Pain

Key points

  • Screen for pain regularly
  • When pain is present, perform a comprehensive assessment.
  • Identify those for whom special care is required, including:
    • The elderly
    • Those with comorbidities including renal and hepatic impairment, low platelets, peptic ulcer disease
    • Those undergoing surgery
    • Those who do not speak English
    • Those with a high risk of opioid misuse.
  • Review pain control regularly: for severe pain - review within 24 hours.
  • Prevent and manage adverse effects of analgesia, including constipation.

Assessment

  • Complete a comprehensive pain assessment if either of the following apply:
    • a new patient reports a pain score of 2 or more on self-reported numerical rating scale of zero to 10;   
    • an existing patient reports a new pain or a sudden, unexpected change in intensity of pain.
    • An alternative screening tool is the Wong-Baker Faces tool
  • A comprehensive pain assessment addresses the following:
    • Disease status and treatment
    • Pain severity (using a validated tool)
    • Pain experience
    • Current and previous management of pain
    • Pain meaning
    • Psychosocial status, including risk factors for opioid misuse
    • Cognitive function
    • Physical examination, and where needed, further investigations
    • Functional status
    • Risk factors for poorly controlled pain
    • Patient and family preferences (goals and expectations for comfort, advance directives)
    • Factors suggesting an oncological emergency.
    • See Cancer Pain Wiki Assessment
  • Reassess whenever there is a change in pain or a new pain.

Approach to management

  • Principles of pain management include:
    • Communication with patient and caregiver, education, and a focus on self management
    • Pharmacological management
    • In cancer patients - consider anticancer therapy
    • Interventional approaches for non-responsive severe pain
    • Non-pharmacological management.
  • Review pain control regularly (for severe pain - within 24 hours).
  • Provide regular analgesia for persistent pain.
  • Opioid analgesia is required in cancer patients with persistent pain that does not respond to simple analgesics or non-steriodal anti-inflammatory drugs (NSAIDs).
  • Ensure the patient on regular opioids has access to a breakthrough at an effective dose - around one sixth the total daily dose.
  • Prescribe and educate about use of laxatives, and offer PRN antiemetics.
  • Manage adverse effects.
  • Consider the need for adjuvants eg, for neuropathic pain.

Flowchart - Pain assessment and management

Cancer Guidelines Wiki: Overview of pain assessment and management in cancer

Ref: Australian Adult Cancer Pain Management Guideline Working Party. Australian clinical pathway for screening, assessment and management of cancer pain in adults. Sydney: Cancer Council Australia.


Prescribing guidance - Pain

Cancer Guidelines Wiki: Pharmacological management

This guideline provides brief, point-of-care recommendations for screening, assessment and management of cancer-related pain in adults. It focuses on chronic pain rather than acute pain caused by cancer treatments or pain in cancer survivors (which is best addressed by referral to a specialist pain medicine physician).

Ref: Australian Adult Cancer Pain Management Working Group. Pharmacological management [Internet]. 2014 [updated 2014 Jun 6; cited 2015 May 01].


Opioid calculator for opioid dose conversions

EviQ opioid calculator

Use the EviQ opioid calculator to assist with estimating equianalgesic doses of opioids

Register for free to access this tool.

From: Cancer Institute, NSW.


Assessment tool - Wong Baker Faces tool

Wong Baker Faces tool

A pain assessment tool developed for use in children, suitable for anyone over the age of 3

Ref: Wong DL, Baker CM. Pain in children: comparison of assessment scales. Pediatr Nurs. 1998 Jan-Feb;14(1):9-17. (3.20MB pdf)


Assessment tool - Abbey Pain Scale

Abbey Pain Scale (125kb pdf)

A pain assessment tool developed for use in those with dementia who are unable to communicate

Ref: Abbey J, De Bellis A, Piller N, Esterman A, Giles L, Parker D, et al. Abbey Pain Scale. Funded by the JH & JD Gunn Medical Research Foundation 1998–2002.


More information - Pain assessment in older people

Pain management poster (2.25MB pdf)

Contains information on identifying pain types, signs of pain in older people, and non-pharmacological options for pain management

Ref: Pain in Residential Aged Care Facilities - Management Strategies. The Australian Pain Society, 2005.


Evidence summary - Pain

Pain
Summarises the palliative care literature

From: CareSearch



Patient / Caregiver resource - Overcoming cancer pain: A guide for people with cancer, their families and friends

Overcoming Cancer Pain

The booklet includes information, resources (eg, helplines), a pain measurement scale and a prompt list of questions to ask medical staff.

Ref: Lovell M, Boyle F. Overcoming Cancer Pain. Cancer Council Australia; 2013 Nov.


Patient / Caregiver resource - Pain diary

My Pain Diary (518kb pdf)

To assist patients to monitor and manage their pain.

From: NPS Medicinewise


Assessment tool - Numerical rating scale for pain (NRS)

Cancer Guidelines Wiki: Pain scale

A self-assessment scale for pain

Verbal: What number describes your worst/average pain, where zero is no pain and ten is worst pain you can imagine
 
Written: Please circle the number that best describes your worst/average pain over the past 24 hours:


Ref: Australian Adult Cancer Pain Management Working Group. Pain scale [Internet]. 2012 [updated 2012 Oct 25; cited 2015 May 04].

Last updated 16 February 2017