathic pain Cramps and spasms, skeletal muscle spasm, bladder spasm,
|Skeletal muscle relaxants-baclofen, dantrolene
|Skeletal and muscle pain
|Neuropathic pain and organ pain e.g. cerebral oedema, spinal cord compression
CAUTIONARY NOTE ON CONSTIPATION
When a person is commenced on an opioid, they should always be commenced on a laxative/aperient as a common side effect of opioids is constipation.
Common side effects of opioid administration
Less common side effects may include:
The Doctrine of Double Effect (DDE) and End of life Decisions
The DDE is a moral principle taken from the teachings of the 13th century Catholic theologian Thomas Aquinas who introduced the idea of actions having two effects. He discusses how a murder maybe justified if a person is acting in self defense because the bad effect (killing the assailant) is not intended, therefore using the ethical principle of Beneficence and the good effect (to save one’s own life) is not unlawful in itself using the ethical principle of Non – Maleficence (Tuckey & Slowther 2009)
The DDE aims to describe best practice when a clinician must differentiate between the intended outcome bringing positive benefits of an intervention, for example high doses of narcotics to alleviate the symptoms of pain and delirium to promote comfort at the end of life, against the possibility of hastening death but not deliberate in the approach.
The clinician caring for people at the end of their life will unfortunately encounter regular ethical dilemmas and according to the eminent palliative care specialist, Robert Twycross (2003), in reality all interventions and treatments carry some inherent risk of foreseeable negative outcomes, therefore collaboration within the interdisciplinary team is imperative when faced with these complex ethical dilemmas.