The Basics of Good Pain Control: Understanding and Assessment
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Transcript of The Basics of Good Pain Control: Understanding and Assessment
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