Simple Techniques Can Improve Pain Assessment, Control

COLUMBUS, Ohio--The evaluation of a cancer patient’s complaint of pain should include an assessment of a variety of characteristics, including psychosocial and emotional factors, said Neil MacDonald, MD, director of the Cancer Ethics Programme, Center for Bioethics, Clinical Research Institute of Montreal.

To enhance diagnosis and pain management, a number of simple techniques for classifying and recording pain have recently been introduced into clinical practice, Dr. MacDonald, who is also professor of oncology at McGill University, said at a conference on the role of narcotics in the treatment of pain, sponsored by Ohio State University.

"We are trained to react to empirical data," Dr. MacDonald said. "It’s important that we attempt to quantify cancer pain, because if we do, we can open doors to address it."

He suggested several memory aids that a physician can use to elicit as much information as possible while assessing a patient’s pain. The first, PQRST, is a simple alphabetical reminder of five physical aspects of pain. Another memory aid, PAIN, can help the physician assess emotional and social factors contributing to pain.

PQRST: Questions to Ask Patients About the Physical Aspects of Pain

Precipitating and palliative factors: What makes the pain better and what makes it worse?

Quality of pain: Is it aching or burning? How does the patient describe it?

Radiation pathways: From its most intense site, where does the pain spread?

Severity of pain.

Temporal factors: When does it occur? Is it constant? Intermittent? Is it triggered by particular activities?

The PAIN Mnemonic for Assessing Emotional and Social Factors Related to Pain

Psychosocial and emotional factors that affect the perception of pain.

Activity: Is pain interfering with normal activity?

Interference with sleep and rest.

Nuances, or the significance assigned by the patient to the pain.

To help patients quantify their symptoms, including depression and anxiety, physicians can use simple assessment scales. Rating scales should also be used at regular intervals after starting or changing treatment, to determine the efficacy of pain relief.

Dr. MacDonald described the Edmon-ton Symptom Assessment System but noted that other scales, including the Memorial Pain Assessment Card and the Wisconsin Brief Pain Questionnaire, are also useful. [See Bruera E et al: The Edmonton Symptom Assessment System (ESAS): A simple method for the assessment of palliative care patients. J Palliative Care 7(2):6-9, 1991.]

Patients can use these scales to indicate whether their medication is allowing them to adequately control their pain while still permitting normal function. Finding this balance requires skillful adjustment of opioids, anticancer therapy, and adjuvant techniques.

Finally, a complete physical examination must also be part of the pain diagnosis. Dr. MacDonald advised taking special note of the patient’s response to pain, including changes in facial expression, during the examination.

Unfortunately, the use of scales like the Edmonton Symptom Assessment System remains "cocooned" within the palliative care setting, Dr. MacDonald said. This is very unfortunate, he added, since it is crucial to address pain from the onset of cancer. Pain that is poorly controlled can actually lead to an increase in overall pain. "Palliation and practice of palliative principles should infuse throughout all medical practice," he said.

Assessment of pain is a "major problem," he said. Every study undertaken to examine the issue has found unrelieved suffering. Women, the elderly, and blacks recorded the highest levels of unaddressed pain, in a study by Cleeland et al (N Engl J Med 330:595, 1994).

This undertreatment of pain begins with the training--or lack thereof--that physicians receive, Dr. MacDonald said. His own 1997 study of Canadian doctors showed that 67% of respondents rated their medical school or basic undergraduate education in pain management as poor or fair (J Pain Symptom Manage 14(6), Dec. 6, 1997.)

Learn to Communicate Quickly

Pain diagnosis benefits from communication between doctor and patient, yet there is a great deal of pressure on physicians to be efficient, Dr. MacDonald said. For this reason, memory aids and measurement scales can improve pain treatment by making assessment simple and convenient. "The lesson is that we’ll have to communicate quickly," he noted. Adding pain assessment scales to patient charts, as Sloan-Kettering has done, can also act as a reminder to busy clinicians.

"There isn’t a physician’s code anywhere that doesn’t include relieving suffering," Dr. MacDonald said. "Yet studies show we’re not achieving this."