The Basics of Good Pain Control: Understanding and Assessment

Dr. Leah Steinberg

On Monday you go to work:

• Meet Mr. Peters• 52 yr old patient with lung cancer• Holding his chest• “It feels like I’m being squeezed and

it is burning” • “I can’t sleep…”• His wife is crying at his side…

Your Learning Objectives:

1. Appreciate the prevalence of pain in patients with advanced cancer and other medical illnesses;

2. Describe the basic mechanism of pain;3. Define the elements of a complete pain

assessment;

How common are symptoms?

Pain 84%Fatigue 69%Weakness 66%Anorexia 65%

Dyspnea 50%Nausea 36%Delirium 21%

Walsh et al, Supportive Care Cancer 2006 N= 922 patients with advanced cancer 

What about non-malignant illness?Congestive Heart FailureEmphysema (COPD)ALSRenal failureAdvanced liver disease

• PAIN

• FATIGUE

• ANOREXIA

• DYSPNEA

Objective 2: What is pain?

• An unpleasant sensation – a feeling• Created by stimulation of receptors

on nerve endings -- nociceptors

Mechanism of pain transmission:

• Cancer damages tissue

• Releases neurotransmitters

• Pain signal

• We now know:

• Cancer itself releases inflammatory mediators

• Inflammatory mediators trigger pain receptors

• Don’t always “see” damage on imaging; size doesn’t matter

Types of pain simplified:

Nociceptive pain

Intact nervous system

Visceral - describe?

Somatic – describe?

Neuropathic pain

Damaged nervous system

Describe?If it sounds

weird…

Back to Mr. Peters:

Sitting in front of you, looking for help…

What have we learned so far?

We now know:

• Common• His disease is causing pain signals• But before we know what to do for

him, we need a good assessment

Objective 3: How do we assess pain?• Thoughts?

How do we assess pain?

Physical Domain+

Psychosocial Domain

TOTAL PAIN

Physical Domain: find etiology

• Location of pain• Timing of pain• Nature (quality): ache, dull, burning, skin• Radiation of pain• Aggrevating/Relieving factors• Severity (use a pain rating scale)• Treatment so far and effect

Past/current medical status

• May assist or complicate assessment:

Assist: Location of cancer: pain syndromes, neuropathic

Complicate: Delirium, dementia, infection, renal function, chronic pain

Mr. Peters: Physical Domain

Now you can start asking some questions!

Physical Domain: Another example• Mrs. C. presented with pain from locally

advanced breast cancer --• Her physical domain assessment:• Sharp, burning, chest wall pain• Started 4 days ago• Worse with movement of arm, dressings• Redness increased• PMH: LABC x 4 yrs, no other illnesses

Mrs. C: What is her pain from?

• What is our going on in this case?

How do we assess pain?

Physical Domain+

Psychosocial Domain

TOTAL PAIN

Psychosocial Domain

• Understanding of disease• Fears, ideas, expectations• History of

depression/anxiety• Fears of opioid use• Family support/awareness• Cultural/religious factors

Affects how your patient perceives and expresses his pain

Mr. Peters: Psychosocial domainNow you can ask more questions!

Psychosocial Domain: Another example• 90 yr old female with bony metastatic

disease to manubrium (lung ca)• Clearly bone (somatic) pain• Clearly uncomfortable• Always said pain was acceptable, never

wanted pain medication – family quite upset

• Assessment revealed fear of sedation and confusion – therefore under expressed pain

Why it is important? Or, how I understand TOTAL PAIN

NOCICEPTION

PERCEPTION

EXPRESSION

Pain receptors and neurotransmission; this is where opioids work

Thalamus and cortex

Psychosocial Domain

Total Pain

• Our patients express pain• Opioids work and they work well• But, remember, it is EXPRESSION of

PAIN• If you are having trouble with

managing pain with opioids, think about the other inputs…

Complete Assessment

• Physical understanding:– Gives you likely etiology and medical

complications

• Psychosocial understanding:– Gives you understanding of how your

treatments will likely work and what other components you need to add to have effect

Summary

Prevalence of painMechanisms of pain First (and hardest) step in treatment:

A good pain assessmentOnce you have that, you know the

path to treatment