Pain Management

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

• Angina
  • Degenerative joint & spine disease e.g. osteoarthritis
  • Leg and foot disorders including neuropathy e.g. diabetes, shingles
  • Cancer
  • Fractures
  • Chest wall pain from coughing or pleurisy
  • Infection e.g. dysuria

 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.

Total Pain

 Examples of Pain Assessment Tools

Wong-Baker Scores

• 0=no hurt
• 2=hurts a little bit
• 4=hurts a little more
• 6=hurts even more
• 8=hurts whole lot
• 10=hurts worst

Brief Pain Inventory

Please press Ctrl and click to display the brief pain inventory tool

http://www.painbc.ca/sites/default/files/events/materials/BriefPainInventory-ShortForm.pdf

Pain Assessment

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

• Cognitive impairment
• Language barrier
• Fear
• Body language
• Curling into themselves
• Holding self or guarding
• Pushing staff away
• Moaning
• Becoming quiet or withdrawn

 Through Visual Cues

• Grimacing, frowning
•  Looking tearful, sad, not smiling
•  Other facial expressions that suggest pain

   Vital Sign Changes

• Sweating, pallor, ↑pulse and blood pressure
•  Shallow breathing, shortness of breath (often linked to acute pain)

History                   

It is essential to have knowledge of the resident’s disease states, all of which may relate to their pain

Diagnosis

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:

• about discomfort/ache/sore rather than pain
• if discomfort prevents them from going off to sleep
• if they wake with pain or discomfort
• if discomfort prevents normal activities of daily living
• if they are ever ‘completely comfortable’

Location

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.

Radiation

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

‘Quality’ refers to the words the person uses to describe their pain:

• Somatic pain tends to be described as ‘aching or sharp’ or ‘throbbing’
• Visceral pain may be described as ‘throbbing or deep’
• Organ capsule pain may be described as ‘sharp’
• Obstruction of hollow organs tends to be described as ‘gnawing’, ‘cramping’, or ‘colicky’.
• Neuropathic pain may be described as ‘burning’, ‘stinging’, ‘shooting’, ‘stabbing’, ‘pins and needles’ and radiating’

Pain quality also gives insights into how the person is reacting to their pain – ‘unbearable’, ‘intolerable’ or ‘annoying’ or ‘uncomfortable’.

Severity

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.

Timing

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.

Physical examination

• Do not neglect physical examination
• Physical examination is also likely to highlight incident pain or altered sensation which is important for diagnosis and treatment

The physical examination should usually include:

• Observation of movement and of the person’s ability to perform activities of daily living
• Observation for pain behaviour and nonverbal clues (particularly if there is some impaired communication)
• Palpitation for tenderness
• Neurological examination including nerve stretch tests, and assessment of sensation (pinprick, light touch, and temperature)

Document pain assessment in the medical record; it can influence decision-making both at the time of the assessment and in the future

• Screening:

As pain is a common symptom, people who are identified as needing palliative care should be assessed for the presence of pain

• Initial Assessment:

The components of pain assessment as above should be documented

• Ongoing Assessment:

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.

https://www.albertahealthservices.ca/assets/info/peolc/if-peolc-palliative-care-tips-issue32.pdf

Non- Medication Treatment options include:

Adjust the environment

• noise, light, temperature
• favourite music

Apply physical comforts

• cold packs / heat packs
•  massage / TENS machine
•   repositioning
•   diversional activities
•   reassurance

Medication treatment of pain in advanced dementia

START LOW >>>>>> GO SLOW                      

• Simple analgesia – e.g. Paracetamol
• Weak opioids – e.g. Norspan patch
• Strong opioids – e.g. Morphine

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

https://geriatricpain.org/sites/geriatricpain.org/files/wysiwyg_uploads/painad_tool_with_sm_logo_3.pdf

Abbey Pain Scale

Caution when using pain assessment tools

• Observation tools are more likely to identify less pain and the person will receive less analgesia than a person able to report his/her own pain
• Tools are a lot less effective than physical assessment, and are best used before and after pain interventions to evaluate the effectiveness of the intervention

Principles of Pain Management

It is important to discuss the person’s expectations and to set both short and long-term treatment goals:

• Complete relief of pain may not be a realistic goal, but pain can usually be minimized by using regular and breakthrough dosing whenever appropriate
• Relief of pain may need to be balanced against the person’s desire to stay alert
• Goals associated with mobility or social activity may need to be set more realistically
• Negotiating with the person, family, and carers and agreeing acceptable goals help in planning and implementing effective pain relief. Issues that often require discussion include:
• Reluctance to take opioids and concerns about addiction and tolerance
• Avoiding taking too much medication
• Cultural and religious attitudes and beliefs about pain

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

• Music therapy
• Massage therapy
• Pet therapy
• Acupuncture
• Reflexology

The treatment plan should address the ways that pain can be reduced

• Reduce the noxious stimuli by:
  • anticancer therapy to a painful primary or metastatic site                                    (e.g. RXT to a bone lesion)
  • reducing local inflammation by physical or pharmacological means
  • minimizing activities that cause pain (e.g. with help of OT or physio)

• Improve the person’s perception of and psychological ability to cope with and manage the pain by:
  • showing concern and care
  • careful explanation or treatment modalities
  • addressing and treating anxiety or depression

• Reduce the transmission of pain impulses with analgesics, including using titrating opioids by increasing dose and potency as necessary
• Consider appropriate co-analgesic drugs early in the management of neuropathic pain

Questions that can help to clarify a plan of action

• What is the nature of the pain(s) that the person is experiencing?
• What non-drug measures might help relieve the pain?
• What drug(s) are most likely to control this person’s pain?
• Are there any other practical issues that might influence the choice of drugs?
• Can you introduce the drugs one at a time or should they be introduced simultaneously?
• What routes of delivery are appropriate and possible for this person?
• What actions will you have to take to ensure that the drugs are obtained and administered to the person in the appropriate manner?
• What information and education should you give to the person in care, their family, care team members and other supports?
• What alternatives have you considered if your first plan is not successful?

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:

• Lack of training for the care team
• Fears from people in our care, their families, and health professionals around addictions/accidental overdoses/respiratory distress
• Poor pain assessments
• Lack of accountability from the health system

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.

• There is a limit to the dose of morphine I can use.

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.

•  If I use it now, it will be ineffective when I really need it.

There is no ceiling dose when using morphine. If the pain is severe enough to use morphine, it should be used.

• I will become addicted.

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.

• Morphine is only used when death is imminent.

If a person has moderate to severe pain, a strong opioid such as morphine would be considered appropriate.

• People may require morphine for their pain relief many months before they begin to deteriorate or are close to death.

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.

• Mild pain is usually controlled by paracetamol and/or non-steroidal anti-inflammatories (NSAIDS)
• Opioids may be required for severe pain at any stage of an illness. The combination of paracetamol with an opioid is often more effective than an opioid alone and can reduce the dose of opioid required. Other drugs may also be indicated at any stage                 (e.g. NSAIDS) for bone pain, tricyclic antidepressant drugs or antiepileptic drugs for neuropathic pain).
• While neuropathic pain commonly responds only partially to opioids, these are still the most effective analgesics for this pain and opioids should be used in the first instance either by themselves or in conjunction with co-analgesics. The early use of co-analgesics may improve response and allow a lower dose of opioid.
• Pain due to increased tissue pressure in a confined volume (e.g. cerebral metastases) may respond to corticosteroids.

• Spasm of smooth muscle or skeletal muscle may respond better to drugs that relax muscle. For smooth muscle, use hyoscine (hydro bromide or butyl bromide). For skeletal muscle spasm use benzodiazepines or baclofen.
• If oral opioids and co-analgesics are not effective or not an option, delivery by other routes may be necessary.

Evaluation of pain relief

• Assess and document 30 – 45 minutes after any pain relief measures are introduced
• Assess until pain is stable (48 hours after controlled).
• After a new type of pain
• After new analgesia or increase in dose started
• If person returns from hospital

Pain reporting to a physician/GP

Reporting should include:

•  Tool used to assess pain baseline
•  Pain relief data:
  •  Response to non-pharmacological methods
  •  Response to ordered medication
  •  Response to breakthrough PRN Medication

Why is Advocacy with Physicians/GPs important for Pain management?

To ensure:

• comfort is maintained
•  pain symptoms are treated in timely fashion with a management plan in place before symptoms occur
•  medication is on hand when needed
•  The route for medication is appropriate for the person

SPECIFIC DRUGS USED TO MANAGE PAIN

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

• sedation,
• dizziness
• nausea and vomiting
• constipation
• respiratory depression

Less common side effects may include:

• delayed gastric emptying
• hyperalgesia
•  immunologic and hormonal dysfunction
•  muscle rigidity and myoclonus

The Doctrine of Double Effect (DDE) and End of life Decisions

History

The DDE is a moral principle taken from the teachings of the 13^th 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.