Journal Club

Pain Management: Predicting Outcomes

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Glossary

The Institute for Clinical Systems Improvement (ICSI) published a set of guidelines on pain management, which was updated in October of 2002.³ In these guidelines an algorithm is presented to assist care providers to logically assess and treat pain appropriately. Among those included are the following steps:

1. Determine the type of pain. An assessment may reveal one or more types of pain including somatic, visceral, and neuropathic. 
   1. Somatic pain is localized and may be described by the patient as a stabbing, sharp, or pinprick sensation. Examples of somatic pain problems include surface burns or other lesions or injection sites.
   2. Visceral pain is more generalized and may be described by the patient as sharp, an ache, or a sensation of pressure. These may include joint pain, muscle spasm, kidney stones, and other deeper pain sensations.
   3. Neuropathic pain may be a radiating or specific type of pain that may be described as burning or tingling. Examples include neuralgias, neuropathy, or amputations.
2. Complete diagnostic work-up. Pain should be considered a symptom and the cause should be determined in order to most appropriately individualize treatment. This can occur while pain treatment begins, but in some cases it may be appropriate to delay treatment until the cause or causes are determined. 
3. Implement treatment plan. Therapies may include the following:
   1. Somatic pain: non-steroidal anti-inflammatory drugs (NSAIDs), local anesthetics, topical therapies, and others
   2. Visceral pain: NSAIDs, opioids, and intraspinal anesthetics
   3. Neuropathic pain: antidepressants, anticonvulsants
4. Reassess at regular intervals. It may be necessary to monitor and treat side effects and provide follow-up patient and caregiver education.

Different strategies are suggested for acute versus chronic pain. While pain management is the primary goal in acute pain, pain prevention is an important primary goal in chronic pain. Acute pain has a well-defined onset with both subjective and objective signs, including increased heart rate and blood pressure and restlessness or anxiety. Chronic pain is defined as pain that persists for more than six months and may be less definable by objective signs. Patients with chronic pain may show signs of exhaustion, depression, and withdrawal. 

In 2002, the National Comprehensive Cancer Network published clinical practice guidelines and a listing of clinical trials.⁵ Fainsinger and Fallon suggested that guidelines are important to provide a common language in the pain management field. They also suggested more research to support and refine use of guidelines and continuously update treatments indicated is needed. The Joint Commission on Accreditation of Healthcare Organizations lists and updates standards for pain assessment and management.⁶