Module 7: Pain Management – Topic A Compare different types of pain (e.g., acute, chronic, palliative, emotional, spiritual).

Learning Objectives

By the end of this topic, the student should be able to:

• Describe the characteristics and physical and psychological impact of different types of pain.
• Differentiate between acute pain and chronic pain, and palliative, neuropathic, nociceptive, emotional, and spiritual pain.
• Describe the physical and psychological impacts of different types of pain.

Key Concepts

• Pain is a very common experience, accounting for up to 78 percent of all emergency department visits in Canada each year.
• Pain and related suffering represent significant economic, social, and health challenges in Canadian society and increase health care costs, have negative impacts on social relationships, reduce workplace productivity, and increase financial compensation.
• The absence of appropriate treatment of pain can have adverse physical, psychological, and social outcomes.
• The experience of pain is variable and individualized and thus treatment should be tailored to the type and level of pain experienced by each person.
• The appropriate use of validated pain scales reduces the risk of under-treatment and helps the persons experiencing pain improve their outcomes.
• Social factors can positively impact resilience and chronic pain (Sturgeon & Zautra, 2016).

Nature of Pain and its Management

Pain is one of the most common symptoms reported by people seeking health care. The experience of pain is individual, variable, and affected by a multitude of personal, physical, psychological, and social factors.

Effective pain management requires comprehensive, individualized, and repeated pain assessment to identify the source, nature, and experience of pain.

• Opioids have a place in the treatment of acute and chronic pain, but there are risks in prescribing opioids that practitioners and people using them for pain need to be aware of.
• Practitioners need to monitor opioid use for pain to ensure that the treatment is safe and effective.

Acute Versus Chronic Pain

Acute Pain

Health Quality Ontario (2018) described acute pain as “typically a normal, predicted response to surgery, acute illness, trauma, or other injury. It is recent in onset and is a self-limiting process that generally lasts from hours to days or a month after the precipitating event. The duration of acute pain is associated with the time it normally takes for healing to occur” (p. 3).

Onset

Usually, the onset of acute pain is sudden, localized, and lasts for a few minutes or up to several months. It can be accompanied by a physiological response such as sweating, tachycardia, elevated blood pressure, or pallor.

Causes

Causes of acute pain include injury, surgery, dental procedures, myocardial infarction, labour, and appendicitis among others.

Treatment

Acute pain usually responds to treatment. Acute pain may result in short-term disability, usually limited to the duration of the pain. When acute pain is not managed appropriately, chronic pain can develop.

Chronic Pain (Non-Cancer) or Persistent Pain

The World Health Organization has recently recognized chronic pain as a disease (International Association for the Study of Pain, 2019). Chronic pain is often accompanied by:

• anger,
• anxiety,
• depression,
• altered sleep,
• frustration, as well as
• degrees of functional disability.

Chronic pain can negatively impact social and familial relationships.

The course of chronic pain may include:

• a slow onset and long duration,
• recurrent episodes of pain that last longer than three to six months,
• pain originating from an acute injury that persists beyond normal healing,
• pain accompanying a non-healing injury, or
• chronic pain resulting from inadequately treated acute pain.

Causes

Chronic pain is not associated with a cancer diagnosis. Causes of chronic pain include:

• arthritis,
• muscle strain (for example, low back pain),
• peripheral nerve damage (neuropathy), among many others.

Cancer and End-Of-Life Pain

Cancer Pain

Cancer pain is classified as secondary chronic pain. This classification includes chronic pain that is associated with specific medical conditions such as cancer or diabetes and others.

Pain can be related to cancer or cancer treatment (e.g., peripheral nerve damage from pharmacotherapy and skin ulceration and fibrosis secondary to radiation). Chronic pain may be a serious consequence of surviving cancer or cancer treatment.

Pain can be related to cancer or cancer treatment (e.g., peripheral nerve damage from pharmacotherapy and skin ulceration and fibrosis secondary to radiation). Chronic pain may be a serious consequence of surviving cancer or cancer treatment.

Pain in Palliative Care

A goal of treatment is freedom from pain. Palliative care prevents and relieves suffering through the early identification, assessment, and treatment of pain and other physical, psychosocial, and spiritual problems.

• Opioids are recommended for chronic and severe pain, often in combination with other non-opioid treatments
• A team approach is often required for the management of pain at the end of life.

Types of Physiological Pain

Bookbinder, Marilyn & McHugh, Marlene. (2010).

Neuropathic Pain

Neuropathic pain originates from a disturbance or pathological change in a nerve.

Neuralgic pain is burning type of pain caused by an irritated or damaged nerve.

Nociceptive Pain

Nociceptive pain results from mechanical, chemical, or thermal irritation of peripheral sensory nerves, such as after surgery, trauma or with degenerative disease (Goucke, 2003). Visceral and somatic pain are nociceptive subtypes. Visceral pain comes from the organs and somatic pain comes from external structures (Sikandar & Dickenson, 2012).

alexandragl1/iStock (brain, joint, skin, vascular icons)

Additional Types of Pain

Spiritual Pain

Suffering that is commonly experienced by persons with significant or life-threatening illness and their families may be spiritual pain.

• The inability to clinically manage physical pain can be due, in part, to emotional and spiritual needs.

Emotional Pain

Assessing Pain

The experience of pain is a private, multidimensional, subjective, emotional, and physical experience that is different for each individual. A variety of factors influence an individual’s experience of pain, whether acute or chronic.

Societal factors can influence how pain is assessed. Norms, beliefs, and biases about pain can result in under-diagnosis and under-treatment of pain. Pain is sometimes seen as a normal part of life. Some may believe that the experience of pain is different depending on gender or sex. An expression of pain or a request for treatment may be seen as drug-seeking or aberrant behaviour in persons with perceived or actual substance use disorder.

Assessment of pain requires a comprehensive history that includes past and present experiences of pain, as well as:

• past and present health issues,
• social and functional status,
• relationships,
• sleep,
• activity, and
• nutrition.

Pain Scales

Pain scales are a means of assessing the domains of pain, including intensity, quality, site, and interference. Pain scales may be unidimensional (intensity) or multidimensional and include functional and social status assessments to measure the interference of pain in an individual’s quality of life.

GrafVishenka/iStock

An assessment of pain intensity can be measured by validated numeric scales. Although this type of assessment can be limited, it can be useful for assessing acute pain and response to analgesia or other interventions. Examples of validated numeric scales include the following:

• A multidimensional and holistic assessment of an individual’s experience of pain requires a validated instrument that includes questions about the impact of pain on functional status (work, quality of life) and the impact of pain on daily life, including social/family interactions, sleep, nutrition, activities of daily living, socioeconomic status, sexual health, and relationships.
• Tools such as the Brief Pain Inventory (BPI) are recommended for baseline and repeated assessments to measure change in a person’s functional status and pain intensity over time in response to treatment. Although pain intensity may not change, functional status may, and this should be the focus of pain management for people experiencing chronic pain.
• However, repeated diagnostic tests can be of limited value as finding the cause of pain can become the focus of care and treatment rather than improving the person’s functional status and quality of life.
• Results of the use of unidimensional or multidimensional pain scales should be recorded in a person’s health record just as vital signs are recorded.
• Validated pain scales are available in multiple languages, for specific cultural groups, for people who are unable to communicate, for people with cognitive impairment, and for children.

All health and social service providers should be trained in the use of the diagnostic tools related to pain assessment.

See Module 7, Topic E for more information about pain scales. 

Questions

True or false: Chronic non-cancer pain is pain that persists for longer than three months.

a. True

b. False

Correct! Chronic non-cancer pain persists for longer than three months.

Incorrect. The correct answer is a. Chronic non-cancer pain persists for longer than three months.

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According to the WHO, what is the goal of pain management in palliative care?

a. Improved function

b. Reduced need for pain medication

c. Relief of suffering

d. A 30 percent reduction in reported pain

Correct! For persons experiencing palliative pain, the goal of treatment is relief of suffering.

Incorrect. The correct answer is c. For persons experiencing palliative pain, the goal of treatment is relief of suffering.

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Which of the following describes the purpose of using a pain scale in assessing chronic non-cancer pain? Select all that apply. (Select all that apply.)

a. To determine the intensity of pain

b. To assess the response to analgesic pain medication

c. To measure multiple factors associated with the experience of pain

d. To determine if the client is experiencing real pain

Check

Please select an answer.

Correct! Pain is a complex multidimensional, personal experience. Pain scales should be validated and should measure pain intensity, as well as the person’s functional and social capacity.

Incorrect. The correct answers were a, b, and c. Pain is a complex multidimensional, personal experience. Pain scales should be validated and should measure pain intensity, as well as the person’s functional and social capacity.

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References