Initial Assessment
Patient Self-Report
Physical Examination
Assessment of the Outcomes of Pain Management

Failure to assess pain is a critical factor leading to undertreatment. Assessment involves both the clinician and the patient. Assessment should occur:

• At regular intervals after initiation of treatment.
• At each new report of pain.
• At a suitable interval after pharmacologic or nonpharmacologic intervention, e.g., 15 to 30 minutes after parenteral drug therapy and 1 hour after oral administration.

Identifying the etiology of pain is important to its management. Clinicians treating patients with cancer should recognize the common cancer pain syndromes (see table below). Prompt diagnosis and treatment of these syndromes can reduce morbidity associated with unrelieved pain. Distinct cultural components may need to be incorporated into a multidimensional assessment of pain.[1-4] A comprehensive review of cancer pain with a focus on neuropathic pain provides an overview of pain pathophysiologies and an extensive review of available and investigational pharmacotherapies.[5]

The goal of the initial assessment of pain is to characterize the pathophysiology of the pain and to determine the intensity of the pain and its impact on the patient’s ability to function. For example, one study evaluated the association between psychological distress and pain in 120 patients with advanced cancer. Pain intensity and pain that interfered with walking ability, normal work, and relations with other people as measured by the Brief Pain Inventory (Greek version) were found to be significant predictors of anxiety as measured by the Hospital Anxiety and Depression Scale on multivariate analysis. Using the same tools, the authors also found pain that interfered with enjoyment of life was a predictor of depression.[6] Factors that may influence analgesic response and result in persistent pain include changing nociception due to disease progression, intractable side effects, tolerance, neuropathic pain, and opioid metabolites.[7] The following are essential to the initial assessment:

• Detailed history.



• Physical examination.



• Psychosocial assessment.[8]



• Diagnostic evaluation.

The experience of cancer pain is complex and includes physical, psychosocial, and spiritual dimensions. There is no universally accepted pain classification measure that would assist with predicting the complexity of pain management, particularly for cancer pain patients, who may be more difficult to treat. Clinicians and researchers lack a common language to discuss and compare outcomes of cancer pain assessment and management. Oncologists use the tumor, nodes, metastases (TNM) system to provide a universal language to describe a variety of cancers. The need for a similar classification system for cancer pain resulted in the development of the Edmonton Staging System.[9,10] This system has been further refined in two reports that have gathered construct validity evidence using an international panel of content experts [11] and a multicenter study to determine interrater reliability and predictive value.[12] The development of an internationally recognized classification system for cancer pain could play a significant role in improving the assessment of cancer pain, allow a more meaningful assessment of clinical prognosis and treatment, and better enable researchers to compare results with regard to cancer pain management.

The mainstay of pain assessment is the patient self-report; however, family caregivers are often used as proxies for patient reports, especially in situations in which communication barriers exist, such as cognitive impairment or language difficulties. Family members who act as proxies typically, as a group, report higher levels of pain than patient self-reports, but there is individual variation.[13] Differences in clinician assessment of pain intensity are also significant. A retrospective review of 41 patient charts using pain ratings of palliative care consultants as the gold standard found high agreement with assessments performed by bedside nurses (registered nurses [RNs] and clinical nurse assistants [CNAs]) when pain was not present or was mild but poor agreement for moderate or severe pain (sensitivity: RNs, 45%; CNAs, 30%).[14]

Pain assessment tools may be unidimensional or multidimensional. Multiple assessment tools exist. Among the more commonly used bedside tools are numeric rating scales, verbal rating scales, visual analog scales, and picture scales.[15,16] To enhance pain management across all settings, clinicians should teach families to use pain assessment tools in their homes. The clinician should help the patient to describe:

Pain

• Listen to the patient’s descriptive words about the quality of the pain; these provide valuable clues to its etiology. Elicit the temporal features including onset, duration, and diurnal variation. Ask about breakthrough or episodic pain (a transitory increase in pain that occurs in addition to persistent pain). Some patients may have episodic pain without persistent pain.[17]

Location

• Ask the patient to indicate the exact location of the pain on his or her body, or on a body diagram, and whether the pain radiates.

Intensity or Severity

• Encourage the patient to keep a log of pain-intensity scores to report during follow-up visits or by telephone. Examples of simple self-report pain-intensity scales include the simple, descriptive, numeric, and visual analog scales.

Aggravating and Relieving Factors

• Ask the patient to identify factors that cause the most pain and also what relieves the pain.

Cognitive Response to Pain

• Cognitive appraisals of pain can be based on a range of psychological variables such as perceived control, meaning attributed to pain experience, fear of death, and hopelessness.[18] All these variables appear to contribute to the experience of cancer pain and suffering. A study of women with metastatic breast cancer found that although the site of metastasis did not predict the intensity of pain report, greater depression and the belief that pain represented the spread of disease significantly predicted the degree of pain experienced.[19] It was also reported that patients who thought that their pain represented disease progression reported more pain-related interference with function.[20]

Cognitive Impairment

• Note behavior that suggests pain in patients who are cognitively impaired or who have communication problems relating to education, language, ethnicity, or culture. Cognitive impairment itself and the degree of cognitive impairment may impact patient self-report of pain. Preliminary data suggest that mild degrees of cognitive impairment are associated with increased intensity of pain-report in older patients with cancer who are receiving hospice care.[13] In contrast, cognitively impaired nursing home residents are less likely to report pain. Use appropriate (e.g., simpler or translated) pain assessment tools.

Goals for Pain Control

• Document the patient’s preferred pain assessment tool and the goals for pain control (such as scores on a pain scale).



• Encourage use of the pain diary: The daily pain diary is a well-established tool in symptom management research and in clinical practice. Benefits of using a pain diary include heightened awareness of pain, guidance for pain management behaviors, enhanced sense of control, and a tool for communication.[21] It is difficult to get good pain-diary compliance with adolescents who are experiencing intense chronic pain.

A thorough physical examination is required to determine the pathophysiology of pain. Specific features of the neurologic examination such as altered sensation (hypoesthesia, hyperesthesia, hyperpathia, allodynia) in a painful area are suggestive of neuropathic pain. Physical findings of tumor growth and metastasis are also important to identify.

Changes in pain pattern or the development of new pain should trigger diagnostic evaluation and modification of the treatment plan. Persistent pain indicates the need to consider other etiologies (e.g., related to disease progression or treatment) and alternative (perhaps more invasive) treatments.

Pain-related outcomes: Clinicians should document and be aware of outcomes of pain therapy. It is helpful to think of pain-related outcomes as primarily measured in two ways: decreased pain intensity and improvement in psychosocial functioning. Using rating scales of pain intensity at its worst and on average and using pain interference scales can help clinicians monitor outcomes. Measurement of the percentage of pain relief is also useful, though measuring patient satisfaction is less useful because of the low expectations patients sometimes hold for pain control.[22,23]

Drug-taking outcomes: Clinicians prescribing chronic opioids should also monitor and document patients’ drug-taking behaviors. Outcomes related to addiction in cancer patients are rare but nonetheless should be periodically assessed; these assessments can be reassuring to patients. Tolerance and dependence are not addiction related. Documentation of patients’ compliance with regard to changes in dosing and duration of prescriptions is essential in all pain practice.

The clinical assessment of drug-taking behaviors in medically ill patients with pain is complex. Aberrant drug-taking behavior from cancer pain management is related to premorbid history of drug addiction and the likelihood of other pain treatment. A pilot questionnaire was used to characterize drug-related behaviors and attitudes in cancer and AIDS patients. Despite limitations, this study highlights wide potential variation among different palliative care populations in patterns of past and present aberrant drug-taking behaviors and the need for a clinically useful screening approach. The implications for psychosocial and pharmacological management of symptoms such as pain, as well as any aberrant behavior, remains unclear.[24-26]

Previous drug abuse is likely to lead to specific needs for appropriate dosing during cancer pain therapy. A prospective open-label study compared morphine dosage and effectiveness in AIDS patients with and without previous substance abuse. Results demonstrated that both groups benefited, but patients with a history of drug use require and will tolerate substantially higher morphine doses to achieve stable pain control.[27] This study should increase confidence in providing appropriate pain management to patients who have a history of drug use.[28]

References

1. Chung JW, Wong TK, Yang JC: The lens model: assessment of cancer pain in a Chinese context. Cancer Nurs 23 (6): 454-61, 2000.  [PUBMED Abstract]
   
   
2. Cleeland CS, Nakamura Y, Mendoza TR, et al.: Dimensions of the impact of cancer pain in a four country sample: new information from multidimensional scaling. Pain 67 (2-3): 267-73, 1996.  [PUBMED Abstract]
   
   
3. Greenwald HP: Interethnic differences in pain perception. Pain 44 (2): 157-63, 1991.  [PUBMED Abstract]
   
   
4. Bates MS, Edwards WT, Anderson KO: Ethnocultural influences on variation in chronic pain perception. Pain 52 (1): 101-12, 1993.  [PUBMED Abstract]
   
   
5. Fine PG, Miaskowski C, Paice JA: Meeting the challenges in cancer pain management. J Support Oncol 2 (6 Suppl 4): 5-22; quiz 23-4, 2004 Nov-Dec.  [PUBMED Abstract]
   
   
6. Mystakidou K, Tsilika E, Parpa E, et al.: Psychological distress of patients with advanced cancer: influence and contribution of pain severity and pain interference. Cancer Nurs 29 (5): 400-5, 2006 Sep-Oct.  [PUBMED Abstract]
   
   
7. Mercadante S, Portenoy RK: Opioid poorly-responsive cancer pain. Part 1: clinical considerations. J Pain Symptom Manage 21 (2): 144-50, 2001.  [PUBMED Abstract]
   
   
8. Otis-Green S, Sherman R, Perez M, et al.: An integrated psychosocial-spiritual model for cancer pain management. Cancer Pract 10 (Suppl 1): S58-65, 2002 May-Jun.  [PUBMED Abstract]
   
   
9. Bruera E, MacMillan K, Hanson J, et al.: The Edmonton staging system for cancer pain: preliminary report. Pain 37 (2): 203-9, 1989.  [PUBMED Abstract]
   
   
10. Bruera E, Schoeller T, Wenk R, et al.: A prospective multicenter assessment of the Edmonton staging system for cancer pain. J Pain Symptom Manage 10 (5): 348-55, 1995.  [PUBMED Abstract]
    
    
11. Nekolaichuk CL, Fainsinger RL, Lawlor PG: A validation study of a pain classification system for advanced cancer patients using content experts: the Edmonton Classification System for Cancer Pain. Palliat Med 19 (6): 466-76, 2005.  [PUBMED Abstract]
    
    
12. Fainsinger RL, Nekolaichuk CL, Lawlor PG, et al.: A multicenter study of the revised Edmonton Staging System for classifying cancer pain in advanced cancer patients. J Pain Symptom Manage 29 (3): 224-37, 2005.  [PUBMED Abstract]
    
    
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14. Bruera E, Willey JS, Ewert-Flannagan PA, et al.: Pain intensity assessment by bedside nurses and palliative care consultants: a retrospective study. Support Care Cancer 13 (4): 228-31, 2005.  [PUBMED Abstract]
    
    
15. Jensen MP, Karoly P: Measurement of cancer pain via patient self-report. In: Chapman CR, Foley KM, eds.: Current and Emerging Issues in Cancer Pain: Research and Practice. New York, NY: Raven Press, 1993, pp 193-218. 
    
    
16. Hølen JC, Hjermstad MJ, Loge JH, et al.: Pain assessment tools: is the content appropriate for use in palliative care? J Pain Symptom Manage 32 (6): 567-80, 2006.  [PUBMED Abstract]
    
    
17. Mercadante S, Radbruch L, Caraceni A, et al.: Episodic (breakthrough) pain: consensus conference of an expert working group of the European Association for Palliative Care. Cancer 94 (3): 832-9, 2002.  [PUBMED Abstract]
    
    
18. Mystakidou K, Tsilika E, Parpa E, et al.: Exploring the relationships between depression, hopelessness, cognitive status, pain, and spirituality in patients with advanced cancer. Arch Psychiatr Nurs 21 (3): 150-61, 2007.  [PUBMED Abstract]
    
    
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