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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