Pain management is a difficult and complex challenge for both patients and clinicians.  Pain may be underreported and undertreated for a number of patients.  Maintenance and improvement of quality of life and normal daily functions are strongly related to successful pain management strategies, especially in cases of chronic pain associated with progressive disease. 

Adequate patient assessment includes variables of patient history, physical examination, and tools designed to adequately evaluate types, levels, and factors associated with pain.  Several guidelines exist to assess, initiate, and monitor pain management strategies.  Patient-oriented materials are available to help patients to understand their options and “rights” for adequate pain management.  In addition to opioid and other pain medications, it will be important to include a history of any CAM therapies that the patient employs including self-treatment strategies. 

This Journal Club evaluated three aspects of pain management:

            Assessment tool development,

            Pain management outcomes using established guidelines, and

            Differences in pain perception parameters according to race/ethnicity.

Pain assessment tools have been tested for validity and reliability.  Authors in the first study reviewed suggest that there was a need to develop a simple prognostic tool to predict the potential for pain management success while following standardized guidelines.  The researchers used objective and subjective items from previously validated instruments including the Brief Pain Inventory (BPI), visual analogue scales of quality of life (VASQOL) and other VAS, records of side effects, Functional Assessment of Caner Therapy (FACT-G), Memorial Symptom Assessment Scale Short Form (MSAS-SF), and patient expectation and satisfaction surveys.  BPI categorizes pain severity, pain relief, and pain interference factors.  Quality of life measures and the FACT-G include physical, emotional, social/family, and functional well-being.  The MSAS-SF includes symptoms and distress indices for physical and psychological factors.  Patient expectations for pain relief and satisfaction with treatment include interview questions that are rated on a scale.

Pain relief was predicted by a combination of factors including worst severity, average pain, pain interference, pain relief, and Morphine Oral Equivalent Daily Dose in mg (MEDD).  Strong independent predictors after one week of pain treatment included the BPI worst pain severity and FACT-G emotional well-being scores.  After the second week of pain treatment additional predictors included initial opioid dose, FACT-G emotional well-being, and nociceptive pain.  The authors suggested that though there were limitations to the prognostic tool developed during this study, it could be used to predict the likelihood of pain relief using standardized protocols and the ability to identify patients less likely to respond well who may need a more individualized and intensive plan for treatment.

In the second study, patient expectations and satisfaction for pain treatment were surveyed with questions about the level of pain relief they wanted and expected at baseline with weekly questions on how well treatment has met expectations for pain control.  Patient dissatisfaction is historically associated with more severe pain while satisfaction is associated with pain relief.  While many patients (34%) did not know how to answer the question on expectations, most wanted complete pain relief and expected between 80-100% (46%) or 50-70% (15%).  Patients who had higher expectations were more satisfied with pain treatment.

Side effects of pain management are considered important outcomes to evaluate and treat by several guidelines.  However, it was difficult for researchers and patients to be confident that the symptoms patients reported were actually a direct effect of pain treatment rather than the underlying disease.  In this study the side effects of opioid treatment remained static on each of the weekly assessments and were mostly dry mouth, drowsiness, fatigue, constipation, and anorexia.

In the third study a four-stage schematic for pain progression was tested for racial and ethnic differences.  The stages included pain intensity (Stage I), affective response as unpleasantness (Stage II), longer-term contemplation about the impact of pain (Stage III), and behavioral manifestations of pain (Stage IV).  There were no differences seen between White and African American participants for pain intensity.  However, several significant differences were seen in each of the other stages with higher levels of unpleasantness, emotional response, and pain behaviors reported by African Americans compared to Whites.  The authors speculate that that there might have been several social variables that could help to explain this difference which were not included in this study.  Among those variables described in previously published studies of African Americans or other minority populations compared to Whites were distrust of care providers, skepticism about what physicians could do for patients, previous experiences of not receiving needed care, disparities in prescribing of pain medication and underestimation of pain in minority populations, more fear and anxiety about the impact of pain on employment in lower wage earners, and others.    

The authors point to a need to include other types of pain management strategies that address the differences between Whites and African Americans such as diagnosis and treatment of depression or other factors that could explain the strong link between emotional responses and pain behaviors in African American patients.

This Journal Club has explored the challenging factors related to successful pain management including predictive factors, assessment and treatment guidelines, and ethnic/racial differences in response to pain.  The clinician should be aware of pain potential, assessment factors, and ways to monitor and adjust pain management for patients likely to experience pain.

References:

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[2] Crespi-Lofton J. Profiles in Pain Management: assessing pain in older patients with cognitive impairment. Pharmacy Today. 2003 9(3):18.

[3] Updated summary available from the National Guidelines Clearinghouse (NCG) at  http://www.guidelines.gov/VIEWS/summary.asp?guideline=002327&summary_type=brief_summary&view=brief_summary&sSearch_string=pain+management

[4] National Comprehensive Cancer Network. Clinical Practice Guidelines in Oncology: Cancer Pain. Version 1. 2002.  Accessed at http://www.nccn.org/physician_gls/f_guidelines.html.

[5] Fainsinger RL, Fallon MT. New strategies for managing cancer pain. 10^th World Congress on Pain. August 17-22, 2002. San Diego, CA. Abstract 713 and presentation.  Access Congress summary: Congress Reporter Vol 1, Issue 1, November 2002 at http://www.aspmn.org/html/CongRep.pdf.

[6] Enter search term “pain” at this site for a listing of JCAHO pain assessment and management standards: http://www.jcrinc.com/publications.asp?durki=4

[7] Jacobi J, Fraser GL, Coursin DB, Riker RR, Fontaine D, Wittbrodt ET, Chalfin DB, Masica MF, Bjerke HS, Coplin WM, Crippen DW, Fuchs BD, Kelleher RM, Marik PE, Nasraway SA, Murray MJ, Peruzzi WT, Lumb PD. Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Crit Care Med. 2002;30(1):119-141.  The original article can be downloaded at: http://www.ashp.org/bestpractices/tg/Therapeutic%20Guideline%20Sedatives%20and%20Analgesics.pdf.

[8] Hazard Vallerand A, Fouladbakhsh JM, Templin T. The use of complementary/alternative medicine therapies for self-treatment of pain among residents of urban, suburban, and rural communities. Am J Pub Health. 93(6):923-925.

[9] Weiner DK, Rudy TE. Attitudinal barriers to effective treatment of persistent pain in nursing home residents. J Amer Geriatr Soc. 2002;50(12):2035-2040.

[10] Pain Management Rights. LaPorte Hospital and Health Services, Indiana. http://www.laportehealth.org/healthcare/painmanage/painrights.html.