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Managing chronic pain in adults NS765 Barrie J, Loughlin D (2014) Managing chronic pain in adults. Nursing Standard. 29, 7, 50-58. Date of submission: May 1 2014; date of acceptance: July 11 2014.

Aims and intended learning outcomes

Abstract The management of chronic pain is complex. Services and support for people living with chronic pain are variable despite the publication of a number of reports highlighting the problem. Due to the epidemiology of pain, nurses deliver care to patients with persistent pain in a variety of settings. It is important that nurses have the knowledge, skills and correct attitude to deliver compassionate, person-centred care, in line with best practice in chronic pain management.

Authors Janette Barrie Nurse consultant for long-term conditions, NHS Lanarkshire, Community Health Services, Buchanan Centre, Coatbridge, Scotland. Diane Loughlin Lecturer in Adult Nursing, University of West of Scotland, Hamilton, Scotland. Correspondence to: [email protected]

Keywords Chronic pain, complex pain, long-term conditions, non-pharmacological management, pain assessment, pain management, person-centred care, pharmacological management, older adults

Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software.

Online For related articles visit the archive and search using the keywords above. To write a CPD article: please email [email protected] Guidelines on writing for publication are available at: rcnpublishing.com/r/author-guidelines

The aim of this article is to provide the reader with an overview of chronic pain in adults, its assessment and management. After reading the article and completing the time out activities you should be able to: Describe the multidimensional nature of chronic pain. Discriminate between nociceptive and neuropathic pain. Discuss factors that influence pain assessment in adults. Describe a comprehensive assessment of an adult patient with complex pain. Outline the pharmacological management of chronic pain. Outline the benefits of multidisciplinary pain management.

Introduction The International Association for the Study of Pain (IASP) (2012) defines pain as an ‘unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage’. It further defines chronic pain as pain without apparent biological value that has persisted beyond normal tissue healing time, usually three months. Reports highlighting the prevalence of chronic pain, deficiencies in services for people with chronic pain and a variable level of knowledge and understanding within practitioner groups have been published (NHS Quality Improvement Scotland (QIS) 2008, Department of Health 2009, Healthcare Improvement Scotland 2014). The management of chronic pain presents a challenge for healthcare practitioners of all

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disciplines. Although it is a common condition, with epidemiological studies indicating a prevalence of between 11% and 36% (Breivik et al 2006, Azevedo et al 2012, Scottish Intercollegiate Guidelines Network (SIGN) 2013), patients report complex and sometimes difficult journeys to access the right services and support. Chronic pain can be a concern for patients who may think a surgical procedure related to the pain has gone wrong or that an additional pathological process is present requiring further investigation (Goubert et al 2004). Chronic pain can affect every aspect of the patient’s life.

Effect of chronic pain Pain is subjective with no two people responding in the same way to a similar situation. Chronic pain has a detrimental effect on all aspects of health, with tolerance being exacerbated by personality and pre-existing psychological experiences (Pudner 2010). Chronic pain is associated with many long-term conditions, such as osteoarthritis, rheumatoid arthritis and multiple sclerosis; however, it is also recognised as a condition in its own right (NHS QIS 2008). The personal effects of living with chronic pain include sleep disturbance, fatigue (Wong and Fielding 2012), helplessness and depression (Chiu et al 2005). The emotional effect of chronic pain is well recognised, with patients reporting loss of employment, breakdown of relationships, and feelings of social isolation. It is therefore not surprising that a connection between chronic pain and depression has been established (Fishbain et al 1997). The financial implications for the individual and to the healthcare system are significant. The mean direct and indirect costs of chronic pain in Ireland were estimated at €5,665 (£4,408) per patient, per year across all grades of chronic pain (Raftery et al 2012). In considering the connection between chronic pain, long-term conditions and an ageing population, a high prevalence of chronic pain in the older adult population would be expected. However, in some studies, the highest prevalence was found in those aged 50-60 years – people of working age who are actively participating in society and perhaps with families to support (Breivik et al 2006). Complete time out activity 1

Types of pain and their assessment Identifying the type of pain is essential because this will influence the patient’s treatment decisions and management plan. Traditionally, pain has been categorised as nociceptive or neuropathic. Nociceptive pain is related to a physical cause. This physical cause stimulates pain receptors in the tissue and pain messages are relayed via the spinal cord to the brain for processing and response. This pain is usually considered as a warning of possible or ongoing tissue damage and prompts a response that removes the person from harm (Godfrey 2005). Neuropathic pain can be of peripheral or central origin depending on the area affected and is caused by a lesion or disease of the somatosensory nervous system (IASP 2012). In many cases, the pain will stop when damaged tissue heals; however pain may continue for some individuals beyond what is considered usual healing time. While clear recognition of the type of pain would be expected, patients with chronic pain can present with a complex mixture of nociceptive and neuropathic pain, reinforcing the importance of clinical examination and accurate and detailed assessment. As a result of the subjective nature of pain, the patient’s self-report of pain should always be included in any assessment. Several assessment tools are available to assist the assessment of pain. While these assessment tools have been shown to be useful in pain research, they should also be practical to use in a clinical setting. Visual analogue scales are useful to establish the pain intensity using

BOX 1 Case study Kevin, a widower, aged 72, was referred to the pain clinic with chronic abdominal pain by the GP. He was unable to sleep at night, was fatigued during the day and was unable to concentrate on his usual hobbies. He had no motivation to cook and had lost his appetite. His daughter visits two or three times per week. His son lives 200km away and visits every few months, although he telephones his father every week. Previously Kevin had undergone three major abdominal operations and the pain appears to be related to extensive adhesions. He feels unable to cope with yet another operation and will not consider this as a pain management option. Kevin now feels he has to live with the pain.

1 Read the scenario in Box 1 and consider what factors might lower Kevin’s tolerance to pain. How might these factors be changed to increase his pain tolerance and coping strategies?

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CPD pain management a numerical, vertical or horizontal scale (SIGN 2013). However, the effect of chronic pain on the patient’s ability to function, and on his or her mood and quality of life should be established. Some assessment tools can be found at: http://prc.coh.org/pain_ assessment.asp To identify the presence of neuropathic pain, several screening questionnaires are available and can be used in conjunction with clinical examination and history taking. These include (Haanpää et al 2011): Leeds Assessment of Neuropathic Symptoms and Signs (LANSS). Neuropathic Pain Questionnaire (NPQ). Douleur Neuropathique en 4 Questions (DN4). PainDETECT. ID-Pain. Patients can describe distinctive features of neuropathic pain such as the sensation of burning, shooting, electric shocks or numbness. They may also describe allodynia, a painful response to a stimulus that would not normally cause pain. Allodynia is commonly described by patients with post-herpetic neuralgia or chronic surgical pain and can be distressing. Some features of neuropathic pain are outlined in Box 2. Complete time out activity 2

2 Neuropathic pain is associated with sensory changes. Consider some examples that you may have observed in patients. List five actions that could be taken to help address this pain. What resources are available to nurses and patients? 3 What pain assessment tools are used in your clinical area? Are these tools appropriate for use for patients experiencing chronic pain? List any potential barriers that exist within the clinical team that might hinder the effective use of these tools.

Patients may experience multiple types of pain and the use of a body chart during consultation is effective and may

BOX 2 Common terms used to describe neuropathic pain Allodynia – pain as a result of a stimulus that would not usually cause pain, for example a light, gentle touch, or clothing touching the area. Dysaesthesia – an unpleasant sensation, which can be spontaneous or evoked. Hyperalgesia – an increased response to a stimulus that would usually be considered painful. Hyperaesthesia – an increased sensitivity to stimulation, for example heat or touch. Hypoalgesia – a diminished response to a stimulus that would usually cause pain. Hypoaesthesia – a decreased sensitivity to stimulation, for example heat or touch. Paraesthesia – an abnormal sensation, which can be spontaneous or evoked. (Adapted from International Association for the Study of Pain 2012)

help the patient describe each pain in more detail (Türp et al 1998). To assist patients articulate their experience of pain, it is important to show empathy and understanding during the consultation (Chu and Tseng 2013). The assessment may include: Diagnosis of pain – cause of pain, duration. Physical assessment – location of pain, distribution, intensity, quality, strange sensations. Identification of underlying causes of neuropathy, if neuropathic pain is present. Identification of comorbidities. Evaluation of psychosocial factors – relationship with family members, loss of employment, ongoing litigation, depression, self-motivation. Evaluation of functional status (activity levels) – physical deconditioning. Assessment of current and previous medication administered: possible interactions, side effects, and if it was discontinued, why. Determination of the personal outcome the patient would like to achieve. Identification of achievable goals with the patient. Development of a targeted treatment plan to monitor progress. Determination of when to refer to a specialist or multidisciplinary team (pain clinic) if necessary. The duration of pain is important, and any change in the character of the pain or any reports of new pain should be evaluated further (NHS QIS 2006).

Chronic pain assessment pathway To agree a management plan with the patient, accurate assessment of the patient and the pain experienced is essential. Given the multidimensional effect of chronic pain, assessment must include all elements to inform a comprehensive plan of management, which should also include a self-management approach. Management of Chronic Pain (SIGN 2013) states that the type of pain, and its severity and effect should be assessed before treatment is started. This will provide a baseline on which to measure effect, progress and possible adverse effects of treatment. Complete time out activity 3

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A detailed history, physical examination, and assessment of the type of pain, function and full biopsychosocial assessment is recommended and considered good practice, although no specific assessment tools are identified (SIGN 2013). To assist this approach, an assessment pathway is presented that includes elements of what would be considered a comprehensive assessment (Figure 1). A more detailed interactive pathway is available at The British Pain Society website (www.britishpainsociety.org). As a result of the complex nature of the condition, the patient should be allowed sufficient time to tell their story and for the clinician to identify the type of pain and the effect on quality of life. Investing time at this stage may improve outcomes for patients (SIGN 2013). A person-centred approach is suggested and patients should be actively encouraged to participate in agreeing the management plan.

Psychological risk factors The psychological risk factors that may hamper a patient’s progress are known as ‘yellow flags’. These relate to the patient’s attitude, beliefs, emotions and behaviours, and his or her family and workplace. Yellow flags were initially developed to screen patients who may be at risk of developing disability from musculoskeletal pain and who could benefit from early referral for psychological support. Psychological yellow flags include (Nicholas et al 2011): The belief that pain is harmful or severely disabling. Fear avoidance behaviour – avoiding activity because of fear of pain. Low mood or social withdrawal. Expectation that passive treatment rather than active participation will help. Where a patient exhibits psychological risk factors, practitioners should reinforce positive strategies and agree an achievable action plan with the patient to minimise the risk of disability. Complete time out activities 4 and 5

high as 50% in the community, while up to 80% of care home residents report poorly managed intractable pain (Abdulla et al 2013). Good observational skills could highlight that an older person is experiencing pain, even if it is denied. It is possible that the presence of comorbidities may reduce an

FIGURE 1 Chronic pain assessment pathway Patient presents with chronic pain

Using a person-centred approach, explain options and involve patients in decisions

Consider serious pathology and investigate if necessary

Identify the duration of the pain

Assess pain severity at different sites

Identify if there is an element of neuropathic pain present

Assess functional effect as part of biopsychosocial assessment

Identify patients at increased risk of poor outcomes; consider comorbidities, yellow flags and full biopsychosocial assessment

Listen actively, validate and educate

Assist in the development of self-management skills and support the patient

Encourage the patient to stay active and stay at work

Pain in older adults The presence of pain in older adults is often underreported and as a consequence may remain undermanaged. Undertreated pain in the older population is thought to be as

Agree pain management plan (Adapted from Scottish Intercollegiate Guidelines Network 2013)

4 Reflecting on some of the patients in your clinical area, list the main reasons why pain might be undertreated in older patients. 5 In your own words, explain the challenges that exist when assessing pain in older adults.

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CPD pain management individual’s ability to recognise a new pain source and, despite almost no physiological difference in the pain pathway of an older person, many accept pain as part of the ageing process (Pudner 2010). Assessment of pain in older adults can be further complicated by communication difficulties. Many older people can have problems with their vision, hearing difficulties or cognitive impairments, which can affect the usefulness of visual pain assessment tools. Therefore, more time may be required to undertake initial assessment, repeat assessment questions and allow the patient time to respond (Herr and Garand 2001). Observational and behavioural assessment tools can be helpful in these circumstances to ensure pain is recognised and managed as efficiently and effectively as possible. Examples of observational and behavioural pain assessment scales include: Doloplus-2 scale (Lefebvre-Chapiro 2001). Abbey pain scale (Abbey et al 2004). PAINAD (Pain Assessment in Advanced Dementia) scale (Warden et al 2003). PACSLAC (Pain Assessment Checklist for Seniors with Limited Ability to Communicate) scale (Fuchs-Lacelle and Hadjistavropoulos 2004).

Pharmacological management Pharmacological therapies are often the first step for patients in the management of chronic pain. Numerous analgesics are available and response to these preparations is variable, therefore detailed assessment and identification of the type of pain can help inform the choice of medication and reduce exposure to side effects. Simple analgesics should be considered for patients with mild to moderate pain. Paracetamol can be used as a preparation on its own or in combination with other analgesics (SIGN 2013). However, care should be taken not to exceed the recommended dosage since cases of unintentional overdose have been reported (Guggenheimer and Moore 2011). Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used for patients with inflammatory conditions such as arthritis and have been found to be effective in the management of low back pain (Roelofs et al 2008). However, NSAIDs have been linked to gastric and cardiovascular side effects (Bhala et al 2013).

Opioid analgesics are increasingly being used in the management of chronic pain and can be effective in the short to medium term for patients who are supervised while on opioid therapy and have no history of depression or substance misuse disorders (Noble et al 2010). The British Pain Society (2010) recommends that the patient is screened before opioids are prescribed, is made aware of the risks, is monitored by pain specialists and has regular reviews. Topical preparations are preferred in some circumstances because of the reduced risk of systemic absorption. Topical agents are useful where the pain is localised and easily targeted by application of agents such as capsaicin cream or the use of a lidocaine 5% local anaesthetic patch. This patch is effective in the relief of peripheral neuropathic pain such as that experienced with post-herpetic neuralgia (Dworkin et al 2007). Capsaicin cream is effective for peripheral neuropathic pain and pain from arthritic conditions (Mason et al 2004). However, patient education on the use of capsaicin is essential. Patients should be instructed to wear gloves and to expect a temporary burning sensation on application. Patients should wash their hands immediately following application. Capsaicin is also available in the form of an 8% patch; however, this treatment should be supervised by a pain management specialist. Some anticonvulsant therapies are known to be effective in the management of neuropathic pain (Dworkin et al 2010). The most common anticonvulsants used in the management of neuropathic pain are gabapentin, pregabalin and carbamazepine. Although effective, some patients experience side effects such as sedation, dizziness, peripheral oedema and weight gain. Anticonvulsant therapies should be introduced at low dosages and titrated slowly. Abrupt withdrawal should be avoided (Dworkin et al 2010, McCarberg et al 2012). Tricyclic antidepressants such as amitriptyline and nortriptyline are well proven in the management of neuropathic pain (Lynch and Watson 2006). However, patients report side effects such as dry mouth, sedation, urinary retention and constipation, which can influence the patient’s decision to continue therapy (Dworkin et al 2010). Other antidepressant therapies such as duloxetine are also effective in the

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management of diabetic peripheral neuropathy (SIGN 2013). Complete time out activity 6

Multidisciplinary pain management Given the multidimensional nature of chronic pain, effective pain management depends on a multidisciplinary approach. The main aim of multidisciplinary or interdisciplinary care in pain management is to provide the necessary knowledge and skills related to pain, thus encouraging discussion of all relevant aspects of the patient’s physical and psychosocial needs as well as other factors affecting the patient’s care. Complete time out activity 7 While many patients manage their pain with the help of the GP, there are patients who require specialist multidisciplinary support from the local pain clinic. The aims of a multidisciplinary approach to pain management are to: Provide biopsychosocial assessment of pain. Decrease subjective experience of pain. Increase general level of activity. Reduce medication consumption. Help the patient return to employment where possible, or improve quality of life. Provide education. Promote self-management. For patients whose pain has a behavioural component such as fear avoidance, for example where exercise or tasks are avoided for fear of causing further harm, and for patients who use passive coping strategies, a multidisciplinary approach to care has been shown to be effective (Scascighini et al 2008). Elements of a multidisciplinary approach include education on pain, pacing skills, goal setting, physiotherapy, exercise, relaxation and psychology.

attending a pain management programme. This programme is a psychologically based rehabilitative treatment delivered in a group setting. The focus is not on finding a cure for pain, rather it is an approach designed to change behaviour and negative thoughts related to the effects of pain. Programmes are usually spread over a number of weeks and include therapeutic discussion, physical activity, education, pacing, goal setting and an exploration of the relationship between thoughts, feelings and behaviour (The British Pain Society 2013). Therapies such as acceptance and commitment therapy are gaining popularity (Scascighini et al 2008, Dysvik et al 2010, Veehof et al 2011). Acceptance and commitment therapy is a type of cognitive behavioural therapy that has been shown to be an effective treatment for depression, anxiety and pain when delivered by a suitably trained nurse or allied health professional (Veehof et al 2011). This therapy is based on the principle that emotions such as fear, negative memories and symptoms of pain can influence behaviour, leading to psychological inflexibility or avoidance. Through a process of changing the association patients have with the thoughts and emotions connected with pain, it can improve functioning and help the person re-engage with his or her life, despite the presence of pain. The therapy does not attempt to reduce the level of pain – the goal is to improve function and wellbeing (Hayes and Duckworth 2006).

Physiotherapy and exercise The role of physiotherapy and exercise within pain management is well recognised with the assessment and improvement of physical function, a crucial element in rehabilitation and quality of life (SIGN 2013, O’Riordan et al 2014).

Psychological interventions

Transcutaneous electrical nerve stimulation

Assessing patients without addressing the psychological effects of pain can result in failed interventions, with the patient becoming increasingly frustrated. Therefore, within the specialist setting, the value of psychological therapies is well recognised as an important part of the multidisciplinary approach to assist the patient towards self-management. As a result of the psychological effect of pain, some patients may benefit from

Transcutaneous electrical nerve stimulation (TENS) is a frequently used approach to manage pain. It is non-invasive and relies on the delivery of an electrical current by a small device though electrodes applied to the skin at specific points. This electrical current stimulates nerves to alter sensation and is based on the gate control theory proposed by Melzack and Wall (1965). Following instruction and depending on the device chosen, the patient can manipulate

6 Neuropathic pain is often difficult to manage and often requires treatment with medications that are primarily not licensed as analgesics. Read Management of Chronic Pain (SIGN 2013) and note examples of the medications prescribed in your clinical area. 7 List the benefits of having an interprofessional team working in pain management.

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CPD pain management the electrical current at different frequencies to achieve analgesia. Although the evidence of efficacy is variable, patients with specific pain conditions report a temporary improvement in pain (Dailey et al 2013). A recent systematic review of the literature conducted by Johnson (2014) showed that studies using appropriate technique and dosage are more likely to demonstrate clinical efficacy and concluded that TENS should continue to be used as a pain management intervention. TENS machines can be purchased without prescription; however, there are some contraindications to its use and patients should be instructed on how to use the device (Jones and Johnson 2009).

Complementary therapies

8 Make a list of the potential advantages and disadvantages of complementary therapies. Further information on the use of complementary therapies can be found at: http://tinyurl.com/ complementary therapies

Complementary and alternative therapies are actively sourced by patients in an attempt to achieve pain relief. There is a lack of robust scientific evidence to support the efficacy of these therapies. However, patients report that certain therapies, such as reflexology and aromatherapy, assist relaxation and may reduce stress and enhance the ability to cope (Long et al 2001). Anecdotal reports suggest that these approaches are pleasurable, patients feel involved and the therapeutic relationship enhances wellbeing (Lutgendorf et al 2000). However, complementary therapies are often criticised for lack of regulation, and many are not readily available within the NHS, and therefore patients sourcing these therapies privately can find them expensive. Acupuncture has been used in the management of pain for thousands of years. It is an approach that involves the stimulation of specific anatomical points. Although there have been challenges proving the efficacy of acupuncture, there is sufficient evidence to show that it can be an effective approach for the management of back and neck pain (Vickers et al 2012). It can also be an effective adjunct for patients already established on pharmacological preparations who have osteoarthritis of the knee (Maurommatis et al 2012). Complete time out activity 8

Self-management Living with chronic pain can affect every aspect of a person’s life. Undertaking routine tasks is exhausting and can result in many

negative emotions. Healthcare professionals and patients should work collaboratively to manage chronic pain, with the aim of assisting the patient in attaining a sense of control and wellbeing. Therefore, service models for chronic pain should include self-management as an integral component at every level (Long-Term Conditions Alliance Scotland and Scottish Government 2008). Self-management is not an alternative to medical care; it is a collaborative process that includes a range of interventions to help develop coping mechanisms and confidence through information and education (Holman and Lorig 2004). This approach can be delivered on a one-to-one basis, by attending local support groups or structured, professionally led education programmes. However, it is important that attendees are fully engaged in their own health and are willing to participate. In an attempt to promote self-management and improve health outcomes, there is a focus on health literacy. Patients with poor health literacy are thought to be less likely to engage in the management of their condition, have a poor ability to self-manage, and are less likely to adhere to treatment management plans (Andrus and Roth 2002). Given the short duration of a consultation, patients need to have a role in the management of their condition for any treatment plan to be successful. Nurses should provide sufficient information in a manner patients can understand for the patients to gain the necessary skills and confidence to achieve their goals, anticipate when the condition may be changing, and know what action to take to address self-management confidently. Although research is necessary to establish the long-term benefits of self-management approaches, there is sufficient evidence to support its usefulness (Blyth et al 2005).

Specialist services Patients with complex pain problems may require invasive interventions undertaken by medical pain specialists. These invasive interventions include: Local anaesthetic and corticosteroid injections to trigger points. Nerve blocks and epidurals. Insertion of implantable devices. Ongoing management of patients with such complex pain problems requires good

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communication with patients, families, the GP and members of the multidisciplinary pain team.

Conclusion The management of chronic pain in adults is complex. However, a range of treatment options is available, including pharmacological treatment, physiotherapy, exercise, TENS and complementary therapies. Ensuring the patient accesses the most appropriate treatment requires early recognition of chronic pain, a detailed and individualised assessment and a patient-centred approach to care. Nurses have a responsibility to ensure

patients receive effective pain management, regardless of the care setting. Nurses require the correct knowledge, skills and attitude to encourage and support self-management and promote effective pain relief for patients NS Complete time out activity 9

USEFUL RESOURCES The Pain Toolkit: www.paintoolkit.org Action on Pain: www.action-on-pain.co.uk Pain Association Scotland: www.painassociation.com (Last accessed: September 11 2014.)

9 Now that you have completed the article, you might like to write a reflective account. Guidelines to help you are on page 62.

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CPD pain management

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Managing chronic pain in adults.

The management of chronic pain is complex. Services and support for people living with chronic pain are variable despite the publication of a number o...
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