Eileen Mann, nurse consultant pain management
Managing pain effectively is one of the biggest challenges in medicine, and one of the areas of clinical practice where a good doctor-patient relationship can, potentially, help improve the end result. But it takes time to get this right—and requires help from other healthcare professionals, argues a nurse consultant in pain management.
Scientists are beginning to understand how and why we feel acute pain, and the complex interplay of neurones and messenger molecules that leads to its perception. However, researchers are only just starting to explain the contribution of emotional affect, cognitive function, and how the human response to feelings such as anger, frustration, depression, anxiety, fatigue, and hopelessness can impact on the perception of pain.
Our improved understanding of acute pain has led to an explanation of how and why the majority of analgesics work and why conventional approaches such as analgesic medications are often so effective. But it has also led to chronic pain emerging as a distinct phenomenon on its own.1 Although it may share nociception, which describes the tissue irritation that accompanies acute pain, other factors may be associated with pain that does not go away, such as abnormal nerve activity and alteration within the central nervous system. Increased suffering also adds a dimension, and changes in behaviour mean that chronic pain affects the person as a whole and is not just confined to a part of the body.2
Given the myriad of influences on pain perception, it becomes clear that applying a traditional biomedical model that just looks for an organic cause of pain may fail some sufferers as it does not routinely take into account the multidimensional nature of pain. If strong analgesia or surgery is offered to patients whose pain may have become chronic and is intensified by the complex interplay of psychosocial factors, this may induce iatrogenic damage caused by the medicine or the medical intervention itself.
The general pattern of current medical training and Western attitudes to disease may make it difficult for a doctor to fully believe a report of pain in the absence of identifiable disease. Phantom limb pain and fibromyalgia are typical of chronically painful conditions that currently defy a full explanation. Previously inadequate education about pain management, not just for doctors but for all healthcare professionals, has compounded the challenges facing patients.3-5
Keys to improved control
On a practical level, the keys to improving pain control are the same as for any clinical activity: good communication, comprehensive assessment of the patient, and giving a proper and thorough explanation of treatment options.
Effective communication between doctor and patient and recognition of the contribution made by other relevant members of the healthcare team, such as nurses, physiotherapists and carers, can provide a more complete picture of the patient's experience and widen treatment options.
Clinicians need to find out details of the pain—its nature, evolution, precipitating and relieving features—as these may provide clues to its cause and possible treatment. How patients describe their pain and the words they use can be crucial. For instance, an ongoing chronic pain that is related to damage within the nervous system is often described as burning or stabbing in nature. Conventional analgesia for this type of pain often elicits a poor response, but drugs traditionally used to treat epilepsy or depression may be more effective in reducing the abnormal nerve activity that causes this pain. Whatever drug is prescribed, by asking the patient what the effect is, especially if the patient or carer keeps a record of this in a diary, the clinician will be able to decide if the medication is appropriate, whether the dose is adequate, and how frequently it should be taken.
Clinicians must also find out about the patient's experience of unacceptable side effects as many patients may regard these as unavoidable and decline further medication, fearing that nothing else can be done. Some individuals may simply accept pain as an unavoidable burden and not appreciate the wider benefits of effective pain control. Not all chronic pain will respond to currently available analgesia, and non-pharmacological treatments may well represent the most effective approach. Non-pharmacological treatments are routinely incorporated into the care offered by multidisciplinary pain management teams, which are well established in some areas of clinical medicine to treat patients with chronic pain syndrome.
After trauma or surgery, pain will be acute and may be severe, but the mechanisms of acute pain are better understood and it will usually respond well to pharmacological treatments such as paracetamol, non-steroidal anti-inflammatory drugs, opioids, and local anaesthetics or a combination of all of these.6 Patients should be told of the hazards associated with poorly managed acute pain, such as serious cardiovascular complications. Uncontrolled pain can also cause sleep disturbance, anorexia, muscle wasting, and depression. Unless the benefits of effective analgesia are reinforced, poor communication and misinformation may combine to strengthen erroneous ideas, such as the concern that strong analgesics are addictive and should be viewed only as drugs of last resort for people who are terminally ill.
The role of the nurse
Carrying out detailed and frequent acute pain assessments and modifying treatment as a result is certainly time consuming. But doctors and patients must recognise that there are valuable partners in this process. Nurses can make major contributions in this area, as good pain management and strategies for patients' comfort are the very essence of nursing. However, many nurses, like patients, can feel powerless and frustrated when doctors do not act on their requests for additional or alternative analgesia. Even when effective analgesia is prescribed, many patients may feel they don't want to trouble the busy nurses by telling them when they are in pain, a factor that regular assessment in hospital should overcome.
Nurses on acute wards tend to spend most time with patients, getting to know them intimately and often developing a close bond. Unlike doctors, they cannot easily withdraw when patients are distressed and in pain. It is not surprising, therefore, that nurses can report considerable personal stress when attending patients who are prescribed inadequate analgesia.
Elderly people in nursing homes often experience high levels of pain.7 Much of this pain may be chronic in nature, but again good communication with the staff in residential homes, spouses, carers, and loved ones may improve the range of treatments available.
The internet is now an extremely valuable resource that is giving healthcare professionals and patients access to the latest research and analysis of the efficacy of pain management treatments. Organisations such as the Cochrane Collaboration (www.cochrane.org/) and Bandolier (www.jr2.ox.oc.uk/bandolier/) can enable care to reflect the results of current research, and they reduce the theory-practice gap that accompanied much of healthcare practice in the past. The National Clearinghouse is another website that provides evidence based guidelines for the treatment of a wide range of painful conditions.8 Even within the controversial area of opioids, such as morphine for chronic non-malignant pain, the British Pain Society is developing guidelines for their use as well as an information leaflet for patients.9
Frustration due to poor experience of pain management may lead patients to consult alternative practitioners; perhaps they view them as a last resort instead of a provider of a complementary therapy.10 Alternative therapies can offer patients an individual approach tailored to their specific needs. Even when the treatment fails to add substantially to pain relief, patients may still perceive benefit from the personal interaction of a holistic, empathetic approach and the feeling that their pain is taken seriously.
These are valuable strategies that can rarely be exploited in a busy surgery or on a hard-pressed understaffed ward but form the basis of care within multidisciplinary pain management clinics.
If the principles of alternative therapists could be combined with the efficacy of a carefully assessed, evaluated, and flexible pharmacological regimen, much of the misery of pain could be reduced. Perhaps now is the time to accept the limitations of conventional medicine and a "one size fits all policy" and to embrace a comprehensive multidimensional approach to pain management.
The internet is an extremely valuable resource giving access to the latest research on pain management. Visit www.painsociety.org, www.jr2.ox.ac.uk/bandolier/booth/painpag/, and www.cochrane.org.uk
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