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 or pain score is 3 or more on the Abbey Pain Scale;
    • an existing patient reports a new pain or a sudden, unexpected change in intensity of pain.
  • Choosing an appropriate assessment tool:
    1. Simple pain assessment
      • verbal numeric scale (0 to 10)
      • Pain thermometer – visual tool for older people
      • Verbal descriptor scales
      • Faces pain scale for kids
    2. Complex pain assessment
      • Brief pain inventory
      • Modified brief pain inventory (for RACF)
      • Consider neuropathic screening – LANNS and sLANNS, NPQ or the painDETECT tools
    3. Pain assessment for non-verbal
      • Abbey, PAINad and Doloplus 2 for older people with cognitive impairment
      • Modified PAINad for younger people who are non-verbal (people with a disability)​
  • 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 e.g., for neuropathic pain.

Pain type according to patient descriptions

Identifying the type of pain the patient is experiencing is essential to guide the development of treatment plans and management options for patients. Patient descriptions of pain can help to identify whether it is nociceptive or neuropathic pain. See Cancer Pain Wiki Assessment

  • Nociceptive:
    • Aching
    • Cramping
    • Gnawing
    • Pressure
    • Sharp
    • Stabbing
    • Throbbing
  • Neuropathic:
    • Hot-burning
    • Cutting-lacerating
    • Pins and needles
    • Pricking
    • Tingling
    • Tight-stretched
    • Numb
    • Electric shocks
    • Jumping-bursting
    • Radiating
    • Stabbing-shooting

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

Opioid Calculator

From: Faculty of Pain Medicine, Australian and New Zealand College of Anaesthetists.


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 (3.20MB pdf). Pediatr Nurs. 1998 Jan-Feb;14(1):9-17.


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.


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 28 July 2020