Pain

Key points

• Screen for pain regularly
  • Use a simple, validated pain assessment tool (Cancer Guideline Wiki).
• When pain is present, perform a comprehensive assessment.
• Identify those for whom special care is required, including:
  • The elderly
  • Those with comorbidities including renal and hepatic impairment, low platelets, peptic ulcer disease
  • Those undergoing surgery
  • Those who do not speak English
  • Those with a high risk of opioid misuse.
• Review pain control regularly: for severe pain - review within 24 hours.
• Prevent and manage adverse effects of analgesia, including constipation.

Assessment

• Complete a comprehensive pain assessment if either of the following apply:
  • a new patient reports a pain score of 2 or more on self-reported numerical rating scale of zero to 10 or pain score is 3 or more on the Abbey Pain Scale;
  • an existing patient reports a new pain or a sudden, unexpected change in intensity of pain.
• Choosing an appropriate assessment tool:
  1. Simple pain assessment
     • verbal numeric scale (0 to 10)
     • Pain thermometer – visual tool for older people
     • Verbal descriptor scales
     • Faces pain scale for kids
  2. Complex pain assessment
     • Brief pain inventory
     • Modified brief pain inventory (for RACF)
     • Consider neuropathic screening – LANNS and sLANNS, NPQ or the painDETECT tools
  3. Pain assessment for non-verbal
     • Abbey, PAINad and Doloplus 2 for older people with cognitive impairment
     • Modified PAINad for younger people who are non-verbal (people with a disability)​
• A comprehensive pain assessment addresses the following:
  • Disease status and treatment
  • Pain severity (using a validated tool)
  • Pain experience
  • Current and previous management of pain
  • Pain meaning
  • Psychosocial status, including risk factors for opioid misuse
  • Cognitive function
  • Physical examination, and where needed, further investigations
  • Functional status
  • Risk factors for poorly controlled pain
  • Patient and family preferences (goals and expectations for comfort, advance directives)
  • Factors suggesting an oncological emergency.
  • See Cancer Pain Wiki Assessment
• Reassess whenever there is a change in pain or a new pain.

Approach to management

• Principles of pain management include:
  • Communication with patient and caregiver, education, and a focus on self management
  • Pharmacological management
  • In cancer patients - consider anticancer therapy
  • Interventional approaches for non-responsive severe pain
  • Non-pharmacological management.
• Review pain control regularly (for severe pain - within 24 hours).
• Provide regular analgesia for persistent pain.
• Opioid analgesia is required in cancer patients with persistent pain that does not respond to simple analgesics or non-steriodal anti-inflammatory drugs (NSAIDs).
• Ensure the patient on regular opioids has access to a breakthrough at an effective dose - around one sixth the total daily dose. This may require a PBS authority to provide larger quantities of medicines should the PBS standard quantity be insufficient. The Clinical Decisions section has more on managing opioids
• Prescribe and educate about use of laxatives, and offer PRN antiemetics.
• Manage adverse effects.
• Consider the need for adjuvants e.g., for neuropathic pain.

Pain type according to patient descriptions

Identifying the type of pain the patient is experiencing is essential to guide the development of treatment plans and management options for patients. Patient descriptions of pain can help to identify whether it is nociceptive or neuropathic pain. See Cancer Pain Wiki Assessment

• Nociceptive:
  • Aching
  • Cramping
  • Gnawing
  • Pressure
  • Sharp
  • Stabbing
  • Throbbing
• Neuropathic:
  • Hot-burning
  • Cutting-lacerating
  • Pins and needles
  • Pricking
  • Tingling
  • Tight-stretched
  • Numb
  • Electric shocks
  • Jumping-bursting
  • Radiating
  • Stabbing-shooting