Pain and Pain Management
In June 2001 a California jury awarded $1.5 million to the family of a terminally ill eighty-five-year-old man, finding the doctor liable for elder abuse and reckless negligence because he had failed to order appropriate pain medication. This court judgment brought the issue of pain control for the terminally ill into sharper focus. The thought of dying in pain can contribute to the desire for suicide or assisted suicide. Since the 1990s a movement has emerged to improve pain management and thereby reduce the anxiety of both patients and caregivers.
What Is Pain?
Pain has been characterized in a variety of ways. There are physical definitions such as an unpleasant sensation; a warning that something is wrong; or the body's response to a thermal, chemical, or mechanical injury. There are also definitions that attempt to provide a meaning or explanation. For example, pain is a punishment; it lets the body know it is alive; it is a teacher helping to modify future behavior; or it is "all in one's head."
Two definitions have become particularly influential among health care providers, educators, and researchers. The International Association for the Study of Pain (IASP) proposes that pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Margo McCaffery suggested as early as 1968 the widely accepted definition, "Pain is whatever the experiencing person says it is, existing whenever the experiencing person say it does" (McCaffery and Beebe 1989, p. 7). Both definitions point to the fact that pain is much more than tissue damage that triggers a response from the nervous system. The management of pain therefore involves more than treating the tissue injury. The individual's cultural background, present circumstances, and state of mind all require assessment and attention. It has become clear that cultural learning leads to differences in the way that people express pain. Furthermore, it is also becoming increasingly accepted among the medical community that, in contrast to previous medical beliefs, children feel pain even when they are too young to express it effectively. Elderly people may also have different, less obvious, ways of expressing pain, especially if affected by Alzheimer's disease. Health care providers are therefore improving their expertise in recognizing signs of pain across a broad span of patients.
How Does Pain Work?
Research about pain is still limited, but is going forward on many fronts. A major focus is the search for a molecular description of how a pain stimulus is signaled to the brain and how the brain signals its response. Until that process has been firmly identified, caregivers and researchers can utilize the following overview of pain pathways.
Cell damage occurs. Proteins trigger specific channels that set off the pain signal. As chemicals are released the area becomes inflamed and swollen. Identification of the specific pain channels may lead to the development of highly selective local anesthetics with reduced side effects for the rest of the body.
When the tissue damage threshold is reached, nerve fibers in the area carry a message to the spinal column. There are three types of nerve fibers, each of which has a distinctive role in producing pain sensations. Small, myelinated fibers known as A delta carry localized and sharp thermal and mechanical impulses to the neospinothalamic tract. The small, unmyelinated C fibers carry aching, throbbing, burning, dull, unlocalized messages to the paleospinothalamic tract and on to the brain stem and thalamus. A beta fibers, which are large and myelinated, serve to inhibit impulses from the A delta and C fibers, thereby modulating the number and intensity of impulses sent up the spinal tracts.
The physiologist Patrick Wall, one of the world's foremost authorities on pain, describes what happens in the dorsal horn of the spinal cord, "If the input message comes only from the large A beta fibers as a result of touch, the cell fires briefly and then is turned off. If, however, the input volley comes from tissue damage detection fibers, A delta and C, the cell fires more vigorously and exaggerates the output. During all this time, the brain is sending down control messages to amplify, diminish, or ignore the signal" (Wall 2000, p. 40). An example of this occurs when hitting one's shin on a sharp object. The immediate response is to reach down and rub the area. The rubbing message is carried by the A beta fibers closing the gate to messages from the A delta and C fibers.
Once in the spinal cord the messages cross to the opposite side of the spinal column. Next they travel upward through the spinothalamic tract, conveying information about the nature and location of the stimulus to the thalamus, cerebral cortex, and spinoreticular tract. This process activates autonomic and limbic (motivational-affective) responses in the brain stem and thalamus. Messages descend the spinal cord as a result of these responses.
It is in the brain stem and the cerebral cortex that the pain messages are analyzed. Here the body meets the mind. While little research is available, there are theories and some pieces of the puzzle to suggest what is happening.
Endorphins. Endorphins are important pieces of the puzzle. Scientists know something of the body's defenses against pain. Some neuropeptides, such as Substance P, appear to be pain specific transmitters. Other peptides, such as the endorphins and enkephalins, provide profound analgesic (pain-relieving) effects. Morphine and other opioid medications were in use long before the opioid receptor sites in neural tissue were discovered in the 1970s. The word endorphin was coined as a contraction to the terms endogenous (meaning "a natural property of the body") and morphine. Methods to turn on secretion of the endorphins have been studied. Massaging or moving a painful part may owe some of its effectiveness to stimulating endorphin production. The "runner's high," a good feeling as a result of exercise, has also been attributed to endorphin release.
Placebo response. Less well explained is the "placebo effect." This occurs when a treatment produces an effect primarily because of its intent rather than its specific therapeutic physical or chemical properties (e.g., taking a pill that actually contains no medicine). People sometimes report that they feel better even though they have had only the expectation and appearance of a treatment. The double-blind research technique that pits a new drug against an inactive substance has been developed to offset the placebo effect. The placebo would be expected to produce no effects. In actuality, however, placebo users frequently report positive effects. An important aspect of the placebo effect seems to be that the person trusts the person administering the treatment and believes that the treatment will be effective. The placebo effect can be a useful supplement to therapeutic treatment but its effectiveness differs markedly from person to person and is not entirely reliable.
Both the presence of endorphins and the well-documented placebo response point to the power of the mind-body connection in pain management.
Treatment of Pain in the Terminally Ill Person
Pain is the most common symptom experienced by hospice patients. The World Health Organization has estimated that more than two-thirds of patients in the advanced stages of cancer experience pain. Other studies confirm this estimate. Unrelieved pain leads to fatigue, nausea, and loss of appetite. Daily activities and sleep patterns are disrupted. The patient may experience depression and anxiety that damage relationships because loved ones do not know what to say or do.
Careful assessment of the patient's pain is the starting point for achieving adequate control. Patient and family understanding of the purpose and goals of assessment enhance communication with the health care provider. Patient communication starts with awareness of the location, quality, and intensity of the pain. "Stabbing," "throbbing," "burning," or "cramping" help identify the quality of the pain. Choosing words carefully can help the health care provider understand the pain and monitor changes in the quality over time.
The intensity of pain is often monitored through the use of a pain scale, typically asking the patient to choose a number from one (no pain) to ten (worst pain). The Waley/Baker Faces Rating scale, depicting five faces (from smiling to frowning with tears) assists children and some adults to indicate pain intensity. Health care providers also ask about the factors that precipitate or aggravate the pain. Patients are asked to identify any ways they may have discovered to control the pain and how they carry on with their activities of daily living.
Understanding the meaning of pain can be elusive for both the patient and his or her family and the health care provider. The patient's background, beliefs, and values can affect how the pain is interpreted and consequently the expectations for pain control. For example, some children have been raised to bear scrapes and injuries without tears and sobs, and some have learned to keep their vulnerabilities to themselves when in the company of strangers. Still others have been taught that suffering is a test of spiritual strength, therefore it is a moral weakness to admit to pain. People with such backgrounds may inhibit their expressions of pain even during a terminal illness. It is then up to the caregivers to detect signs of suffering and provide relief without challenging the patient's intention to appear in control of herself.
Thorough assessment of the many factors of pain is essential when selecting appropriate treatment. The patient and health care provider form an active collaboration. Confidence that the health care provider understands the patient and that the pain will be managed is a crucial first step to
Techniques to Control Pain
Often patients and family assume that new and increasing pain must be expected. In actuality, a search for cause should be conducted at the earliest possible time. Identifying potential causes of pain can lead to effective prevention and control. The same approach should also be used with regard to other symptoms, such as constipation, pressure ulcers, and respiratory difficulties. These symptoms can often be prevented with attentive care.
Regular comfort measures deserve constant attention. As energy for activities of daily living and self-care wanes near the end of life, it is not uncommon for the patient to omit regular movement, mouth care, and basic physical cleanliness. Assistance with passive exercises, bathing, tooth brushing, and hair care may not seem like pain control, but in actuality these details can play a big part in maintaining comfort. A warm shower, if possible, provides dermal stimulation, relaxation of muscles, and a decrease in anxiety because it is such a routine part of life.
Use of Noninvasive Pain Control Measures
The first methods of pain control probably included stimulation of the skin with heat, cold, massage, and vibration, all of which have the ability to relieve pain without causing injury, at a low cost, and with little experience. Other types of stimulation of the skin include massage with mentholbased lotions, transcutaneous electrical nerve stimulation (an electrical current administered through skin patches), and acupressure (gentle pressure applied to acupuncture points).
Rubbing a bumped shin or applying a cool cloth to a forehead works to relieve discomfort. A parent's kiss to make everything "all better" helps a child through a painful experience. It reminds the individual that the presence of a loved one has a role in relieving pain.
Assisting the patient to focus attention on stimuli other than pain is another effective noninvasive pain control measure. Because the pain stimulus does not go away, but instead becomes "more bearable," this strategy has the advantage of being under the patient's control. It is also inexpensive. Many patients use the distraction strategy without realizing it by watching television, reading, doing crossword puzzles, listening to music, or attending to the company of friends and relatives. Meditation and guided visual imagery are also in this group of therapies. A disadvantage is that the existence of the pain may be doubted by others if the patient can be distracted. Distraction requires concentration and may drain the energy resources of the patient, perhaps leading to increased fatigue and irritability. The method is particularly effective for brief painful episodes.
Freedom from skeletal muscle tension and anxiety produces the relaxation response, characterized by specific physiological responses (decreased oxygen consumption, decreased respiratory rate, decreased heart rate, decreased muscle tension, normal blood pressure, and increased alpha brain waves) and a lowering of the subjective sense of distress. Conscious attempts can be made to interrupt the cycle of pain that leads to anxiety and muscle tension with increased pain as a result. The relaxation response requires active patient involvement. Many patients need specific instruction to invoke the relaxation response effectively. Some techniques include deep breathing exercises, jaw relaxation, review of peaceful past experiences, and a meditative or progressive relaxation script or tape.
Use of medication. While the noninvasive therapies are useful for mild pain, they should be considered supplements to the effective management of moderate to severe pain. Moderate to severe pain are often treated with medication and invasive pain control measures.
The World Health Organization developed the "analgesic ladder" to illustrate a systematic plan for the use of pain medication. Mild pain is treated with medications such as aspirin, acetominophen, and non-steroidal anti-inflammatory drugs (NSAIDs). Maximum recommended doses of these drugs restrict amounts in order to prevent toxicity and damage to the liver and kidneys. As pain increases, opioids such as oxycodone may be used. Severe pain requires morphine or other long-acting opioids. The dose is matched to the pain level. Although there are side effects to these drugs, the amount of drug is not limited. If pain level increases, the route by which the medication is given may change from the slower acting oral route to a faster route, whether transdermal, transmucosal, or intravenous. It is important to avoid routes that actually cause pain, such as intramuscular injection.
For continuous pain, medical practitioners often maintain that continuous pain medication should be available. This requires drugs that are long acting and given on a continuous schedule. The goal is to keep pain in check, rather than waiting until it is out of control before administering more medication.
Side effects of the drugs should be anticipated and prevented. The most common and preventable side effect of the opioids is constipation. Prevention includes adequate fluid and fiber intake and the possible use of stool softeners and laxatives.
It is important to remember that withstanding pain uses energy. When pain is first adequately relieved with medication, the patient may sleep for an extended period of time. This sleeping does not indicate that too much medication is being taken, it means that the person's body is recuperating and regaining energy. This sleepiness can lead family and caregivers to fear that the disease is progressing or that too much medication is being given. If the person arouses easily, then it is an indication that he or she is not taking too much medication.
Invasive Pain Relief Strategies
Some approaches to pain relief are called invasive because tissue damage may be caused by the procedure itself. The procedure may involve stimulation of nerves, the spinal cord, or areas of the brain. Blocking the nerves with medication or by actually cutting the nerve may reduce pain. These approaches may be useful if the patient is not able to withstand extensive surgical procedures. Acupuncture is considered an invasive approach to pain because the needles enter the skin. It is unknown whether acupuncture analgesia is superior to placebo analgesia or other types of hyperstimulation procedures.
The fear of unrelieved pain raises anxiety for terminally ill patients and their families. Many caregivers remember instances when they felt helpless in the face of pain. Giving the patient information about pain leads to better pain control and lowered anxiety. The confidence that pain will remain in control and the continued presence of the health care provider can go a long way to assure that pain will not be an issue at the end of life.
The patient plays a significant role in providing information about the pain and in selecting and using diverse pain control methods. The patient is the best judge of the adequacy of control. Caregivers may hear statements such as the following that express personal preference:
- • "It is okay if I only have pain when I move."
- • "I want to continue to be up and walking, so I will need more medication."
- • "A warm shower, meditation, and pain medication at bedtime helps me get a good night's sleep."
- • "I just want to have no pain. I don't care if all I do is sleep."
The adequacy of pain control can be judged by the patient's feeling of comfort and ability to participate in activities of daily living. The goal of complete freedom from pain may not be achievable.
Fear of addiction is often an issue with pain control, especially when opioids are used. Psychological dependence is a pattern of compulsive drug use characterized by a continued craving for an opioid and the need to use the opioid for effects other than pain relief. Addiction resulting from medical treatment regimen is extremely rare. On the other hand, the need to increase doses over time is not uncommon because of tolerance for the drug or changes in the disease process. Other drugs may be added to the regime. Medical practitioners cite the importance of not abruptly stopping the medications.
Health care providers themselves may be a barrier. It is important to seek out providers who believe the pain is real, who are willing to provide diverse approaches to the pain, and who plan for continued contact. Concerns about providing sufficient medication to relieve pain without precipitating the death of a terminally ill person should be discussed openly. If large doses of opioids are required, the physician may be hesitant to order them and nurses may be reluctant to administer the needed dose because the actions might be considered performing euthanasia or assisting suicide. The line between relieving pain and hastening death may not be clear. Patients can help with the ethical issues by making their wishes clear and by seeking the assistance of a like-minded counselor or medical professional in explaining their preferences.
Pain Management: The Future
Research concerning the physiologic mechanisms of pain continues in the early twenty-first century. These research efforts will most likely reveal new, more specific pain control measures. In the meantime, the controversy between governmental control of opioids to prevent abuse and the need for opioid use for pain relief continues. Professional care providers need education and organizational support that establishes standards and accountability for pain management. A recent initiative to require that pain be assessed as often as the patient's temperature, heart rate, respiratory rate, and blood pressure are taken provides a starting place for standards and accountability. Dissemination of information about pain-relieving drugs and other interventions remains crucial to quick, effective responses to pain. Access to analgesic medication and pain is crucial. Paying for the cost of health care should not become a barrier to pain management. Professionals must continue to advocate for patients in pain as American society struggles to afford health care for the entire population.
The public should be appropriately educated about pain and pain relief if it is to advocate for the use of pain medications. Fears that medication will cause addiction and the inability to experience and control life decisions prevents use of some effective pain measures. Patients' fear of stigma if they offer complaints of pain can keep providers from understanding patients' extent of pain and thus appropriately treating it.
Researchers and leading edge practitioners agree that people in pain can be empowered by knowing what to expect from health professionals in relation to pain management. Assessment of the pain and its causes is the first step. Professionals should seek a clear understanding of the meaning of the pain to the patient and family. Multiple approaches to the pain can be recommended. Concerns about addiction and other effects of the controls measure can be addressed through patient education and referral to pain specialists. The knowledge, skills, and tools exist to meet the goal that no one should die in pain.
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McCaffery, Margo, and Alexandra Beebe. Pain: Clinical Manual for Nursing Practice. St. Louis, MO: C. V. Mosby, 1989.
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P ALLIATIVE C ARE
See H OSPICE O PTION .
See E MERGENCY M EDICAL T ECHNICIANS .