PAIN assessment and management in

PC
Objectives

By the end of the session, we should be able to:

1. Effectively communicate with patients in pain

2. Explain which steps to take to assess pain
3. Compare the different pain scales and select the appropriate
one
4. Discuss myths about pain assessment

2
Core principles of pain assessment and
management

Patients have the right to appropriate assessment and

management of pain.
Pain is always subjective.
Assessment approaches, including tools, must be
appropriate for the patient and Family members
Pain can exist even when no physical cause can be found

Pain: Current understanding of assessment, management and treatments (2001) 3

Core principles of pain assessment

Different patients can experience different levels of pain in

response to comparable stimuli
Pain tolerance varies among and within individuals depending on
factors including heredity, energy level, coping skills, and prior
experiences with pain
Patients with chronic pain may be more sensitive to pain and other
stimuli
Unrelieved pain has adverse physical and psychological
consequences.
Pain is an unpleasant sensory and emotional experience, so
assessment should address physical and psychological ,social,
aspects of pain
Pain: Current understanding of assessment, management and treatments (2001) 4
Communication skills
Communication
Listen carefully is important to
adequately
assess pain
Always be
respectful and
polite Spend time
establishing trust

Give information
rather than
advice Take time to
assess properly
Ask open-ended
questions

Worldwide Palliative Care Alliance. Palliative Care Toolkit improving care from the roots up in resource-limited settings (2008) 5
 Communication skills

Only give Check if the patient has

accurate understood you. See if
information they have any more
questions for you

Don’t
underplay what
you hear

Avoid medical terms that the

patient may not understand
It is all right to
say you do not
know

6
Worldwide Palliative Care Alliance. Palliative Care Toolkit improving care from the roots up in resource-limited settings (2008)
Steps in pain assessment

Note:
1. Ask a patient about the presence of pain
When the patient is in
severe pain and unable
to undergo an
2. Conduct the PQRST assessment
assessment, an initial
analgesic can be
prescribed*
3. Indicate the pains in a body chart
The assessment can be
conducted when the
4. Conduct physical examination
pain is manageable for
the patient
5. Report all findings

6. Monitor pain by scoring it regularly

7
PQRST assessment
• Precipitating and relieving factors
P • What makes the pain worse? What makes the pain better?

• Quality
Q • How would you describe the pain? What does it feel like?

• Radiation
R • Is the pain in one place or does it move around your body?

• Site and Severity

S • Where is your pain? On a scale of 0-10, how bad is your pain?

• Timing and Treatment history

T • When did pain start? How often do you get it?
• What are the patterns of the pain? Is it constant, or does it come and go?
• Are you or have you been on treatment for the pain? Does it help?

•The outcomes of the assessment need to be recorded in the patient chart. A

specific page, including a body chart, might be used
Beating Pain, 2nd Ed. APCA (2012) 8
Pain rating scales

• Pain rating scales provide simple means for patients to rate

pain intensity
• Most scales use numbers (e.g., 0-10), words, or images to
measure pain or pain relief
• The tool used should be appropriate for the individual patient
• The tool used should be reliable, valid, and easy to use
• Pain intensity levels are measured at the initial encounter,
following treatment, and periodically
• Record the pain level to make treatment decisions, follow-up,
and compare between examinations

Pain: Current understanding of assessment, management and treatments (2001) 9

Common scales: Numeric Rating Scale (NRS)

0 1 2 3 4 5 6 7 8 9 10
No Worst
pain possible
pain

• Most commonly used rating scale

• Patients rate their pain on a 0-10 scale
– 0 represents ‘no pain at all’
– 10 represents ‘the worst possible pain’
• It can be used verbal: ‘What number describes your pain from 0 (no pain)
to 10 (worst pain you can imagine)?’
• It can be used in writing: ‘Circle the number that describes your pain’

Adult Cancer Pain, NCCN Harmonized Guidelines for Sub-Saharan Africa (3.2019)
Pain: Current understanding of assessment, management and treatments (2001) 10
Pain Scale: What It Is and How to Use It (2017)
Common scales: Visual Analogue Scale (VAS)

No Worst
pain possible
pain

Haefeli M, Elfering A. Pain assessment (2006) 11

Pain Scale: What It Is and How to Use It (2017)
Common scales: Verbal pain intensity scale

• This pain scale gives patients the option to describe the intensity of their
pain
• How to score this scale:
– No pain 0
– Mild pain 2
– Moderate pain 4
– Severe pain 6
– Very severe pain 8
– Worst possible pain 10
12
Common scales: Wong-Baker FACES scale

Wong-Baker FACES Scale (2014) 13

Common scales: Faces pain scale- revised

• Unlike the original version, images on the revised scale do not present
smiles or tears, but instead, a series of grimaces
• Multiple studies have found that people often tend to demonstrate
grimacing when they are in pain, which is a very common, non-verbal
communication

0 2 4 6 8 10

14
Exercise 1

Jamal is 30 years old and this is his first day following abdominal
surgery. As you enter his room, he is lying quietly in bed and
grimaces as he turns in bed. Your assessment reveals the
following information: BP = 120/80; HR = 80; RR = 18; on a scale
of 0 to 10 (0 = no pain/discomfort, 10 = worst pain/discomfort),
he rates his pain as 7.
On the patient’s record, you must mark his pain on the scale
below. Which number that represents your assessment of
Jamal’s pain would you circle?

0 1 2 3 4 5 6 7 8 9 10
No Worst
pain possible
pain
15
Let’s tackle some myths about pain
assessment
1. You can tell if a person is in pain by only observing their face or behavior
False, you cannot tell if a person is in pain by only observing their face or
behavior. Self-report is the most reliable pain assessment. Observation should only
be used when the patient is not able to communicate
2. If a person can be distracted or can sleep, it means they are not in significant pain
False, some people can sleep or be distracted even if they are in
significant pain. Culture and previous experiences with pain can influence the
way people express pain
3. You can give a patient a placebo to determine if their pain is real
False, you should never give a patient a placebo to determine if their
pain is real. Placebo might sometimes be used in clinical trails but it is not an
ethical and proven method to use a placebo to assess someone’s pain.
Remember, pain is what the patient says it is

16
Let’s tackle some myths about pain
assessment

4. Painful conditions cause the same amount of pain in all people

False, when people have the same painful condition, it doesn’t mean
they have the same amount of pain. Pain is a personal experience influenced by
mechanisms in the body, previous experiences, and culture
5. Vital signs are a reliable indicator of the severity of pain
False, although vital signs can be influenced by pain (e.g., higher pulse,
increased breathing rate, increased blood pressure), they are not reliable
indicators of the severity of pain
6. In order to adequately diagnose pain, it should not be suppressed by analgesics
False, although the existence of pain can support a diagnosis, it does
not mean you should wait to suppress the pain until after the
assessment and diagnosis. When a patient is in severe pain, you might
give analgesia before continuing the assessment

17
Take home messages

• Always ask about your patient’s pain

• Though pain is subjective.
• Some patients may need some time and education by the
healthcare provider to understand how to use the different
scales
• Pain assessments can be a useful clinical tool in treatment and
pain management
• Effective pain measurement leads to appropriate pain
management

18
PAIN MANAGEMENT

19
Objectives

By the end, we should be able to:

1. Understand the guiding principles for pain management

2. Review the World Health Organization (WHO) analgesic
ladder
3. Discuss treatment for mild, moderate, and severe pain
4. Review additional treatment principles when using opioids

20
Pain management guiding principles

Analgesics, including opioids, must be accessible:

both available and affordable

Administration of analgesic medicine should be given:

• By mouth whenever possible
• By the clock
• For the individual
• With attention to detail

Pain management should be integrated as part of care

WHO Guidelines for the pharmacological and radiotherapeutic management of cancer pain in adults and adolescents (2018) 21
WHO analgesic ladder: adults

Step 3
Opioid for severe
Step 2 +/-pain
non-opioid
+/- +/-
non-opioid
adjuvant
Opioid for moderate
+/- adjuvant
pain
+/- adjuvant +/- non-opioid
Step 1
Non-opioid +/- adjuvant
+/- adjuvant

Step up if pain persists or increases Step down if pain decreases

WHO | WHO’s cancer pain ladder for adults 22

WHO Guidelines for the pharmacological and radiotherapeutic management of cancer pain in adults and adolescents (2018)
Using the WHO ladder for adults
Mild pain Start with a non-opioid, +/- adjuvant. Move up a step if pain remains
uncontrolled
Non-opioids Ibuprofen or other non-steroidal anti-inflammatory drug (NSAID),
paracetamol (acetaminophen), or aspirin

Moderate pain Start with an opioid for moderate pain, +/- non-opioid and +/-
adjuvant. Move up a step if pain remains uncontrolled
Opioids for moderate pain Codeine, tramadol, or low-dose morphine

Severe pain Start with an opioid for severe pain, +/- non-opioid and +/- adjuvant
Opioids for severe pain Morphine, fentanyl, oxycodone, hydromorphone, among others

Adjuvants Can be used at any step

Adjuvants Antidepressant, anticonvulsant, antispasmodic, muscle relaxant,
bisphosphonate, or corticosteroid

The goal of pain management is to reduce pain to levels which allow an

acceptable quality of life
Pain control does not mean the complete absence of pain
Beating Pain, 2nd Ed. APCA (2012) 23
WHO Guidelines for the pharmacological and radiotherapeutic management of cancer pain in adults and adolescents (2018)
Exercise

Esther, a 28-year-old woman with cancer, reports a pain score of 5 out

of 10. Which medicines would you consider prescribing?
A. Ibuprofen
B. Methadone
C. Low-dose morphine

When prescribing low-dose morphine, what is Esther’s starting dose?

2.5mg every four hours

What other prescriptions must be written at the same time?

Laxatives 24
Take home message

• The WHO ladder is an important tool to manage the different

severities of pain
• Pain is well-controlled if it has changed from a moderate or
severe pain into a mild pain. A patient doesn’t have to be
completely pain-free to have controlled pain
• Follow up regularly with patients to determine whether opioids
are meeting treatment goals
• Never stop opioids abruptly; instead decrease in steps
• Don’t convert opioids if you are not familiar with the
conversions. Consult an expert or another colleague
• For non-responsive pain, please refer to a pain specialist
25
Breakthrough, emergency, and
incident pain
Objectives

By the end,WE should be able to:

• Define breakthrough pain and learn how to use rescue doses

to treat it
• Learn how to adjust daily doses of opioids based on rescue
dose requirements
• Learn how to diagnose a pain emergency and how to treat it
• Define and outline treatment for incident or procedural pain
• Define and outline treatment for end-of-dose failure

27
Breakthrough pain

Breakthrough pain:
A sudden, temporary flare of moderate to severe pain that
occurs on a background of otherwise controlled pain

May be more common during first three days of

treatment as the opioid dose is titrated from starting
dose to effective dose

Adult Cancer Pain, NCCN Harmonized Guidelines for Sub-Saharan Africa (3.2019)
Beating Pain, 2nd Ed. APCA (2012); Guide to Pain Management in Low-Resource Settings, IASP (2010) 28
WHO Guidelines for the pharmacological and radiotherapeutic management of cancer pain in adults and adolescents (2018)
Rescue dose

Breakthrough pain should be treated with a rescue

medicine, which should be an opioid, such as morphine, in
its immediate release formulation

In addition to regular
A rescue dose, which is
administration, patients
50-100% of the regular
should have access to a
4-hour dose, may be
rescue medicine or rescue
considered
dose

A rescue dose can be given as often as required to treat

breakthrough pain. Write orders that include rescue doses
and record when they are given
29
Breakthrough pain and rescue doses

After giving a rescue dose, continue

A rescue dose should the next regular dose on schedule
be administered at
the first sign of The rescue dose must be increased
breakthrough pain whenever the regular dose is
increased
Pain that is allowed
to build up is harder Rescue dosing is suitable for all
to control immediate-release opioids, not just
morphine

Adult Cancer Pain, NCCN Harmonized Guidelines for Sub-Saharan Africa (3.2019)
Beating Pain, 2nd Ed. APCA (2012); Guide to Pain Management in Low-Resource Settings, IASP (2010 ) 30
WHO Guidelines for the pharmacological and radiotherapeutic management of cancer pain in adults and adolescents (2018)
 Adjusting the background dose

• A frequency of 4 or fewer rescue doses per day is normal

• If a patient requires more than 4 rescue doses per day, you should
increase the background dose
– Add total rescue doses to the normal daily dose and divide by 6
– Example: in a patient taking 10mg every 4 hours and 5 rescue
doses of 10mg, the new daily dose is (10*6)+(10*5)=110mg,
given as 15 or 20mg every 4 hours

• If there is no need for rescue doses, you may try a small reduction
in the background dose
Adult Cancer Pain, NCCN Harmonized Guidelines for Sub-Saharan Africa (3.2019)
Beating Pain, 2nd Ed. APCA (2012); Guide to Pain Management in Low-Resource Settings, IASP (2010)
WHO Guidelines for the pharmacological and radiotherapeutic management of cancer pain in adults and adolescents (2018)
31
Pain emergency

If a patient is in excruciating pain (pain score 9 or 10), it is

considered a pain emergency

Administer rescue dose

Wait for dose to take effect (10
intravenously (IV)
minutes for IV and 30 minutes
Remember to convert oral dose
for oral), and then reassess.
to IV dose with ratio 3:1
Repeat dose if pain score is 5 or
(divide the oral morphine in
higher
three to get IV dose)

If the pain is between pain score 5-8, an oral rescue dose can be given

The goal is to control pain (i.e., to get pain score below 5 out of 10)

Adult Cancer Pain, NCCN Harmonized Guidelines for Sub-Saharan Africa (3.2019);
Beating Pain, 2nd Ed. APCA (2012); Guide to Pain Management in Low-Resource Settings, IASP (2010); 32
WHO Guidelines for the pharmacological and radiotherapeutic management of cancer pain in adults and adolescents (2018)
Take home messages

• Breakthrough pain may require rescue doses that are

determined by the patient’s pain, in addition to regular pain
treatment
• The goal of treating pain emergencies is to control pain
• Respiratory depression can be prevented with the proper
balance of pain and opioid doses
• Rescue doses given before painful procedures or activities can
reduce the pain they cause

33