02 PAIN ASSESSMENT
Pain is a universal human experience and the most common reason people
seek medical care. Pain tells us something is wrong in the structure or
function of our body and that we need to do something about it. Because pain is
such a strong motivator for action, it is considered one of the body’s most
important protective mechanisms.
Definitions of Pain
The International Association for the Study of Pain defines pain as “an
unpleasant sensory and emotional experience associated with actual or potential
tissue damage or described in terms of such damage” (2012). Pain, however, is
much more than a physical sensation caused by a single entity. It is subjective
and highly individual, a complex mechanism with physical, emotional, and cognitive
components.
Pain cannot be objectively measured in the same way as, for example, the
chemical content of urine or the oxygen content level of blood. Only the person
who is suffering knows how the experience feels. For these reasons, McCaffery
defined pain as “whatever the experiencing person says it is and whenever he
says it does” (1979). The American Pain Society goes further by stating that it
is not the responsibility of clients to prove they are in pain; it is the nurse’s
responsibility to accept the client’s report of pain (2009).
Pain alters the quality of life more than any other health-related
problem. It interferes with sleep, mobility, nutrition, thought, sexual
activity, emotional well-being, creativity, and self-actualization.
Surprisingly, even though pain is such an important obstacle to comfort, it is
one of the least understood, most undertreated, and oft-discounted problems of
healthcare providers and their clients. For this reason, some nurses and
therapists add “comfort” to Maslow’s hierarchy of basic human needs (1968). The
American Pain Society goes further, declaring the relief of pain a “basic human
right” (2009).
Traditionally, pain has been considered merely a physical symptom of
illness or injury, a simple stimulus-response mechanism. Though the historic
role of nurses has been to relieve pain and suffering, there has been little
understanding of the complexity of pain and only limited ways to manage it.
Recent research shows pain to be a distinct disorder, with physical, emotional,
and cognitive components. This view of pain has broadened our understanding of
pain and given us new ways to understand its characteristics.
PAIN-RELATED TERMINOLOGY
Algesia: Sensitivity to pain.
Breakthrough pain: Transitory increase in pain to a
level greater than the client’s well-controlled baseline level.
Hyperalgesia: Excessive sensitivity to pain.
Idiopathic pain: Pain for which there is no
identifiable psychological or physical cause.
Intractable pain: Pain that is not relieved by ordinary
medical, surgical, and caregiving measures (Mosby’s Dictionary, 2012).
Pain syndrome: A group of symptoms of which pain is
the critical element, such as headaches and post-herpetic neuralgia.
Pain threshold: Amount of pain required before
individuals feel the pain. The lower the threshold, the less pain they can
endure; the higher the threshold, the more pain they can endure.
Pain tolerance: Maximum amount and duration of pain a
person can endure. Tolerance varies widely among people and is influenced by
emotions and cultural background.
Phantom limb pain syndrome: Pain that occurs in the place of a
missing limb after it is removed or as a result of severe damage to the
affected nerve plexus due to perceptual disruption in the brain (Mosby’s
Dictionary, 2012).
Psychogenic pain: Chronic pain with no identified
organic explanation.
Radiating pain: Pain that begins at one place and
extends out into nearby tissues.
Referred pain: Pain that is felt at a different
location than where tissue was damaged. This phenomenon occurs because pain
fibers in the damaged area synapse near fibers from other areas of the body;
for example, a myocardial infarction may create referred pain in the left
shoulder.
Types of Pain
Pain is classified as acute and chronic. Acute pain has an identifiable cause and occurs
soon after an injury to tissues in the body, such as bone, skin, or muscle.
Acute pain is protective in that it motivates a person to take action
immediately. Its onset may be sudden or slow, and its intensity may vary from mild
to severe. Acute pain is temporary and subsides as healing takes place. Severe
acute pain activates the sympathetic nervous system, causing diaphoresis,
increased respiratory and pulse rates, and elevated blood pressure.
Chronic pain lasts beyond an expected healing
phase, is non-protective in that it serves no function, and may not have an
identifiable cause (Patterson, 2007). When pain goes on for more than six
months, it moves from being a “symptom” to a “condition.” Chronic pain afflicts
more than 1 in 5 Americans and is one of the most pervasive and thorny medical
conditions in the United States. Such pain is described as nonmalignant
(noncancerous), malignant (cancerous), and intractable.
·
Nonmalignant, noncancerous chronic
pain typically accompanies such conditions as osteoarthritis and peripheral
neuropathy. The lack of purpose and uncertainty of duration of such pain may
lead to depression, fatigue, insomnia, anorexia, apathy, learned helplessness,
and other psychosocial consequences. If it is severe, chronic pain—like
prolonged stress—activates the parasympathetic nervous system, resulting in
muscle tension, decreased heart rate and blood pressure, and failure of body
defenses.
·
Malignant, cancerous chronic
pain may be due to tumor progression, invasive procedures, infection,
toxicities of treatment, and physical limitations. Such pain may be felt at the
tumor site or some distance from it. Since clients with cancer may experience
both chronic and acute pain, healthcare providers need to investigate
immediately any new pain in these clients.
·
Intractable chronic pain is
pain from any cause that is resistant to medical, surgical, and nursing
measures. Persistent and ongoing, intractable chronic pain may be psychogenic
in nature (Mosby’s Dictionary, 2012).
·
Sources of Pain
The sources (causes) of pain are divided into three main categories:
nociceptor, non-nociceptor, and psychogenic.
Nociceptor pain results when tissue damage produces a
pain-producing stimulus that sends an electrical impulse across a pain receptor
(nociceptor) by way of a nerve fiber to the central nervous system. Nociceptor
pain is further divided into visceral and somatic pain.
·
Visceral pain results from stimulation
of nociceptors in the abdominal cavity and thorax.
·
Somatic pain is divided into deep
somatic and cutaneous pain. Deep somatic pain arises from bones, tendons,
nerves, and blood vessels. Cutaneous pain originates in the skin or
subcutaneous tissue. Some body tissues, such as the brain and lung, have no nociceptors,
and some tissues have many.
Non-nociceptor (neuropathic) pain is caused by direct injury to
structures of the nervous system.
Psychogenic pain is pain for which there is little or
no physical evidence of organic disease or identified injury to tissues in the
body. Lack of evidence, however, does not mean clients are malingering or that
they are not suffering.
|
PHYSIOLOGIC SOURCES OF PAIN |
|
|
Source: Adapted with permission from Ignatavicius et
al., 1999. |
|
|
Nociceptor:
Visceral |
|
|
Physiologic
structures |
Organs
and linings of body cavities |
|
Mechanism |
Activation
of nociceptors |
|
Characteristics |
Poorly
localized, diffuse, deep, cramping, or splitting |
|
Sources
of acute pain |
Chest
tubes, abdominal drains, bladder and intestinal distention |
|
Sources
of chronic pain syndromes |
Pancreatitis,
liver metastases, colitis |
|
Nociceptor:
Somatic |
|
|
Physiologic
structures |
Cutaneous:
skin and sub-cutaneous tissues |
|
Mechanism |
Activation
of nociceptors |
|
Characteristics |
Well-localized,
constant, achy |
|
Sources
of acute pain |
Incisional
pain, insertion sites of tubes and drains, wound complications, orthopedic
procedures, skeletal muscle spasms |
|
Sources
of chronic pain syndromes |
Bony
metastases, osteoarthritis, rheumatoid arthritis, low-back pain, peripheral
vascular disease |
|
Non-nociceptor
(neuropathic) |
|
|
Physiologic
structures |
Nerve
fibers, spinal cord, central nervous system |
|
Mechanism |
Non-nociceptive
injury to nervous system structures |
|
Characteristics |
Generalized
along distribution of damaged nervous structures |
|
Sources
of acute pain |
Poorly
localized: shooting, burning, fiery, shock-like, sharp, painful numbness |
|
Sources
of chronic pain syndromes |
Nervous
tissue injury due to diabetes, HIV, chemotherapy, neuropathies,
post-therapeutic neuralgia, trauma, surgery |
|
Psychogenic |
|
|
Physiologic
structures |
No
organic structures |
|
Mechanism |
Emotional |
|
Characteristics |
Variable,
often numerous |
|
Sources
of acute pain |
Nonorganic |
|
Sources
of chronic pain syndromes |
Nonorganic
psychological factors |
Physiology of Pain
Though a person is not consciously aware of the process, the experience
of pain involves a complex sequence of biochemical and electrical events or
processes beginning with tissue damage and followed by transduction,
transmission, perception, and modulation.
TISSUE
DAMAGE
When tissue is damaged, there is an immediate release of inflammatory
chemicals called “excitatory neurotransmitters,” such as histamine and
bradykinin, a powerful vasodilator. Increased blood in the area causes the
injured area to swell, redden, and become tender. The bradykinin stimulates the
release of prostaglandins and substance P, a potent neurotransmitter that
enhances the movement of impulses across nerve synapses.
TRANSDUCTION
AND TRANSMISSION
Transduction occurs as the energy of the stimulus is converted to
electrical energy. Transmission of the stimulus takes place when this energy
crosses into a nociceptor at the end of an afferent nerve fiber.
Two types of peripheral nerve fibers conduct painful stimuli: the fast,
myelinated A-delta fibers and the very small, slow, unmyelinated C-fibers.
A-fibers send sharp, distinct sensations that localize the source of the pain
and detect its intensity. C-fibers relay impulses that are poorly localized,
burning, and persistent. For example, after burning a finger, a person
initially feels a sharp localized pain as a result of A-fiber transmission.
Within a few seconds the pain becomes more diffuse and widespread as a result
of C-fiber transmission.
Pain stimuli travel quickly to the substantia gelatinosa in the dorsal
horn of the spinal cord, where the “gating” mechanism (discussed below) occurs.
Pain impulses then cross over to the opposite side of the spinal cord and
ascend to the higher centers in the brain via the spinothalamic tracts and on
to the thalamus and higher centers of the brain, including the reticular
formation, limbic system, and somatosensory cortex. (See figure.)
Neurologic transmission of pain stimuli. (Source:
Jason M. Alexander. © 2005, Wild Iris Medical Education.)
PERCEPTION
When pain stimuli reach the cerebral cortex, the brain interprets the
signal; processes information from experiences, knowledge, and cultural
associations; and perceives pain. Thus, perception is the awareness of pain.
The somatosensory cortex identifies the location and intensity of pain, and the
associated cortex determines how an individual interprets its meaning.
MODULATION
Once the brain perceives the pain, the body releases neuromodulators,
such as endogenous opioids (endorphins and enkephalins), serotonin,
norepinephrine, and gamma aminobutyric acid. These chemicals hinder the
transmission of pain and help produce an analgesic, pain-relieving effect. This inhibition
of the pain impulse is called “modulation.” The descending paths of the
efferent fibers extend from the cortex down to the spinal cord and may
influence pain impulses at the level of the spinal cord.
GATE-CONTROL
THEORY
Melzack and Wall proposed the gate-control theory to explain the
relationship between pain and the emotions (1996). According to the theory, a
gating mechanism occurs when a pain impulse travels to the substantia
gelatinosa in the dorsal horn of the spinal cord. There, trigger (T) cells
influence the transmission of pain impulses. When their activity is inhibited,
the gate closes and impulses are less likely to be transmitted to the brain.
This mechanism is controlled by descending nerve fibers from the thalamus and
cerebral cortex, areas of the brain that regulate thought and emotions. The
gate-control theory helps explain how thoughts and emotions modify the
perception of pain and why interventions such as imagery and distraction help
relieve it.
Factors That Influence Pain
The perception of pain is influenced by physiologic, psychological, and
cultural factors, all of which nurses need to consider.
PHYSIOLOGIC
FACTORS
Age
Age affects the way people respond to pain. It influences both the
development and decline of the nervous system. Aging affects the whole body,
causing many painful degenerative disorders (such as osteoarthritis), secondary
injuries (such as skin abrasions and fractures), and a host of common surgical
procedures (such as cataract and hip replacement). Age also affects the way
families and nurses respond to complaints of pain.
The following table gives a brief overview of the perception of pain
relative to age.
|
AGE
AND THE PERCEPTION OF PAIN |
|
|
Age |
Pain
Perception |
|
Pre-term
infants |
Have
anatomical and functional ability to process pain by mid to late gestation;
seem to have greater sensitivity to pain than term infants or children |
|
Newborn
infants |
Response
to pain is inborn and does not require prior learning; respond to pain with
behaviors such as crying, grimacing, moving the body |
|
Infants,
1 month |
Can
metabolize analgesics and anesthesia effectively; can recognize nurse as
comforter |
|
Toddlers/preschoolers |
Can
describe pain, its location and intensity; respond to pain by crying, anger,
sadness; may consider pain a punishment; may hold someone accountable for
pain and remember experiences in a certain location, such as a clinic |
|
School-age
children |
May
try to be brave when facing a painful procedure, may regress to an earlier
stage of development, seek understanding of reasons for pain |
|
Adolescents |
May
be slow to acknowledge pain, may consider showing signs of pain a weakness,
may regress to earlier stages of development with persistent pain |
|
Adults |
Fear
of pain may prevent some from seeking care, many believe admission of pain is
a weakness and inappropriate for age or sex, some consider pain a punishment
for moral failure |
|
Older
adults |
May
have decreased sensations or perceptions of pain; may consider pain an
inevitable part of aging; chronic pain may produce anorexia, lethargy,
depression; may not report pain due to fear of expense, possible treatment,
and dependency; often describe pain in nonmedical terms such as “hurt” or
“ache”; may fear addiction to analgesics; may not want to bother nurses or be
a “bad patient” |
Fatigue
Fatigue decreases coping abilities and heightens the perception of pain.
When people are exhausted from physical activity, stress, and lack of sleep,
their perception of pain may be heightened and their coping skills diminished.
Thus, sleep and rest from physical, emotional, and social demands are important
measures to manage pain.
Genetic Makeup
Recent research suggests that sensitivity to and tolerance for pain may
be a genetically linked trait (Fincke, 2010). This finding does not negate the
need to manage pain adequately, regardless of inherited traits.
Memory
Memory of painful experiences, especially experiences that occurred as a
very young child, may increase sensitivity and decrease tolerance to pain. For
example, even young children remember the pain of an immunization injection at
the doctor’s office and henceforth may be afraid to visit the office again.
Stress Response
Research has shown that “severe, unrelieved pain can cause an
overwhelming stress response in both pre-term and full-term infants which can
lead to serious complications and even death” (Pasero, 2004).
Healing
Research suggests that unrelieved acute pain slows postoperative wound
healing (McGuire et al., 2006). This evidence is not surprising, given our
increasing knowledge of the effect of stress on the human body.
Neurologic Function
Any factor that interrupts or interferes with normal pain transmission
affects the awareness and response of clients to pain and places them at risk
for injury. Analgesics, sedatives, and alcohol depress the functioning of the
central nervous system. Likewise, rare congenital conditions exist in which an
individual cannot feel physical pain.
Some diseases, such as leprosy, damage peripheral nerves, decrease
sensitivity to touch and pain, and render sufferers more vulnerable to injury.
People with diabetes mellitus can have diabetic neuropathy, which may impair
their ability to feel pain. They may injure themselves and be totally unaware
of the injury, especially if it is in an area of the body they cannot see, such
as the bottom of the feet, sacral area, or back of the head. The same may apply
to people with traumatic nerve injuries, such as those with spinal cord damage
or postsurgical nerve impairment.
PSYCHOLOGICAL
FACTORS
Fear and Anxiety
The relationship between pain and fear is convoluted and complex. Fear
tends to increase the perception of pain, and pain increases feelings of fear
and anxiety. This connection occurs in the brain because painful stimuli
activate portions of the limbic system believed to control emotional reactions.
People who are seriously injured or critically ill often experience both pain
and heightened levels of anxiety due to their feelings of helplessness and lack
of control. Healthcare providers need to address both pain and anxiety and use
appropriate measures to relieve suffering.
Coping
People manage pain and other stressors of life in different ways. Some
see themselves as self-sufficient, internally controlled, and independent. As a
result, they may deny pain or be slow to admit they are suffering. Others see
themselves as insufficient, externally controlled, and dependent on others to
treat their pain. Self-sufficient, internally controlled people may do better
with patient-controlled analgesia (PCA), whereas dependent, externally
controlled individuals may prefer nurse-administered analgesia. No matter what
the coping style, it is the responsibility of providers to relieve pain.
CULTURAL
FACTORS
Cultural beliefs and values affect the way people respond to pain. As
children, people learn what is and is not acceptable behavior when they
experience pain. In some cultures, any expression of pain is considered
cowardly and shameful. In others, noisy demonstrations of pain are expected and
acceptable. The meaning of pain itself may be markedly different in different
cultures. Some ethnic groups see pain as a punishment for wrongdoing. Others
see pain as a test of faith. Still others view pain as a challenge to be
overcome. Recent immigrants to the United States are more likely to view pain
from their cultural roots. Regardless of an individual’s language, religion, or
situation, nurses are obliged to respect every person and strive to alleviate
pain and suffering.
PAIN AND THE CAREGIVING PROCESS
The caregiving process includes assessment, diagnosis, planning,
intervention, and evaluation. To manage pain responsibly, healthcare providers
use each step of the process.
Basic to every strategy for managing pain is showing respect for the
validity of a client’s experience of pain. To communicate respect, nurses:
· Acknowledge
pain and take action to manage it
· Give
accurate information to reduce anxiety and facilitate relief of pain
· Reduce
environmental stressors that add to the experience of pain
· Encourage
disclosure of feelings and fears
· Provide
privacy and maintain confidentiality
Assessing Pain
Pain is a red flag. It tells us there is a problem somewhere in the body
that is crying out for attention. In fact, pain is such an important indicator
of health, its assessment has been called the “fifth vital sign,” joining
temperature, pulse, respiration, and blood pressure. Even so, until we know
more about a specific pain, we cannot address it. To do this, nurses must
gather information from as many sources as possible, especially the primary
source, the person in pain. This investigation includes obtaining a
comprehensive pain history, making observations of behaviors, performing an
appropriate physical examination, and consulting with other healthcare
professionals.
PAIN
HISTORY
A pain history is obtained from written documents and from interviews
with the person in pain, family members, and other nurses. It asks specific
questions about the location, intensity, quality, and history of the pain, as
shown in the following box. In some facilities these questions are printed on
an assessment form, with space for answers to be recorded beside each question.
A variety of pain scales have been developed for use with adults as well
as with children. (See the “Pain Assessment Scales” table later in this course
for a list of such scales. See also “Partners Against Pain” in the resources
section at the end of this course.)
OBTAINING A PAIN HISTORY
Following are questions a healthcare provider can ask as part of taking a
pain history:
Location: Where is your pain? Ask client to
point to the area of pain.
Intensity: On a scale of 0 to 10, with 0
representing no pain, how much pain would you say you are experiencing? If your
pain were a temperature, how hot would it be (warm, hot, blistering)? If your
pain were a sound, how loud would it be (silent, quiet, strident, booming)?
Quality: In your own words, tell me what your
pain feels like (worms under the skin, shooting, needle pricking, tingling,
stabbing, etc.).
Chronology/pattern: When did the pain start? Does your
pain come and go? How often? How long does it last?
Precipitating factors: What triggers the pain, or what makes
it worse?
Alleviating factors: What measures have you found that
lessen or relieve the pain? What pain medications do you use? How much and how
often?
Associated symptoms: Do you have other symptoms before,
during, or after your pain begins (dizziness, blurred vision, nausea, shortness
of breath)?
BEHAVIORAL
OBSERVATIONS
Most people who suffer pain usually show it either by verbal complaint or
nonverbal behaviors. The following table lists some typical behaviors nurses
may observe when they assess people in pain.
|
NONVERBAL BEHAVIORS INDICATING PAIN |
|
|
Facial
Expressions |
·
Clenched teeth ·
Wrinkled forehead ·
Biting lips ·
Scowling ·
Closing eyes tightly ·
Widely opened eyes or mouth |
|
Vocalizations |
·
Crying ·
Moaning ·
Gasping ·
Groaning ·
Grunting |
|
Body
Movements |
·
Restlessness ·
Protective body movement ·
Muscle tension ·
Immobility ·
Pacing ·
Rhythmic movement |
|
Social
Interaction |
·
Silence ·
Withdrawal ·
Reduced attention span ·
Focus on pain relief measures |
PHYSICAL
EXAMINATION
A physical examination is most fruitful when the pain history interview
and behavioral observations are conducted at the same time. Because pain may be
referred from some other area of the body, the examination should include a
full scan from head to toe. A physical examination includes inspection, auscultation,
palpation, and percussion.
Inspection includes general and specific
observations, beginning when the provider first encounters the patient and
notes any obvious sign of pain, such as limping or any unusual posture of the
body. A specific inspection involves an examination of the place where there is
pain using adequate light and appropriate instruments.
Auscultation involves listening to sounds produced
by internal body structures, such as the heart, lungs, and bowels. The provider
must be able to block out noises in the environment and sounds emanating from
other organs. To help isolate sounds, one can close the eyes and concentrate on
one auscultation sound at a time.
Palpation involves using one’s hands to gather
information about skin temperature, bodily pulsations, vibrations, internal
masses, and tenderness or rigidity of organs and structures. When assessing the
abdomen, perform palpation after auscultation because palpation may increase
intestinal activity, causing misleading findings such as increased bowel sounds
(Mosby, 2009).
Percussion involves tapping the patient’s skin
with the one’s fingers or hands to elicit sound, evaluate reflexes, uncover
abnormal masses, and detect pain. Tapping produces an audible vibration that
helps to reveal the location, size, and density of underlying structures.
Sounds are classified as dull, flat, tympanic, resonant, or hyper-resonant,
depending on what part of the body one is tapping.
Diagnosing Pain
An accurate diagnosis depends on an appropriate assessment that focuses
on the exact nature of the pain. The more specific the diagnosis, the more
effective interventions can be. The North American Nursing Diagnosis
Association (NANDA) has identified two primary diagnoses for pain: acute and
chronic.
A complete caregiving diagnosis, however, goes further. After identifying
whether the pain is acute or chronic, it adds “related to” to the medical
diagnosis. For example, “chronic pain related to osteoarthritis of the left
hip.” Then, it adds “manifested by” and lists the various symptoms experienced
by the client or signs confirmed by objective data. Thus, a complete diagnosis
might be “chronic pain, related to osteoarthritis, manifested by stabbing pain
in the left hip with weight-bearing.”
The advantage of clear, specific information is that it leads to more
effective interventions. In this case, an appropriate intervention might be an
assistive devise such as a cane or walker and referral to a physical therapist
or orthopedic surgeon for further evaluation.
Planning and Goal Setting
During the planning stage, healthcare providers synthesize information
from many sources and, together with the clinician, plan appropriate treatment.
The goal of these interventions is to relieve pain and facilitate the highest possible
level of functioning. Practically speaking, this means identifying what
activity the pain is preventing and the best way to achieve a return of
function. For instance, in the case study below, Mrs. Low’s hip pain is
obstructing her mobility.
Planning interventions means working in partnership with clients and
other nurses to provide specific measures to manage the pain. These
interventions may be independent or collaborative. Independent actions fall
within the scope of the nurse’s specialty. Collaborative actions involve
cooperative interventions with other members of the healthcare team, such as
nurses, physical therapists, occupational therapists, pharmacists, and
physicians.
Goal setting involves the identification of attainable objectives and reasonable
priorities. Because every person is different, nurses discuss various
alternatives with the client and together set priorities. For example, after
consulting an orthopedic surgeon, Mrs. Low may have decided to delay hip
replacement surgery and maintain mobility as long as possible with the aid of a
cane and analgesic medications.
Interventions
Effective pain management is carried out by a team of professionals,
including physicians, nurses, physical therapists, occupational therapists, and
counselors. During surgery, anesthesiologists administer intravenous fluids,
anesthetics, and analgesic agents. Physicians prescribe medications and oversee
care. Nurses administer analgesics, provide comfort measures, and educate
patients. Physical and occupational therapists teach and assist patients to
facilitate activities of daily living and reduce pain. Although their practices
overlap, each professional evaluates the effectiveness of therapeutic measures
and communicates with others on the team. Such an interdisciplinary approach
helps alleviate pain and promote healing, using both pharmacologic and
nonpharmacologic interventions.
CASE
Mrs. Low was finding it increasingly difficult to walk because of the
pain in her right hip. Finally, she went to her primary care physician, who
ordered x-rays. A radiologist studied the x-rays and wrote a report. When her
physician read the report, he referred Mrs. Low to an orthopedic surgeon, who
recommended hip replacement surgery. She agreed.
Throughout her surgical treatment and healing, the surgeon oversaw Mrs.
Low’s care, managing her pain with analgesics and comfort measures. Nurses
cared for her during and after the surgery, and physical therapists helped her
walk a few steps the day after surgery and ambulate safely. When she went home,
visiting nurses oversaw her care, and Mrs. Low continued therapy until she was
walking without pain.
Measuring pain intensity
When measuring intensity, a numerical scale of ‘0–10’
(in which ‘0’ indicates ‘no pain’ and ‘10’ indicates ‘the worst possible pain’)
is clinically useful. If the person is unable to use a numerical scale, verbal
scales can also be used with descriptors such as ‘no pain’, ‘slight pain’,
‘moderate pain’, ‘severe pain’, or ‘excruciating pain’ (AHCPR 1994). Rating scales
allow health-care professionals to assess and communicate pain intensity, and
the response to pain interventions, on an ongoing basis.
Assessing the quality of pain
The quality of the pain is the person’s description of
how the pain feels. The quality of pain described can help to differentiate
somatic, visceral, and neuropathic pain.
- Somatic pain is bodily pain in tissues other than
viscera and neural tissues. Examples include bone metastases and soft-tissue
inflammation. Somatic pain is usually well localised, and is usually described
as ‘constant’, ‘aching’, or ‘gnawing’.
- Visceral pain results from pathology in thoracic or
abdominal organs. It is often poorly localised and can be experienced (or
‘referred’) elsewhere. Abdominal visceral pain often ‘comes in waves’, and
might be described as ‘cramping’.
- Neuropathic pain is pain emanating from the central
and peripheral nervous systems. The pain might be described as ‘numb’,
‘radiating’, ‘burning’, or ‘shock-like’.
Different types of pain respond to different
medications. For example, inflammatory somatic pain is more likely to respond
to nonsteroidal antiinflammatory agents (NSAIDS), whereas centrally mediated
neuropathic pain is more likely to respond to anticonvulsants.
Temporal aspects of pain
The temporal assessment involves a description of how
the pain feels over time. This includes a description of the onset, duration,
and frequency of the pain. These should be considered in association with an
assessment of factors that exacerbate or relieve the pain. Nurses should pay
particular attention to the following temporal factors (Portenoy & Hagen
1989).
- Incident pain: This is pain that occurs with movement
or activity. Incident pain is usually predictable and can be prevented with
doses of analgesics administered at an appropriate interval before the painful
activity.
- Breakthrough pain: This is an unpredictable
exacerbation of pain that occurs against a background of constant pain that is
otherwise controlled.
- End-of-dose pain: This is pain that occurs just before
the next dose of analgesic is due. This indicates a need to increase the dose
or to decrease the interval of administration.
Ongoing and consistent reassessment of pain is often a
challenge. In 1995, the American Pain Society (APS) conducted a consensus study
to develop quality guidelines on the assessment and management of pain (APSQCC
1995). One recommendation was that institutions make the assessment of pain
highly visible so that it undergoes regular and frequent review. The adoption
of pain as the ‘5th vital sign’ (along with temperature, pulse, respiration,
and blood pressure) is a useful strategy. At every consultation or visit, the
clinician is thus encouraged to assess pain along with other vital signs.
Studies also indicate that formal continuous
quality-improvement programs help to ensure that pain is being measured and
managed on an ongoing basis (Comley & DeMeyer 2001).
Behavioural assessment of pain
In addition to a physiological assessment, nurses
should assess behavioural factors that affect the pain. This might be quite
specific—such as limping or splinting (protection of the injured part). More
generally, behavioural assessment of pain involves an awareness of whether pain
is interfering with a person’s social function. For example, the person might
be unable to shop for groceries because walking for long periods of time
exacerbates the pain.
Behavioural assessment provides information on how the
person is functioning on a day-to-day basis and might lead to a modification in
the plan of care. Adjusting the medication schedule and educating the person
about the control of incident pain might assist him or her in optimal comfort
and functioning.
Psychosocial and spiritual assessment of pain
Psychosocial
and spiritual dimensions also play an important role in pain at the end of
life. Psychosocial assessment includes the effect that pain has on mood, sleep,
coping, goals, and finances (Elliott 1997). Spiritual assessment includes the
effect of suffering on the person’s understanding of meaning and purpose in
life. Nurses can give people ‘permission’ to verbalise their personal feelings
about pain and suffering (Spross & Wolff 1995).
Failure to
assess pain is a critical factor leading to undertreatment. Assessment involves
both the clinician and the patient. Assessment should occur at the following
times:
·
At
regular intervals after initiation of treatment.
·
At
each new report of pain.
·
At
a suitable interval after pharmacologic or nonpharmacologic intervention (e.g.,
15–30 minutes after parenteral drug therapy and 1 hour after oral
administration).
Effective
pain management requires close monitoring of patient response to initiation of
treatment. In a review of 1,612 patients referred to an outpatient palliative
care center where patients with advanced cancer were seen by both a palliative
care nurse and a physician, more than half of patients with moderate to severe
pain did not respond to an initial palliative care consultation, with response
defined as a two-point or more reduction or a 30% or more reduction from
baseline. Also, one-third of patients with mild pain actually progressed to
moderate to severe pain by the time of their first follow-up visit. The authors
concluded that more frequent follow-up visits, calls, and interdisciplinary
clinics should be considered in an effort to optimize pain control. The study
also identified baseline pain intensity, fatigue, and Edmonton Symptom
Assessment System symptom burden as factors predicting response.
Identifying the etiology of pain is
important to its management. Clinicians treating patients with cancer should
recognize the common cancer pain syndromes (see lists below). Prompt diagnosis
and treatment of these syndromes can reduce morbidity associated with
unrelieved pain. Distinct cultural components may need to be incorporated into
a multidimensional assessment of pain. Reviews of cancer pain with a focus on
neuropathic pain describes pathophysiologies as well as available and
investigational pharmacotherapies.
Common Pain Syndromes: Pain
Associated with Tumor
Bone
marrow expansion
Vertebral
syndrome
Local
infiltration
Base
of skull involvement
Hepatic
capsule distension
Retroperitoneal
syndrome
Intestinal
obstruction
Ureteral
obstruction
·
Leptomeningeal
disease
·
Base
of skull metastases
Mononeuropathies
·
Brachial,
cervical, sacral
Cauda
equina syndrome
Osteoarthropathy
Gynecomastia
Sensorimotor
neuropathy
Common Pain Syndromes: Pain
Secondary to Treatment
Enteritis
Radiation
fibrosis
Osteoradionecrosis
Myelopathy
·
Brachial,
sacral
Pain
flare after radiopharmaceutical
Radiation-induced
cystitis
·
Aromatase
inhibitors
Avascular
necrosis
Chronic
abdominal pain
Mucositis
·
Platinum-based
products: Cisplatin, carboplatin, oxaliplatin
·
Taxanes:
Paclitaxel, docetaxel
·
Vinca
alkaloids: Vincristine, vinblastine
·
Epothilones:
Ixabepilone
·
Others:
Bortezomib, lenalidomide, thalidomide
Bone
pain flare
Arthralgia,
myalgia
Acute
postoperative or procedural pain
Phantom
limb pain/postamputation pain
Postnephrectomy
syndrome
Postmastectomy
syndrome
Postthoracotomy
syndrome
Post–radical
neck dissection
Pelvic
floor myalgia
Bone
pain, osteonecrosis
The
goal of the initial assessment of pain is to characterize the pathophysiology
of the pain and to determine the intensity of the pain and its impact on the
patient’s ability to function. For example, one study evaluated the association
between psychological distress and pain in 120 patients with advanced cancer.
Pain intensity and pain that interfered with walking ability, normal work, and
relations with other people, as measured by the Brief Pain Inventory (Greek
version), were found to be significant predictors of anxiety, as measured by
the Hospital Anxiety and Depression Scale on multivariate analysis. Using the
same tools, the authors also found pain that interfered with enjoyment of life
was a predictor of depression. Factors that may influence analgesic response
and result in persistent pain include changing nociception due to disease
progression, intractable side effects, tolerance, neuropathic pain, and opioid
metabolites. The following are essential to the initial assessment:
·
Detailed
medical and pain history.
·
Physical
examination.
·
Psychosocial
and spiritual assessment.
·
History
of substance abuse in patient and family.
·
Diagnostic
evaluation.
The experience of cancer pain is
complex and includes physical, psychosocial, and spiritual dimensions. There is
no universally accepted pain classification measure that assists with
predicting the complexity of pain management, particularly for cancer pain
patients, who may be more difficult to treat. Clinicians and researchers lack a
common language to discuss and compare outcomes of cancer pain assessment and
management. Oncologists use the tumor, nodes, metastases (TNM) system as a
universal language to describe a variety of cancers. The need for a similar
classification system for cancer pain resulted in the development of the
Edmonton Staging System. This system has been further refined in two reports
that have gathered construct validity evidence using an international panel of
content experts and a multicenter study to determine interrater reliability and
predictive value. The development of an internationally recognized
classification system for cancer pain could play a significant role in
improving the assessment of cancer pain, allow a more meaningful assessment of
clinical prognosis and treatment, and better enable researchers to compare
results with regard to cancer pain management.
The
mainstay of pain assessment is the patient self-report; however, family nurses
are often used as proxies for patient reports, especially in situations in
which communication barriers exist, such as cognitive impairment or language
difficulties. Family members who act as proxies typically, as a group, report
higher levels of pain than patient self-reports, but there is individual
variation. Differences in clinician assessment of pain intensity are also
significant. A retrospective review of 41 patient charts using pain ratings of
palliative care consultants as the gold standard found high agreement with
assessments performed by bedside nurses (registered nurses [RNs] and clinical
nurse assistants [CNAs]) when pain was not present or was mild but poor
agreement for moderate or severe pain (sensitivity: RNs, 45%; CNAs, 30%).
Pain
assessment tools may be unidimensional or multidimensional. Multiple assessment
tools exist. Among the more commonly used bedside tools are numeric rating
scales, verbal rating scales, visual analog scales, and picture scales. Pain
intensity at initial assessment has been demonstrated to be a significant
predictor of subsequent pain management complexity (i.e., the need for more
pharmacological and multidimensional approaches) and length of time to achieve
stable pain control. To enhance pain management across all settings, clinicians
should teach families to use pain assessment tools in their homes. The
clinician should help the patient to describe:
·
Listen
to the patient’s descriptive words about the quality of the pain; these provide
valuable clues to its etiology. Elicit the temporal features including onset,
duration, and diurnal variation. Ask about breakthrough pain (BP) or episodic
pain (EP) (a transitory increase in pain that occurs in addition to persistent
pain). Some patients may have EP without persistent pain. The prevalence of
BP-EP varies widely, depending on which definition is used and based on the
clinical scenario and cultural setting. An appropriately designed,
cross-sectional, multicenter study that evaluated BP-EP in patients with
chronic cancer-related pain was completed. The primary aim of the study was to assess
the prevalence and characteristics of BP-EP on the basis of clinical assessment
and through the use of a previously validated, culturally adapted tool, the
Questionnaire for Intense Episodic Pain (QUDEI-Italian), which utilizes a
patient interview technique. Physicians who participated in the study were
trained to define and recognize BP-EP. Patient evaluation and use of the
questionnaire were carried out by different sets of providers. There was an
estimated prevalence of 73% when a BP-EP diagnosis was made by physicians and
66% when the QUDEI was applied. When patients with baseline pain levels of 6 or
lower (based on a numerical rating scale from 0 to 10) were analyzed, the
physician prevalence decreased to 67%, versus 60% with tool utilization. The
authors concluded that because of the frequent occurrence of BP-EP, a more
widely accepted general definition of this phenomenon and specific validated
tools to assist in education and screening are needed.
·
Ask
the patient to indicate the exact location of the pain on his or her body, or
on a body diagram, and whether the pain radiates.
·
Changes
in pain pattern or the development of new pain should trigger diagnostic
reevaluation and modification of the treatment plan. Persistent pain indicates
the need to consider other etiologies (e.g., related to disease progression or
treatment) and alternative (perhaps more invasive) treatments.
·
Encourage
the patient to keep a log of pain-intensity scores to report during follow-up
visits or by telephone. Examples of simple self-report pain-intensity scales
include the simple, descriptive, numeric, and visual analog scales.
Aggravating and Relieving Factors
·
Ask
the patient to identify factors that cause the most pain and also what relieves
the pain.
·
Cognitive
appraisals of pain can be based on a range of psychological variables such as
perceived control, meaning attributed to pain experience, fear of death, and
hopelessness. All these variables appear to contribute to the experience of
cancer pain and suffering. A study of women with metastatic breast cancer found
that although the site of metastasis did not predict the intensity of pain
report, greater depression and the belief that pain represented the spread of
disease significantly predicted the degree of pain experienced. It was also
reported that patients who thought that their pain represented disease
progression reported more pain-related interference with function.
·
Note
behavior that suggests pain in patients who are cognitively impaired or who
have communication problems relating to education, language, ethnicity, or
culture. Cognitive impairment itself and the degree of cognitive impairment may
impact patient self-report of pain. Preliminary data suggest that mild degrees
of cognitive impairment are associated with increased intensity of pain-report
in older patients with cancer who are receiving hospice care. In contrast,
cognitively impaired nursing home residents are less likely to report pain. Use
appropriate (e.g., simpler or translated) pain assessment tools.
·
Document
the patient’s preferred pain assessment tool and the goals for pain control
(such as scores on a pain scale).
·
Encourage
use of the pain diary: The daily pain diary is a well-established tool in
symptom management research and in clinical practice. Benefits of using a pain
diary include heightened awareness of pain, guidance for pain management
behaviors, enhanced sense of control, and a tool for communication. It is
difficult to get good pain-diary compliance with adolescents who are
experiencing intense chronic pain.
A thorough
physical examination is required to determine the pathophysiology of pain.
Specific features of the neurologic examination such as altered sensation
(hypoesthesia, hyperesthesia, hyperpathia, allodynia) in a painful area are
suggestive of neuropathic pain. Physical findings of tumor growth and
metastasis are also important to identify.
Information obtained from the synthesis of history, physical
examination, and diagnostic evaluations is used to generate a pain diagnosis
with respect to etiology (cancer, its treatment, or other) and pathophysiology
(somatic, visceral, and/or neuropathic). This diagnosis, in conjunction with
contributing psychosocial and spiritual factors, is used to generate a
comprehensive pain treatment plan.
Assessment of the Outcomes of Pain Management
Pain-related
outcomes: Clinicians should document and be aware of outcomes of pain therapy.
It is helpful to think of pain-related outcomes as primarily measured in two
ways: decreased pain intensity and improvement in psychosocial functioning.
Using rating scales of pain intensity at its worst and on average and using
pain interference scales can help clinicians monitor outcomes. Measurement of
the percentage of pain relief is also useful, though measuring patient
satisfaction is less useful because of the low expectations patients sometimes
hold for pain control.
Drug-taking outcomes: Clinicians prescribing chronic opioids
should also monitor and document patients’ drug-taking behaviors. Outcomes
related to addiction in cancer patients are rare but nonetheless should be
periodically assessed; these assessments can be reassuring to patients.
Tolerance and dependence are not addiction related. Documentation of patients’
compliance with regard to changes in dosing and duration of prescriptions is
essential in all pain practice.
The clinical assessment of drug-taking behaviors in
medically ill patients with pain is complex. Aberrant drug-taking behavior from
cancer pain management is related to premorbid history of drug addiction and
the likelihood of other pain treatment. A pilot questionnaire was used to
characterize drug-related behaviors and attitudes in cancer and AIDS patients.
Despite limitations, this study highlights wide potential variation among
different palliative care populations in patterns of past and present aberrant
drug-taking behaviors and the need for a clinically useful screening approach.
The implications for psychosocial and pharmacological management of symptoms
such as pain, as well as any aberrant behavior, remain unclear.
Previous drug abuse is likely to lead to specific needs for
appropriate dosing during cancer pain therapy. A prospective open-label study
compared morphine dosage and effectiveness in AIDS patients with and without
previous substance abuse. Results demonstrated that both groups benefited, but
patients with a history of drug use required and tolerated substantially higher
morphine doses to achieve stable pain control. This study should increase
confidence in providing appropriate pain management to patients who have a
history of drug use.
Barriers
to pain relief
Pain
at the end of life is frequently undertreated. The barriers to adequate pain
treatment involve health-care professionals, patients, and the health-care
delivery system.
A large barrier to pain assessment
and management is lack of healthcare provider education.
In order to address pain needs, it
is important to understand the barriers that prevent excellent assessment and
management.
These barriers are prevalent with
Patients, families, healthcare providers, and the healthcare systems:
Barriers
to Effective Pain Management
Problems related to
health care professionals:
Ø Inadequate
knowledge of pain management.
Ø Poor
assessment of pain.
Ø Concern
about regulation of controlled substances.
Ø Fear
of patient addiction.
Ø Concern
about side effects of analgesics.
Ø Concern
about patients becoming tolerant to analgesics.
Problems related to
patients:
Ø Reluctance
to report pain.
Ø Concern
about distracting physicians from treatment of underlying disease.
Ø Fear
that pain means disease is worse.
Ø Lack
of knowledge about principles of basic pain management.
Ø Concern
about not being a “good” patient.
Ø Reluctance
to take pain medications.
Ø Fear
of addiction or of being thought of as an addict. (This fear may be more
pronounced in minority patients.)
Ø Worries
about unmanageable side effects (such as constipation, nausea, or clouding of
thought).
Ø Concern
about becoming tolerant to pain medications.
Ø Poor
adherence to the prescribed analgesic regimen.
Ø Financial
barriers.
Ø Problems
related to the health care system:
Ø Low
priority given to cancer pain treatment.
Ø Inadequate
reimbursement for pain assessment and treatment.
Ø The
most appropriate treatment may not be reimbursed or may be too costly for
patients and families.
Ø Restrictive
regulation of controlled substances.
Ø Problems
of availability of treatment or access to it.
Ø Opioids
unavailable in the patient’s pharmacy.
Ø Unaffordable
medication.
Flexibility is the key to managing
cancer pain. As patients vary in diagnosis, stage of disease, responses to pain
and interventions, and personal preferences, so must pain management. The
recommended clinical approach outlined below emphasizes a focus on patient
involvement.
Ask about pain regularly. Assess
pain and associated symptoms systematically using brief assessment tools.
Assessment should include discussion about common symptoms experienced by
cancer patients and how each symptom will be treated. Asking a patient to
identify his or her most troublesome symptom is also of clinical value because
the most troublesome symptom is not always the most severe, as demonstrated in
a survey of 146 patients in the palliative phase of treatment for lung,
gastrointestinal, or breast cancer.
Believe patient and family reports
of pain and what relieves the pain. (Caveats include patients with significant
psychological/existential distress and patients with cognitive impairment.)
Choose pain-control options
appropriate for the patient, family, and setting.
Deliver interventions in a timely,
logical, coordinated fashion.
Empower patients and their
families. Enable patients to control their course as much as possible.
Highlights
of Patient Management
Effective
pain management is best achieved by a team approach involving patients, their
families, and health care providers. The clinician should:
Initiate
prophylactic anticonstipation measures in all patients (except those with
diarrhea) before or during opiate administration. (Refer to the Constipation
section in the Side Effects of Opioids section of this summary for more
information.)
Discuss
pain and its management with patients and their families.
Encourage
patients to be active participants in their care.
Reassure
patients who are reluctant to report pain that there are many safe and
effective ways to relieve pain.
Consider
the cost of proposed drugs and technologies.
Share
documented pain assessment and management with other clinicians treating the
patient.
Know
state/local regulations for controlled substances.
Nurses
can work to overcome the barriers through education, quality improvement
efforts, and involvement in professional groups that advocate for those in
pain.
Patients
suffer from many of the same myths and attitudes that plague healthcare
professionals. Nurses can reassure Patients that pain control is everyone's
right, that they rely on Patients to report their pain, and that good pain
management will improve their quality of life. Proactive education of Patients
and their family/support persons is necessary, including tolerance,
physiological dependence, and addiction.
Cultural,
religious, spiritual beliefs and practices can impact pain reporting and
management for patients and staff, respectively (NCP, 2009).
·
Cost -- A study (n=40) at Albert Einstein
Healthcare Network in Philadelphia, a setting serving an 80% minority
population, reported that 38% of patients were not financially able to afford
their pain medication. Not one of the study patients was eligible for patient
assistance programs which were also described as time-consuming and burdensome
for physicians, staff and cancer patients (Phipps et al., 2005).
·
Other behaviors to consider
Ø Desire to be a “good” patient
Ø Reluctance to acknowledge pain as this may
mean disease progression
Ø Fear of injection
Ø Poor communication between patient and
healthcare team
Ø Limited capacity to report pain
Ø Personal/family cultural influences
Health-care professionals
often lack
knowledge about the assessment and management of pain. They are also frequently
concerned about addiction, tolerance, and the side-effects of opioids (AHCPR
1994). In reality, the overall incidence of addiction is low (Porter & Jick
1980). This is especially true of patients taking opioids at the end of life.
Nurses and other health-care professionals often misinterpret the meanings of
the terms ‘addiction’, ‘tolerance’, and ‘dependence’. The definitions of these
terms, together with a clarifying comment on each, are presented in Table 8.1.
The
principle of ‘double effect’ is relevant to any discussion of the attitude of
health professionals to the use of opioid medication. ‘Double effect’, a
concept initiated by Roman Catholic moral theologians in the seventeenth
century, justifies a potentially harmful effect when the intention is good. For
example, the opioid dose required for some patients might cause delirium,
sedation, respiratory depression, and even death. However, the positive
benefits of adequate pain relief can outweigh the potentially harmful effects.
The principle continues to be discussed by bioethicists today (Elliott 1997),
and should be kept in mind when assessing the question of pain relief at the
end of life.
Patients can present a barrier to their own pain relief. They
can be reluctant to report pain for fear that their disease is getting worse,
and this can beespecially common in patients who are nearing the end of life.
Concern about not being a ‘good’ patient might also be a concern. In addition,
patients can be reluctant to take pain medications because they fear addiction,
tolerance, and side-effects (AHCPR 1994).
The
health-care delivery system
can also be a barrier to adequate pain treatment, depending on the patient’s
place of residence. In some rural areas, adequate doses and/or an adequate
variety of opioid options might not be available. The cost of analgesics can
also be a problem for some patients, and full reimbursement is not available
from all health-care insurance funds.
The pain of dying of cancer or AIDS is
often unbearable, but it
can be controlled simply and inexpensively with painkillers including morphine and other
opioids (also called opiates).
Although health professionals have long
known that these drugs
are essential for the relief of moderate to severe pain, the amounts used globally are so
small that only a minority of
those in need have adequate pain relief. The problem exists in some developed countries
and is particularly acute in
developing countries. The absence of these drugs is not a problem of supply, but of legal,
political, medical, and other barriers
that prevent them from becoming available.
Scope
of the Pain
At least 2 million
deaths from cancer and 3 million from
AIDS
occur every year in developing countries. About 80
percent of people dying from cancer and 50 percent of those dying from AIDS experience
moderate or severe pain, lasting
for an average of 90 days. Among
those with advanced cancer, researchers consistently report that patients experience
moderate to severe pain, regardless
of their age and sex, and whether they are
bedridden.
The pain can vary according to the type of
cancer,
treatment, and personal characteristics, but the severity
of the pain typically increases with the progression of the disease. Similarly,
researchers report that up to 80
percent
of patients in the last phase of illness experience significant pain requiring
analgesic (painkilling) drugs.
Pain dramatically
reduces quality of life, preventing
patients
from working, socializing, or caring for their families.
Depression and anxiety also increase with pain intensity.
The individual’s suffering radiates through
households
and communities, causing stress to nurses
as
well as financial hardship for entire families. Having AIDS can make matters worse: a
woman dying from the
disease, for example, may keep her illness cloaked in secrecy and shame, with little hope
of receiving relief from her
extreme physical pain.
How
Pain Control Works
The goal of pain
control and palliative care is not to cure
disease,
but to allow patients to function as well as possible with a minimum of pain, including
during treatment.
While there are
numerous ways to relieve pain—including
various
types of anesthetics and neurological procedures, physical
procedures such as massage and acupuncture, and psychological
approaches such as hypnosis or relaxation
therapy—painkilling
drugs are the mainstay of pain relief.
The World Health
Organization (WHO) has developed
a
“three-step analgesic ladder” for treating cancer pain, which is also appropriate for AIDS
patients. The steps in the
ladder represent increasing pain severity and the drugs that should be used at each stage:
• Step 1, mild pain, can
be relieved with widely available
drugs, such as acetaminophen, aspirin,
and
ibuprofen or other anti-inflammatory drugs.
• Step
2, moderate pain, requires a combination of the drug used in Step 1 and an opioid
such as codeine for greater
relief.
• Step 3, severe pain, requires
a strong opioid such as
morphine plus other drugs to provide additional relief
or address the side effects of the painkillers.
Ideally,
a trained professional prescribes pain medication throughout
the course of the illness, according to the
ladder.
In developing countries, however, most patients selfmedicate with over-the-counter or
traditional medicines until
they have late-stage disease that can be treated only with a strong opioid. That is when
they are most likely to seek
formal medical care—at Step 3 of the ladder—yet least likely to obtain it, even from
health professionals.
Barriers to Pain Control
Morphine
is largely unavailable in Africa, the easter
Mediterranean,
and Southeast Asia, but also hard to obtain
in
most other developing regions. In the last few decades, some progress has been made in
making morphine available in
developed countries, widening the gap in access between wealthier and poorer countries. Of
all of the morphine used
legally in 2002, 78 percent was consumed in only six developed countries, and the
remainder in the other 142 countries
that reported use.
Aside
from scarce resources, the major barriers to receiving pain relief as part of end-of-life
care in developing countries include:
•
Lack of national policies and/or low priority assigned to pain relief;
•
Lack of national standards and guidelines for providing
pain control medications;
•
Legal restrictions on the importation and medical use
of opioids, and the greatly exaggerated concern that
the medical use of opioids will lead to drug
abuse
and addiction;
•
Lack of awareness by health professionals and the public—including
families who care for the dying at
home—that
cancer and AIDS pain can be relieved; and
•
Social stigma surrounding cancer and AIDS, which delays
or prevents adequate treatment of the disease and
the pain.
According
to WHO, opioids such as morphine are essential medicines
and should be available to patients who need
them.
A recent report states that “a palliative care program cannot exist unless it is based on
a rational drug policy,” and
this includes “regulations that allow ready access of suffering patients to opioids.”
Although
they are essential medicines, opioids also have the
potential for abuse and are therefore controlled at every stage of production and
distribution to prevent diversion
for
non-medical use. The Single Convention on Narcotic Drugs of 1961 is an international
treaty that aims to prevent the
illicit production, trafficking, and consumption of narcotic drugs while also ensuring
availability for medical and
scientific needs. In addition to requiring countries to report levels of use, it sets
out guidelines from which countries
can develop their own policies and regulations.
For
example:
• Only licensed
individuals may dispense opioids.
• Opioids may only be
transferred between authorized parties.
• They must be
dispensed with a medical prescription.
Many governments have
imposed tighter restrictions than
the treaty calls for. Some countries make morphine available only for terminally ill
cancer patients; impose additional
restrictions on prescriptions; and/or require extra authorizations for releasing
morphine. The requirements can
be so burdensome that patients may die before the paperwork
is completed.
Cost of Morphine for Pain Control
The
price of a month’s supply of immediate-release oral morphine varies greatly among
developing countries, because
the drug costs less where it is produced locally and countries do not acquire and dispense
the drug with equal efficiency.
Even with these variations, however, if barriers to
oral morphine were removed, a total drug cost of 1 cent or less per milligram of oral
morphine could be achieved in most
countries.
Given
the average daily dose used for palliative care, the cost per patient for a day of pain
avoided is estimated to range
from 60 cents to $1.35, resulting in drug costs of oral morphine of about $216 to $420
per year of painfree life
added. Is the pain relief worth the cost? Research shows that people are
willing to give up several months
of
healthy life for access to good end-of-life care, and patients in poor
countries place as great a value on pain relief as patients in wealthy countries.
Estimates
of the annual costs of oral morphine for Chile, Romania,
and Uganda are shown in the table
bellow.
Given that the
prevalence of AIDS and cancer differs among
the
countries, the investment needed varies from as low as $600,000 in Chile to as high as
$4.9 million in Uganda. The cost
per capita ranges from 3 cents to 21 cents.
The analysis excludes
other costs such as those for health
care
delivery, training, and management. But making oral morphine available through a system
of palliative care could
actually save the health system money, by enabling people who would otherwise be
hospitalized to die at home or
by shortening their hospital stays. Even in low-income countries, patients in unbearable
pain are often brought to hospitals
by distressed relatives who are willing to go into debt to ease their suffering.
Strategies to Improve Pain Control
Providing
adequate morphine for pain control involves
medical,
political, legal, and societal change. Tools, resources,
and expertise are available for evaluating national drug policies and improving access
to opioids for medical purposes.2
Model programs, such as Hospice Uganda (see
box),
have demonstrated the feasibility of providing good palliative care, including
morphine, even for poor rural dwellers.
WHO and the International Narcotics Control
Board
support these efforts.
WHO
recommends that countries with low levels of
resources
progressively adopt standards for pain relief and palliative
care at all levels of the health system, with a special focus on reaching those who are
cared for at home. Homebased care
is generally the best way to achieve good quality care
and coverage in countries with strong family support and weak health care systems.
Government Commitment Is Essential
Policymakers
and program managers need to harness
the
following practical tools to improve pain control and palliative care:
•
Study the prevalence of pain and assess the extent of care currently available.
•
Assess the national and local regulatory barriers to
morphine availability to identify the patientrelated, doctor-related, and institutional
barriers that impede drug distribution.
•
Lean about how the drug control system is intended to ensure adequate availability of
opioids for medical purposes.
•
Study the costs of making morphine and other
drugs
available and assess the offsetting savings that could
be achieved by reducing hospital stays.
•
Build an inventory of model programs for pain control
and palliative care and experiment with new
models
for providing pain control, particularly for
poor
and rural residents.
WHO,
in collaboration with the International Narcotics Control
Board and the WHO Collaborating Center at
the
University of Wisconsin, have developed guidelines for national health authorities to
assess regulatory and other
barriers to making the needed drugs available. These institutions, along with several
others, can provide resources and
expertise to develop action plans, implement policy change, and evaluate results.