02 PAIN ASSESSMENT

 

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Pain is a universal human experience and the most common reason people seek medical care. Pain tells us something is wrong in the structure or function of our body and that we need to do something about it. Because pain is such a strong motivator for action, it is considered one of the bodys most important protective mechanisms.

Definitions of Pain

The International Association for the Study of Pain defines pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage (2012). Pain, however, is much more than a physical sensation caused by a single entity. It is subjective and highly individual, a complex mechanism with physical, emotional, and cognitive components.

Pain cannot be objectively measured in the same way as, for example, the chemical content of urine or the oxygen content level of blood. Only the person who is suffering knows how the experience feels. For these reasons, McCaffery defined pain as whatever the experiencing person says it is and whenever he says it does (1979). The American Pain Society goes further by stating that it is not the responsibility of clients to prove they are in pain; it is the nurses responsibility to accept the clients report of pain (2009).

Pain alters the quality of life more than any other health-related problem. It interferes with sleep, mobility, nutrition, thought, sexual activity, emotional well-being, creativity, and self-actualization. Surprisingly, even though pain is such an important obstacle to comfort, it is one of the least understood, most undertreated, and oft-discounted problems of healthcare providers and their clients. For this reason, some nurses and therapists add comfort to Maslows hierarchy of basic human needs (1968). The American Pain Society goes further, declaring the relief of pain a basic human right (2009).

Traditionally, pain has been considered merely a physical symptom of illness or injury, a simple stimulus-response mechanism. Though the historic role of nurses has been to relieve pain and suffering, there has been little understanding of the complexity of pain and only limited ways to manage it. Recent research shows pain to be a distinct disorder, with physical, emotional, and cognitive components. This view of pain has broadened our understanding of pain and given us new ways to understand its characteristics.

PAIN-RELATED TERMINOLOGY

Algesia: Sensitivity to pain.

Breakthrough pain: Transitory increase in pain to a level greater than the clients well-controlled baseline level.

Hyperalgesia: Excessive sensitivity to pain.

Idiopathic pain: Pain for which there is no identifiable psychological or physical cause.

Intractable pain: Pain that is not relieved by ordinary medical, surgical, and caregiving measures (Mosbys Dictionary, 2012).

Pain syndrome: A group of symptoms of which pain is the critical element, such as headaches and post-herpetic neuralgia.

Pain threshold: Amount of pain required before individuals feel the pain. The lower the threshold, the less pain they can endure; the higher the threshold, the more pain they can endure.

Pain tolerance: Maximum amount and duration of pain a person can endure. Tolerance varies widely among people and is influenced by emotions and cultural background.

Phantom limb pain syndrome: Pain that occurs in the place of a missing limb after it is removed or as a result of severe damage to the affected nerve plexus due to perceptual disruption in the brain (Mosbys Dictionary, 2012).

Psychogenic pain: Chronic pain with no identified organic explanation.

Radiating pain: Pain that begins at one place and extends out into nearby tissues.

Referred pain: Pain that is felt at a different location than where tissue was damaged. This phenomenon occurs because pain fibers in the damaged area synapse near fibers from other areas of the body; for example, a myocardial infarction may create referred pain in the left shoulder.

Types of Pain

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Pain is classified as acute and chronic. Acute pain has an identifiable cause and occurs soon after an injury to tissues in the body, such as bone, skin, or muscle. Acute pain is protective in that it motivates a person to take action immediately. Its onset may be sudden or slow, and its intensity may vary from mild to severe. Acute pain is temporary and subsides as healing takes place. Severe acute pain activates the sympathetic nervous system, causing diaphoresis, increased respiratory and pulse rates, and elevated blood pressure.

Chronic pain lasts beyond an expected healing phase, is non-protective in that it serves no function, and may not have an identifiable cause (Patterson, 2007). When pain goes on for more than six months, it moves from being a symptom to a condition. Chronic pain afflicts more than 1 in 5 Americans and is one of the most pervasive and thorny medical conditions in the United States. Such pain is described as nonmalignant (noncancerous), malignant (cancerous), and intractable.

                Nonmalignant, noncancerous chronic pain typically accompanies such conditions as osteoarthritis and peripheral neuropathy. The lack of purpose and uncertainty of duration of such pain may lead to depression, fatigue, insomnia, anorexia, apathy, learned helplessness, and other psychosocial consequences. If it is severe, chronic painlike prolonged stressactivates the parasympathetic nervous system, resulting in muscle tension, decreased heart rate and blood pressure, and failure of body defenses.

                Malignant, cancerous chronic pain may be due to tumor progression, invasive procedures, infection, toxicities of treatment, and physical limitations. Such pain may be felt at the tumor site or some distance from it. Since clients with cancer may experience both chronic and acute pain, healthcare providers need to investigate immediately any new pain in these clients.

                Intractable chronic pain is pain from any cause that is resistant to medical, surgical, and nursing measures. Persistent and ongoing, intractable chronic pain may be psychogenic in nature (Mosbys Dictionary, 2012).

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Sources of Pain

The sources (causes) of pain are divided into three main categories: nociceptor, non-nociceptor, and psychogenic.

Nociceptor pain results when tissue damage produces a pain-producing stimulus that sends an electrical impulse across a pain receptor (nociceptor) by way of a nerve fiber to the central nervous system. Nociceptor pain is further divided into visceral and somatic pain.

           Visceral pain results from stimulation of nociceptors in the abdominal cavity and thorax.

           Somatic pain is divided into deep somatic and cutaneous pain. Deep somatic pain arises from bones, tendons, nerves, and blood vessels. Cutaneous pain originates in the skin or subcutaneous tissue. Some body tissues, such as the brain and lung, have no nociceptors, and some tissues have many.

Non-nociceptor (neuropathic) pain is caused by direct injury to structures of the nervous system.

Psychogenic pain is pain for which there is little or no physical evidence of organic disease or identified injury to tissues in the body. Lack of evidence, however, does not mean clients are malingering or that they are not suffering.

PHYSIOLOGIC SOURCES OF PAIN

Source: Adapted with permission from Ignatavicius et al., 1999.

Nociceptor: Visceral

Physiologic structures

Organs and linings of body cavities

Mechanism

Activation of nociceptors

Characteristics

Poorly localized, diffuse, deep, cramping, or splitting

Sources of acute pain

Chest tubes, abdominal drains, bladder and intestinal distention

Sources of chronic pain syndromes

Pancreatitis, liver metastases, colitis

Nociceptor: Somatic

Physiologic structures

Cutaneous: skin and sub-cutaneous tissues 
Deep somatic: blood, muscle, blood vessels, connective tissue

Mechanism

Activation of nociceptors

Characteristics

Well-localized, constant, achy

Sources of acute pain

Incisional pain, insertion sites of tubes and drains, wound complications, orthopedic procedures, skeletal muscle spasms

Sources of chronic pain syndromes

Bony metastases, osteoarthritis, rheumatoid arthritis, low-back pain, peripheral vascular disease

Non-nociceptor (neuropathic)

Physiologic structures

Nerve fibers, spinal cord, central nervous system

Mechanism

Non-nociceptive injury to nervous system structures

Characteristics

Generalized along distribution of damaged nervous structures

Sources of acute pain

Poorly localized: shooting, burning, fiery, shock-like, sharp, painful numbness

Sources of chronic pain syndromes

Nervous tissue injury due to diabetes, HIV, chemotherapy, neuropathies, post-therapeutic neuralgia, trauma, surgery

Psychogenic

Physiologic structures

No organic structures

Mechanism

Emotional

Characteristics

Variable, often numerous

Sources of acute pain

Nonorganic

Sources of chronic pain syndromes

Nonorganic psychological factors

 

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Physiology of Pain

Though a person is not consciously aware of the process, the experience of pain involves a complex sequence of biochemical and electrical events or processes beginning with tissue damage and followed by transduction, transmission, perception, and modulation.

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TISSUE DAMAGE

When tissue is damaged, there is an immediate release of inflammatory chemicals called excitatory neurotransmitters, such as histamine and bradykinin, a powerful vasodilator. Increased blood in the area causes the injured area to swell, redden, and become tender. The bradykinin stimulates the release of prostaglandins and substance P, a potent neurotransmitter that enhances the movement of impulses across nerve synapses.

TRANSDUCTION AND TRANSMISSION

Transduction occurs as the energy of the stimulus is converted to electrical energy. Transmission of the stimulus takes place when this energy crosses into a nociceptor at the end of an afferent nerve fiber.

Two types of peripheral nerve fibers conduct painful stimuli: the fast, myelinated A-delta fibers and the very small, slow, unmyelinated C-fibers. A-fibers send sharp, distinct sensations that localize the source of the pain and detect its intensity. C-fibers relay impulses that are poorly localized, burning, and persistent. For example, after burning a finger, a person initially feels a sharp localized pain as a result of A-fiber transmission. Within a few seconds the pain becomes more diffuse and widespread as a result of C-fiber transmission.

Pain stimuli travel quickly to the substantia gelatinosa in the dorsal horn of the spinal cord, where the gating mechanism (discussed below) occurs. Pain impulses then cross over to the opposite side of the spinal cord and ascend to the higher centers in the brain via the spinothalamic tracts and on to the thalamus and higher centers of the brain, including the reticular formation, limbic system, and somatosensory cortex. (See figure.)

Illustration

Neurologic transmission of pain stimuli. (Source: Jason M. Alexander. 2005, Wild Iris Medical Education.)

PERCEPTION

When pain stimuli reach the cerebral cortex, the brain interprets the signal; processes information from experiences, knowledge, and cultural associations; and perceives pain. Thus, perception is the awareness of pain. The somatosensory cortex identifies the location and intensity of pain, and the associated cortex determines how an individual interprets its meaning.

MODULATION

Once the brain perceives the pain, the body releases neuromodulators, such as endogenous opioids (endorphins and enkephalins), serotonin, norepinephrine, and gamma aminobutyric acid. These chemicals hinder the transmission of pain and help produce an analgesic, pain-relieving effect. This inhibition of the pain impulse is called modulation. The descending paths of the efferent fibers extend from the cortex down to the spinal cord and may influence pain impulses at the level of the spinal cord.

GATE-CONTROL THEORY

Melzack and Wall proposed the gate-control theory to explain the relationship between pain and the emotions (1996). According to the theory, a gating mechanism occurs when a pain impulse travels to the substantia gelatinosa in the dorsal horn of the spinal cord. There, trigger (T) cells influence the transmission of pain impulses. When their activity is inhibited, the gate closes and impulses are less likely to be transmitted to the brain. This mechanism is controlled by descending nerve fibers from the thalamus and cerebral cortex, areas of the brain that regulate thought and emotions. The gate-control theory helps explain how thoughts and emotions modify the perception of pain and why interventions such as imagery and distraction help relieve it.

Factors That Influence Pain

The perception of pain is influenced by physiologic, psychological, and cultural factors, all of which nurses need to consider.

PHYSIOLOGIC FACTORS
Age

Age affects the way people respond to pain. It influences both the development and decline of the nervous system. Aging affects the whole body, causing many painful degenerative disorders (such as osteoarthritis), secondary injuries (such as skin abrasions and fractures), and a host of common surgical procedures (such as cataract and hip replacement). Age also affects the way families and nurses respond to complaints of pain.

The following table gives a brief overview of the perception of pain relative to age.

AGE AND THE PERCEPTION OF PAIN

Age

Pain Perception

Pre-term infants

Have anatomical and functional ability to process pain by mid to late gestation; seem to have greater sensitivity to pain than term infants or children

Newborn infants

Response to pain is inborn and does not require prior learning; respond to pain with behaviors such as crying, grimacing, moving the body

Infants, 1 month

Can metabolize analgesics and anesthesia effectively; can recognize nurse as comforter

Toddlers/preschoolers

Can describe pain, its location and intensity; respond to pain by crying, anger, sadness; may consider pain a punishment; may hold someone accountable for pain and remember experiences in a certain location, such as a clinic

School-age children

May try to be brave when facing a painful procedure, may regress to an earlier stage of development, seek understanding of reasons for pain

Adolescents

May be slow to acknowledge pain, may consider showing signs of pain a weakness, may regress to earlier stages of development with persistent pain

Adults

Fear of pain may prevent some from seeking care, many believe admission of pain is a weakness and inappropriate for age or sex, some consider pain a punishment for moral failure

Older adults

May have decreased sensations or perceptions of pain; may consider pain an inevitable part of aging; chronic pain may produce anorexia, lethargy, depression; may not report pain due to fear of expense, possible treatment, and dependency; often describe pain in nonmedical terms such as hurt or ache; may fear addiction to analgesics; may not want to bother nurses or be a bad patient

Fatigue

Fatigue decreases coping abilities and heightens the perception of pain. When people are exhausted from physical activity, stress, and lack of sleep, their perception of pain may be heightened and their coping skills diminished. Thus, sleep and rest from physical, emotional, and social demands are important measures to manage pain.

Genetic Makeup

Recent research suggests that sensitivity to and tolerance for pain may be a genetically linked trait (Fincke, 2010). This finding does not negate the need to manage pain adequately, regardless of inherited traits.

Memory

Memory of painful experiences, especially experiences that occurred as a very young child, may increase sensitivity and decrease tolerance to pain. For example, even young children remember the pain of an immunization injection at the doctors office and henceforth may be afraid to visit the office again.

Stress Response

Research has shown that severe, unrelieved pain can cause an overwhelming stress response in both pre-term and full-term infants which can lead to serious complications and even death (Pasero, 2004).

Healing

Research suggests that unrelieved acute pain slows postoperative wound healing (McGuire et al., 2006). This evidence is not surprising, given our increasing knowledge of the effect of stress on the human body.

Neurologic Function

Any factor that interrupts or interferes with normal pain transmission affects the awareness and response of clients to pain and places them at risk for injury. Analgesics, sedatives, and alcohol depress the functioning of the central nervous system. Likewise, rare congenital conditions exist in which an individual cannot feel physical pain.

Some diseases, such as leprosy, damage peripheral nerves, decrease sensitivity to touch and pain, and render sufferers more vulnerable to injury. People with diabetes mellitus can have diabetic neuropathy, which may impair their ability to feel pain. They may injure themselves and be totally unaware of the injury, especially if it is in an area of the body they cannot see, such as the bottom of the feet, sacral area, or back of the head. The same may apply to people with traumatic nerve injuries, such as those with spinal cord damage or postsurgical nerve impairment.

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PSYCHOLOGICAL FACTORS
Fear and Anxiety

The relationship between pain and fear is convoluted and complex. Fear tends to increase the perception of pain, and pain increases feelings of fear and anxiety. This connection occurs in the brain because painful stimuli activate portions of the limbic system believed to control emotional reactions. People who are seriously injured or critically ill often experience both pain and heightened levels of anxiety due to their feelings of helplessness and lack of control. Healthcare providers need to address both pain and anxiety and use appropriate measures to relieve suffering.

Coping

People manage pain and other stressors of life in different ways. Some see themselves as self-sufficient, internally controlled, and independent. As a result, they may deny pain or be slow to admit they are suffering. Others see themselves as insufficient, externally controlled, and dependent on others to treat their pain. Self-sufficient, internally controlled people may do better with patient-controlled analgesia (PCA), whereas dependent, externally controlled individuals may prefer nurse-administered analgesia. No matter what the coping style, it is the responsibility of providers to relieve pain.

CULTURAL FACTORS

Cultural beliefs and values affect the way people respond to pain. As children, people learn what is and is not acceptable behavior when they experience pain. In some cultures, any expression of pain is considered cowardly and shameful. In others, noisy demonstrations of pain are expected and acceptable. The meaning of pain itself may be markedly different in different cultures. Some ethnic groups see pain as a punishment for wrongdoing. Others see pain as a test of faith. Still others view pain as a challenge to be overcome. Recent immigrants to the United States are more likely to view pain from their cultural roots. Regardless of an individuals language, religion, or situation, nurses are obliged to respect every person and strive to alleviate pain and suffering.

PAIN AND THE CAREGIVING PROCESS

The caregiving process includes assessment, diagnosis, planning, intervention, and evaluation. To manage pain responsibly, healthcare providers use each step of the process.

Basic to every strategy for managing pain is showing respect for the validity of a clients experience of pain. To communicate respect, nurses:

  Acknowledge pain and take action to manage it

  Give accurate information to reduce anxiety and facilitate relief of pain

  Reduce environmental stressors that add to the experience of pain

  Encourage disclosure of feelings and fears

  Provide privacy and maintain confidentiality

Assessing Pain

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Pain is a red flag. It tells us there is a problem somewhere in the body that is crying out for attention. In fact, pain is such an important indicator of health, its assessment has been called the fifth vital sign, joining temperature, pulse, respiration, and blood pressure. Even so, until we know more about a specific pain, we cannot address it. To do this, nurses must gather information from as many sources as possible, especially the primary source, the person in pain. This investigation includes obtaining a comprehensive pain history, making observations of behaviors, performing an appropriate physical examination, and consulting with other healthcare professionals.

PAIN HISTORY

A pain history is obtained from written documents and from interviews with the person in pain, family members, and other nurses. It asks specific questions about the location, intensity, quality, and history of the pain, as shown in the following box. In some facilities these questions are printed on an assessment form, with space for answers to be recorded beside each question.

A variety of pain scales have been developed for use with adults as well as with children. (See the Pain Assessment Scales table later in this course for a list of such scales. See also Partners Against Pain in the resources section at the end of this course.)

OBTAINING A PAIN HISTORY

Following are questions a healthcare provider can ask as part of taking a pain history:

Location: Where is your pain? Ask client to point to the area of pain.

Intensity: On a scale of 0 to 10, with 0 representing no pain, how much pain would you say you are experiencing? If your pain were a temperature, how hot would it be (warm, hot, blistering)? If your pain were a sound, how loud would it be (silent, quiet, strident, booming)?

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Quality: In your own words, tell me what your pain feels like (worms under the skin, shooting, needle pricking, tingling, stabbing, etc.).

Chronology/pattern: When did the pain start? Does your pain come and go? How often? How long does it last?

Precipitating factors: What triggers the pain, or what makes it worse?

Alleviating factors: What measures have you found that lessen or relieve the pain? What pain medications do you use? How much and how often?

Associated symptoms: Do you have other symptoms before, during, or after your pain begins (dizziness, blurred vision, nausea, shortness of breath)?

BEHAVIORAL OBSERVATIONS

Most people who suffer pain usually show it either by verbal complaint or nonverbal behaviors. The following table lists some typical behaviors nurses may observe when they assess people in pain.

NONVERBAL BEHAVIORS INDICATING PAIN

Facial Expressions

                     Clenched teeth

                     Wrinkled forehead

                     Biting lips

                     Scowling

                     Closing eyes tightly

                     Widely opened eyes or mouth

Vocalizations

                     Crying

                     Moaning

                     Gasping

                     Groaning

                     Grunting

Body Movements

                     Restlessness

                     Protective body movement

                     Muscle tension

                     Immobility

                     Pacing

                     Rhythmic movement

Social Interaction

                     Silence

                     Withdrawal

                     Reduced attention span

                     Focus on pain relief measures

PHYSICAL EXAMINATION

A physical examination is most fruitful when the pain history interview and behavioral observations are conducted at the same time. Because pain may be referred from some other area of the body, the examination should include a full scan from head to toe. A physical examination includes inspection, auscultation, palpation, and percussion.

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Inspection includes general and specific observations, beginning when the provider first encounters the patient and notes any obvious sign of pain, such as limping or any unusual posture of the body. A specific inspection involves an examination of the place where there is pain using adequate light and appropriate instruments.

Auscultation involves listening to sounds produced by internal body structures, such as the heart, lungs, and bowels. The provider must be able to block out noises in the environment and sounds emanating from other organs. To help isolate sounds, one can close the eyes and concentrate on one auscultation sound at a time.

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Palpation involves using ones hands to gather information about skin temperature, bodily pulsations, vibrations, internal masses, and tenderness or rigidity of organs and structures. When assessing the abdomen, perform palpation after auscultation because palpation may increase intestinal activity, causing misleading findings such as increased bowel sounds (Mosby, 2009).

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Percussion involves tapping the patients skin with the ones fingers or hands to elicit sound, evaluate reflexes, uncover abnormal masses, and detect pain. Tapping produces an audible vibration that helps to reveal the location, size, and density of underlying structures. Sounds are classified as dull, flat, tympanic, resonant, or hyper-resonant, depending on what part of the body one is tapping.

Diagnosing Pain

An accurate diagnosis depends on an appropriate assessment that focuses on the exact nature of the pain. The more specific the diagnosis, the more effective interventions can be. The North American Nursing Diagnosis Association (NANDA) has identified two primary diagnoses for pain: acute and chronic.

A complete caregiving diagnosis, however, goes further. After identifying whether the pain is acute or chronic, it adds related to to the medical diagnosis. For example, chronic pain related to osteoarthritis of the left hip. Then, it adds manifested by and lists the various symptoms experienced by the client or signs confirmed by objective data. Thus, a complete diagnosis might be chronic pain, related to osteoarthritis, manifested by stabbing pain in the left hip with weight-bearing.

The advantage of clear, specific information is that it leads to more effective interventions. In this case, an appropriate intervention might be an assistive devise such as a cane or walker and referral to a physical therapist or orthopedic surgeon for further evaluation.

Planning and Goal Setting

During the planning stage, healthcare providers synthesize information from many sources and, together with the clinician, plan appropriate treatment. The goal of these interventions is to relieve pain and facilitate the highest possible level of functioning. Practically speaking, this means identifying what activity the pain is preventing and the best way to achieve a return of function. For instance, in the case study below, Mrs. Lows hip pain is obstructing her mobility.

Planning interventions means working in partnership with clients and other nurses to provide specific measures to manage the pain. These interventions may be independent or collaborative. Independent actions fall within the scope of the nurses specialty. Collaborative actions involve cooperative interventions with other members of the healthcare team, such as nurses, physical therapists, occupational therapists, pharmacists, and physicians.

Goal setting involves the identification of attainable objectives and reasonable priorities. Because every person is different, nurses discuss various alternatives with the client and together set priorities. For example, after consulting an orthopedic surgeon, Mrs. Low may have decided to delay hip replacement surgery and maintain mobility as long as possible with the aid of a cane and analgesic medications.

Interventions

Effective pain management is carried out by a team of professionals, including physicians, nurses, physical therapists, occupational therapists, and counselors. During surgery, anesthesiologists administer intravenous fluids, anesthetics, and analgesic agents. Physicians prescribe medications and oversee care. Nurses administer analgesics, provide comfort measures, and educate patients. Physical and occupational therapists teach and assist patients to facilitate activities of daily living and reduce pain. Although their practices overlap, each professional evaluates the effectiveness of therapeutic measures and communicates with others on the team. Such an interdisciplinary approach helps alleviate pain and promote healing, using both pharmacologic and nonpharmacologic interventions.

CASE

Mrs. Low was finding it increasingly difficult to walk because of the pain in her right hip. Finally, she went to her primary care physician, who ordered x-rays. A radiologist studied the x-rays and wrote a report. When her physician read the report, he referred Mrs. Low to an orthopedic surgeon, who recommended hip replacement surgery. She agreed.

Throughout her surgical treatment and healing, the surgeon oversaw Mrs. Lows care, managing her pain with analgesics and comfort measures. Nurses cared for her during and after the surgery, and physical therapists helped her walk a few steps the day after surgery and ambulate safely. When she went home, visiting nurses oversaw her care, and Mrs. Low continued therapy until she was walking without pain.

Measuring pain intensity

When measuring intensity, a numerical scale of 010 (in which 0 indicates no pain and 10 indicates the worst possible pain) is clinically useful. If the person is unable to use a numerical scale, verbal scales can also be used with descriptors such as no pain, slight pain, moderate pain, severe pain, or excruciating pain (AHCPR 1994). Rating scales allow health-care professionals to assess and communicate pain intensity, and the response to pain interventions, on an ongoing basis.

Assessing the quality of pain

The quality of the pain is the persons description of how the pain feels. The quality of pain described can help to differentiate somatic, visceral, and neuropathic pain.

- Somatic pain is bodily pain in tissues other than viscera and neural tissues. Examples include bone metastases and soft-tissue inflammation. Somatic pain is usually well localised, and is usually described as constant, aching, or gnawing.

- Visceral pain results from pathology in thoracic or abdominal organs. It is often poorly localised and can be experienced (or referred) elsewhere. Abdominal visceral pain often comes in waves, and might be described as cramping.

- Neuropathic pain is pain emanating from the central and peripheral nervous systems. The pain might be described as numb, radiating, burning, or shock-like.

Different types of pain respond to different medications. For example, inflammatory somatic pain is more likely to respond to nonsteroidal antiinflammatory agents (NSAIDS), whereas centrally mediated neuropathic pain is more likely to respond to anticonvulsants.

 

Temporal aspects of pain

The temporal assessment involves a description of how the pain feels over time. This includes a description of the onset, duration, and frequency of the pain. These should be considered in association with an assessment of factors that exacerbate or relieve the pain. Nurses should pay particular attention to the following temporal factors (Portenoy & Hagen 1989).

-     Incident pain: This is pain that occurs with movement or activity. Incident pain is usually predictable and can be prevented with doses of analgesics administered at an appropriate interval before the painful activity.

-     Breakthrough pain: This is an unpredictable exacerbation of pain that occurs against a background of constant pain that is otherwise controlled.

-     End-of-dose pain: This is pain that occurs just before the next dose of analgesic is due. This indicates a need to increase the dose or to decrease the interval of administration.

Ongoing and consistent reassessment of pain is often a challenge. In 1995, the American Pain Society (APS) conducted a consensus study to develop quality guidelines on the assessment and management of pain (APSQCC 1995). One recommendation was that institutions make the assessment of pain highly visible so that it undergoes regular and frequent review. The adoption of pain as the 5th vital sign (along with temperature, pulse, respiration, and blood pressure) is a useful strategy. At every consultation or visit, the clinician is thus encouraged to assess pain along with other vital signs.

Studies also indicate that formal continuous quality-improvement programs help to ensure that pain is being measured and managed on an ongoing basis (Comley & DeMeyer 2001).

 

Behavioural assessment of pain

In addition to a physiological assessment, nurses should assess behavioural factors that affect the pain. This might be quite specificsuch as limping or splinting (protection of the injured part). More generally, behavioural assessment of pain involves an awareness of whether pain is interfering with a persons social function. For example, the person might be unable to shop for groceries because walking for long periods of time exacerbates the pain.

Behavioural assessment provides information on how the person is functioning on a day-to-day basis and might lead to a modification in the plan of care. Adjusting the medication schedule and educating the person about the control of incident pain might assist him or her in optimal comfort and functioning.

 

Psychosocial and spiritual assessment of pain

Psychosocial and spiritual dimensions also play an important role in pain at the end of life. Psychosocial assessment includes the effect that pain has on mood, sleep, coping, goals, and finances (Elliott 1997). Spiritual assessment includes the effect of suffering on the persons understanding of meaning and purpose in life. Nurses can give people permission to verbalise their personal feelings about pain and suffering (Spross & Wolff 1995).

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

                     At each clinical encounter.

                     At regular intervals after initiation of treatment.

                     At each new report of pain.

                     At a suitable interval after pharmacologic or nonpharmacologic intervention (e.g., 1530 minutes after parenteral drug therapy and 1 hour after oral administration).

Effective pain management requires close monitoring of patient response to initiation of treatment. In a review of 1,612 patients referred to an outpatient palliative care center where patients with advanced cancer were seen by both a palliative care nurse and a physician, more than half of patients with moderate to severe pain did not respond to an initial palliative care consultation, with response defined as a two-point or more reduction or a 30% or more reduction from baseline. Also, one-third of patients with mild pain actually progressed to moderate to severe pain by the time of their first follow-up visit. The authors concluded that more frequent follow-up visits, calls, and interdisciplinary clinics should be considered in an effort to optimize pain control. The study also identified baseline pain intensity, fatigue, and Edmonton Symptom Assessment System symptom burden as factors predicting response.

Identifying the etiology of pain is important to its management. Clinicians treating patients with cancer should recognize the common cancer pain syndromes (see lists 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. Reviews of cancer pain with a focus on neuropathic pain describes pathophysiologies as well as available and investigational pharmacotherapies.

Common Pain Syndromes: Pain Associated with Tumor

Bone lesions/metastases

Bone marrow expansion

Vertebral syndrome

Local infiltration

Base of skull involvement

Visceral

Hepatic capsule distension

Retroperitoneal syndrome

Intestinal obstruction

Ureteral obstruction

Neuropathies/plexopathies

Cranial neuropathies

                     Leptomeningeal disease

                     Base of skull metastases

Mononeuropathies

Polyneuropathies

                     Brachial, cervical, sacral

Cauda equina syndrome

Paraneoplastic syndrome

Osteoarthropathy

Gynecomastia

Sensorimotor neuropathy

Common Pain Syndromes: Pain Secondary to Treatment

Postradiation therapy

Enteritis

Radiation fibrosis

Osteoradionecrosis

Myelopathy

Neuropathy/plexopathies

                     Brachial, sacral

Pain flare after radiopharmaceutical

Radiation-induced cystitis

Postchemotherapy

Arthralgia, myalgia

                     Aromatase inhibitors

Avascular necrosis

Chronic abdominal pain

Mucositis

Neuropathy

                     Platinum-based products: Cisplatin, carboplatin, oxaliplatin

                     Taxanes: Paclitaxel, docetaxel

                     Vinca alkaloids: Vincristine, vinblastine

                     Epothilones: Ixabepilone

                     Others: Bortezomib, lenalidomide, thalidomide

Posthormonal therapy

Bone pain flare

Arthralgia, myalgia

Postsurgery

Acute postoperative or procedural pain

Phantom limb pain/postamputation pain

Postnephrectomy syndrome

Postmastectomy syndrome

Postthoracotomy syndrome

Postradical neck dissection

Pelvic floor myalgia

Bisphosphonates

Bone pain, osteonecrosis

Initial Assessment

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 patients 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. 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. The following are essential to the initial assessment:

                     Detailed medical and pain history.

                     Physical examination.

                     Psychosocial and spiritual assessment.

                     History of substance abuse in patient and family.

                     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 assists 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 as 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. This system has been further refined in two reports that have gathered construct validity evidence using an international panel of content experts and a multicenter study to determine interrater reliability and predictive value. 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.

Patient Self-report

The mainstay of pain assessment is the patient self-report; however, family nurses 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. 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%).

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. Pain intensity at initial assessment has been demonstrated to be a significant predictor of subsequent pain management complexity (i.e., the need for more pharmacological and multidimensional approaches) and length of time to achieve stable pain control. 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 patients 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 pain (BP) or episodic pain (EP) (a transitory increase in pain that occurs in addition to persistent pain). Some patients may have EP without persistent pain. The prevalence of BP-EP varies widely, depending on which definition is used and based on the clinical scenario and cultural setting. An appropriately designed, cross-sectional, multicenter study that evaluated BP-EP in patients with chronic cancer-related pain was completed. The primary aim of the study was to assess the prevalence and characteristics of BP-EP on the basis of clinical assessment and through the use of a previously validated, culturally adapted tool, the Questionnaire for Intense Episodic Pain (QUDEI-Italian), which utilizes a patient interview technique. Physicians who participated in the study were trained to define and recognize BP-EP. Patient evaluation and use of the questionnaire were carried out by different sets of providers. There was an estimated prevalence of 73% when a BP-EP diagnosis was made by physicians and 66% when the QUDEI was applied. When patients with baseline pain levels of 6 or lower (based on a numerical rating scale from 0 to 10) were analyzed, the physician prevalence decreased to 67%, versus 60% with tool utilization. The authors concluded that because of the frequent occurrence of BP-EP, a more widely accepted general definition of this phenomenon and specific validated tools to assist in education and screening are needed.

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.

Changes in Pattern

                     Changes in pain pattern or the development of new pain should trigger diagnostic reevaluation 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.

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. 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. It was also reported that patients who thought that their pain represented disease progression reported more pain-related interference with function.

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. 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 patients 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. It is difficult to get good pain-diary compliance with adolescents who are experiencing intense chronic pain.

Physical Examination

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.

Information obtained from the synthesis of history, physical examination, and diagnostic evaluations is used to generate a pain diagnosis with respect to etiology (cancer, its treatment, or other) and pathophysiology (somatic, visceral, and/or neuropathic). This diagnosis, in conjunction with contributing psychosocial and spiritual factors, is used to generate a comprehensive pain treatment plan.

Assessment of the Outcomes of Pain Management

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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.

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, remain unclear.

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 required and tolerated substantially higher morphine doses to achieve stable pain control. This study should increase confidence in providing appropriate pain management to patients who have a history of drug use.

 

Barriers to pain relief

Pain at the end of life is frequently undertreated. The barriers to adequate pain treatment involve health-care professionals, patients, and the health-care delivery system.

A large barrier to pain assessment and management is lack of healthcare provider education.

In order to address pain needs, it is important to understand the barriers that prevent excellent assessment and management.

These barriers are prevalent with Patients, families, healthcare providers, and the healthcare systems:

 

Barriers to Effective Pain Management

Problems related to health care professionals:

Ø Inadequate knowledge of pain management.

Ø Poor assessment of pain.

Ø Concern about regulation of controlled substances.

Ø Fear of patient addiction.

Ø Concern about side effects of analgesics.

Ø Concern about patients becoming tolerant to analgesics.

Problems related to patients:

Ø Reluctance to report pain.

Ø Concern about distracting physicians from treatment of underlying disease.

Ø Fear that pain means disease is worse.

Ø Lack of knowledge about principles of basic pain management.

Ø Concern about not being a good patient.

Ø Reluctance to take pain medications.

Ø Fear of addiction or of being thought of as an addict. (This fear may be more pronounced in minority patients.)

Ø Worries about unmanageable side effects (such as constipation, nausea, or clouding of thought).

Ø Concern about becoming tolerant to pain medications.

Ø Poor adherence to the prescribed analgesic regimen.

Ø Financial barriers.

Ø Problems related to the health care system:

Ø Low priority given to cancer pain treatment.

Ø Inadequate reimbursement for pain assessment and treatment.

Ø The most appropriate treatment may not be reimbursed or may be too costly for patients and families.

Ø Restrictive regulation of controlled substances.

Ø Problems of availability of treatment or access to it.

Ø Opioids unavailable in the patients pharmacy.

Ø Unaffordable medication.

Flexibility is the key to managing cancer pain. As patients vary in diagnosis, stage of disease, responses to pain and interventions, and personal preferences, so must pain management. The recommended clinical approach outlined below emphasizes a focus on patient involvement.

Ask about pain regularly. Assess pain and associated symptoms systematically using brief assessment tools. Assessment should include discussion about common symptoms experienced by cancer patients and how each symptom will be treated. Asking a patient to identify his or her most troublesome symptom is also of clinical value because the most troublesome symptom is not always the most severe, as demonstrated in a survey of 146 patients in the palliative phase of treatment for lung, gastrointestinal, or breast cancer.

Believe patient and family reports of pain and what relieves the pain. (Caveats include patients with significant psychological/existential distress and patients with cognitive impairment.)

Choose pain-control options appropriate for the patient, family, and setting.

Deliver interventions in a timely, logical, coordinated fashion.

Empower patients and their families. Enable patients to control their course as much as possible.

Highlights of Patient Management

Effective pain management is best achieved by a team approach involving patients, their families, and health care providers. The clinician should:

 

Initiate prophylactic anticonstipation measures in all patients (except those with diarrhea) before or during opiate administration. (Refer to the Constipation section in the Side Effects of Opioids section of this summary for more information.)

Discuss pain and its management with patients and their families.

Encourage patients to be active participants in their care.

Reassure patients who are reluctant to report pain that there are many safe and effective ways to relieve pain.

Consider the cost of proposed drugs and technologies.

Share documented pain assessment and management with other clinicians treating the patient.

Know state/local regulations for controlled substances.

Nurses can work to overcome the barriers through education, quality improvement efforts, and involvement in professional groups that advocate for those in pain.

Patients suffer from many of the same myths and attitudes that plague healthcare professionals. Nurses can reassure Patients that pain control is everyone's right, that they rely on Patients to report their pain, and that good pain management will improve their quality of life. Proactive education of Patients and their family/support persons is necessary, including tolerance, physiological dependence, and addiction.

Cultural, religious, spiritual beliefs and practices can impact pain reporting and management for patients and staff, respectively (NCP, 2009).

        Cost -- A study (n=40) at Albert Einstein Healthcare Network in Philadelphia, a setting serving an 80% minority population, reported that 38% of patients were not financially able to afford their pain medication. Not one of the study patients was eligible for patient assistance programs which were also described as time-consuming and burdensome for physicians, staff and cancer patients (Phipps et al., 2005).

        Other behaviors to consider

Ø Desire to be a good patient

Ø Reluctance to acknowledge pain as this may mean disease progression

Ø Fear of injection

Ø Poor communication between patient and healthcare team

Ø Limited capacity to report pain

Ø Personal/family cultural influences

Health-care professionals often lack knowledge about the assessment and management of pain. They are also frequently concerned about addiction, tolerance, and the side-effects of opioids (AHCPR 1994). In reality, the overall incidence of addiction is low (Porter & Jick 1980). This is especially true of patients taking opioids at the end of life. Nurses and other health-care professionals often misinterpret the meanings of the terms addiction, tolerance, and dependence. The definitions of these terms, together with a clarifying comment on each, are presented in Table 8.1.

The principle of double effect is relevant to any discussion of the attitude of health professionals to the use of opioid medication. Double effect, a concept initiated by Roman Catholic moral theologians in the seventeenth century, justifies a potentially harmful effect when the intention is good. For example, the opioid dose required for some patients might cause delirium, sedation, respiratory depression, and even death. However, the positive benefits of adequate pain relief can outweigh the potentially harmful effects. The principle continues to be discussed by bioethicists today (Elliott 1997), and should be kept in mind when assessing the question of pain relief at the end of life.

Patients can present a barrier to their own pain relief. They can be reluctant to report pain for fear that their disease is getting worse, and this can beespecially common in patients who are nearing the end of life. Concern about not being a good patient might also be a concern. In addition, patients can be reluctant to take pain medications because they fear addiction, tolerance, and side-effects (AHCPR 1994).

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The health-care delivery system can also be a barrier to adequate pain treatment, depending on the patients place of residence. In some rural areas, adequate doses and/or an adequate variety of opioid options might not be available. The cost of analgesics can also be a problem for some patients, and full reimbursement is not available from all health-care insurance funds.

The pain of dying of cancer or AIDS is often unbearable, but it can be controlled simply and inexpensively with painkillers including morphine and other opioids (also called opiates).

Although health professionals have long known that these drugs are essential for the relief of moderate to severe pain, the amounts used globally are so small that only a minority of those in need have adequate pain relief. The problem exists in some developed countries and is particularly acute in developing countries. The absence of these drugs is not a problem of supply, but of legal, political, medical, and other barriers that prevent them from becoming available.

Scope of the Pain

At least 2 million deaths from cancer and 3 million from AIDS occur every year in developing countries. About 80 percent of people dying from cancer and 50 percent of those dying from AIDS experience moderate or severe pain, lasting for an average of 90 days. Among those with advanced cancer, researchers consistently report that patients experience moderate to severe pain, regardless of their age and sex, and whether they are bedridden. The pain can vary according to the type of cancer, treatment, and personal characteristics, but the severity of the pain typically increases with the progression of the disease. Similarly, researchers report that up to 80 percent of patients in the last phase of illness experience significant pain requiring analgesic (painkilling) drugs.

Pain dramatically reduces quality of life, preventing patients from working, socializing, or caring for their families. Depression and anxiety also increase with pain intensity. The individuals suffering radiates through households and communities, causing stress to nurses as well as financial hardship for entire families. Having AIDS can make matters worse: a woman dying from the disease, for example, may keep her illness cloaked in secrecy and shame, with little hope of receiving relief from her extreme physical pain.

How Pain Control Works

The goal of pain control and palliative care is not to cure disease, but to allow patients to function as well as possible with a minimum of pain, including during treatment.

While there are numerous ways to relieve painincluding various types of anesthetics and neurological procedures, physical procedures such as massage and acupuncture, and psychological approaches such as hypnosis or relaxation therapypainkilling drugs are the mainstay of pain relief.

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The World Health Organization (WHO) has developed a three-step analgesic ladder for treating cancer pain, which is also appropriate for AIDS patients. The steps in the ladder represent increasing pain severity and the drugs that should be used at each stage:

Step 1, mild pain, can be relieved with widely available drugs, such as acetaminophen, aspirin, and ibuprofen or other anti-inflammatory drugs.

Step 2, moderate pain, requires a combination of the drug used in Step 1 and an opioid such as codeine for greater relief.

Step 3, severe pain, requires a strong opioid such as morphine plus other drugs to provide additional relief or address the side effects of the painkillers.

Ideally, a trained professional prescribes pain medication throughout the course of the illness, according to the ladder. In developing countries, however, most patients selfmedicate with over-the-counter or traditional medicines until they have late-stage disease that can be treated only with a strong opioid. That is when they are most likely to seek formal medical careat Step 3 of the ladderyet least likely to obtain it, even from health professionals.

Barriers to Pain Control

Morphine is largely unavailable in Africa, the easter Mediterranean, and Southeast Asia, but also hard to obtain in most other developing regions. In the last few decades, some progress has been made in making morphine available in developed countries, widening the gap in access between wealthier and poorer countries. Of all of the morphine used legally in 2002, 78 percent was consumed in only six developed countries, and the remainder in the other 142 countries that reported use.

Aside from scarce resources, the major barriers to receiving pain relief as part of end-of-life care in developing countries include:

Lack of national policies and/or low priority assigned to pain relief;

Lack of national standards and guidelines for providing pain control medications;

Legal restrictions on the importation and medical use of opioids, and the greatly exaggerated concern that the medical use of opioids will lead to drug abuse and addiction;

Lack of awareness by health professionals and the publicincluding families who care for the dying at homethat cancer and AIDS pain can be relieved; and

Social stigma surrounding cancer and AIDS, which delays or prevents adequate treatment of the disease and the pain.

According to WHO, opioids such as morphine are essential medicines and should be available to patients who need them. A recent report states that a palliative care program cannot exist unless it is based on a rational drug policy, and this includes regulations that allow ready access of suffering patients to opioids.

Although they are essential medicines, opioids also have the potential for abuse and are therefore controlled at every stage of production and distribution to prevent diversion for non-medical use. The Single Convention on Narcotic Drugs of 1961 is an international treaty that aims to prevent the illicit production, trafficking, and consumption of narcotic drugs while also ensuring availability for medical and scientific needs. In addition to requiring countries to report levels of use, it sets out guidelines from which countries can develop their own policies and regulations.

For example:

Only licensed individuals may dispense opioids.

Opioids may only be transferred between authorized parties.

They must be dispensed with a medical prescription.

Many governments have imposed tighter restrictions than the treaty calls for. Some countries make morphine available only for terminally ill cancer patients; impose additional restrictions on prescriptions; and/or require extra authorizations for releasing morphine. The requirements can be so burdensome that patients may die before the paperwork is completed.

Cost of Morphine for Pain Control

The price of a months supply of immediate-release oral morphine varies greatly among developing countries, because the drug costs less where it is produced locally and countries do not acquire and dispense the drug with equal efficiency. Even with these variations, however, if barriers to oral morphine were removed, a total drug cost of 1 cent or less per milligram of oral morphine could be achieved in most countries.

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Given the average daily dose used for palliative care, the cost per patient for a day of pain avoided is estimated to range from 60 cents to $1.35, resulting in drug costs of oral morphine of about $216 to $420 per year of painfree life added. Is the pain relief worth the cost? Research shows that people are willing to give up several months of healthy life for access to good end-of-life care, and patients in poor countries place as great a value on pain relief as patients in wealthy countries.

Estimates of the annual costs of oral morphine for Chile, Romania, and Uganda are shown in the table bellow.

Given that the prevalence of AIDS and cancer differs among the countries, the investment needed varies from as low as $600,000 in Chile to as high as $4.9 million in Uganda. The cost per capita ranges from 3 cents to 21 cents.

The analysis excludes other costs such as those for health care delivery, training, and management. But making oral morphine available through a system of palliative care could actually save the health system money, by enabling people who would otherwise be hospitalized to die at home or by shortening their hospital stays. Even in low-income countries, patients in unbearable pain are often brought to hospitals by distressed relatives who are willing to go into debt to ease their suffering.

Strategies to Improve Pain Control

Providing adequate morphine for pain control involves medical, political, legal, and societal change. Tools, resources, and expertise are available for evaluating national drug policies and improving access to opioids for medical purposes.2 Model programs, such as Hospice Uganda (see box), have demonstrated the feasibility of providing good palliative care, including morphine, even for poor rural dwellers. WHO and the International Narcotics Control Board support these efforts.

WHO recommends that countries with low levels of resources progressively adopt standards for pain relief and palliative care at all levels of the health system, with a special focus on reaching those who are cared for at home. Homebased care is generally the best way to achieve good quality care and coverage in countries with strong family support and weak health care systems.

Government Commitment Is Essential

Policymakers and program managers need to harness the following practical tools to improve pain control and palliative care:

Study the prevalence of pain and assess the extent of care currently available.

Assess the national and local regulatory barriers to morphine availability to identify the patientrelated, doctor-related, and institutional barriers that impede drug distribution.

Lean about how the drug control system is intended to ensure adequate availability of opioids for medical purposes.

Study the costs of making morphine and other drugs available and assess the offsetting savings that could be achieved by reducing hospital stays.

Build an inventory of model programs for pain control and palliative care and experiment with new models for providing pain control, particularly for poor and rural residents.

WHO, in collaboration with the International Narcotics Control Board and the WHO Collaborating Center at the University of Wisconsin, have developed guidelines for national health authorities to assess regulatory and other barriers to making the needed drugs available. These institutions, along with several others, can provide resources and expertise to develop action plans, implement policy change, and evaluate results.