Management of chronic pain

CHAPTER 8 Management of chronic pain



Joanne Tollefson, Karen Piggot, Mary FitzGerald



LEARNING OBJECTIVES


When you have completed this chapter you will be able to:


• recognise the significant psychological, social, physical and economic burdens placed on individuals, their family members and society by persistent pain

• acknowledge the central role the person with chronic pain takes in the management of their health

• identify the modalities of health service provision available to people with chronic pain

• appreciate the range of therapies available for the management of chronic pain

• discuss the dynamic role that nurses have as supporters of self-care agency.


KEY WORDS


chronic pain


educative supportive roles


pain assessment


self-care


self-management



INTRODUCTION


Chronic pain is suffered by a significant number of people from all age groups. Most of these people manage the pain themselves in a range of positive and sometimes negative ways—they take analgesics and remedies and modify their lifestyles to accommodate changes that may accrue in elements of life such as function and affect. People who suffer from chronic pain classically refer themselves to general practitioners who now act as agents for a broad range of conventional and complementary specialists to manage chronic pain. The majority of nurses become involved in the care of people with chronic pain when it affects function or psychological wellbeing to such an extent that independence in activities of living (Roper et al, 2000) or self-care needs (Orem, 2001) are adversely affected. These nurses take a supportive and educative role to enable people with chronic pain to recognise positive strategies that ameliorate their state of pain and maximise their independence.


However, there are nurse practitioners who specifically work with people who are referred to pain clinics and there are specialist nurses who work with people with conditions that are particularly associated with enduring pain, for example people with cancer and specialists in oncology nursing, or people with long-term angina and specialists in cardiac rehabilitation nursing. These nurses work in multidisciplinary teams and have extended knowledge of the aetiology of chronic pain and skills in the assessment, therapy and evaluation of chronic pain management.


This chapter is written for nurses and other health professionals as a broad overview of a complex topic. There is no intention to delve into the specifics of specialist diagnosis and treatment but rather to draw a picture of the size and the nature of the problem, and the array of therapies that are available to suit particular individuals with chronic pain. While we refer to nursing and nursing theories of self-care, we recognise that the management of chronic pain is essentially in the hands of individuals and that support for them comes from a range of health professionals whose roles can overlap to a large degree in the offering and delivery of a person-centred philosophy of healthcare service.



CHRONIC PAIN DEFINED


Chronic pain has been identified as an independent entity, rather than a symptom, for a relatively short period of time. Until the middle of the 20th century, chronic pain was thought to be acute pain that did not resolve or was psychosomatic in origin. Over the intervening half century, research by physicians and neuroscientists has altered this view of chronic pain. In 1986, the International Association for the Study of Pain (IASP, 1994) defined chronic pain as



… an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage that lasts continuously or intermittently for a period of 6 months. The cause of chronic pain is often unknown (p. 24).


This definition has since guided both the research and the treatment of people who live with pain. Some experts believe that pain needs to be present for only three months to be termed chronic since that period is the usual time for healing of injury to be completed. From an experiential perspective, anyone who has endured pain will know that three months is a very long time and that this type of argument regarding time may seem irritating and somewhat unsympathetic to the people who have chronic pain, and indeed their families, who are waiting for long-term plans for treatment and management to begin. Undoubtedly, as more is learned about chronic pain and the people who endure it, other definitions and understandings of this phenomenon will evolve.


Chronic pain is the same as persistent pain. Chronic malignant pain is chronic pain that is progressive. It is expected to increase in intensity or duration, or both. It is usually due to the effects of cancers, but can arise from a number of non-neoplastic diseases, for example some types of rheumatoid arthritis, ankylosing spondylitis or multiple sclerosis. Chronic non-malignant pain is chronic pain that is not expected to progress or to progress very slowly over a long time frame. Low back pain, osteoarthritis and neuropathological pains such as those encountered in spinal damage or in diabetes are examples of chronic non-malignant pain. There are also other categories of chronic pain—neuropathic pain is complex pain that commonly involves dysfunction of nerve fibres; nocioceptive pain is biological, resulting from harm or disease to structures in the body; and idiopathic pain is pain for which no pathophysiological basis can be found.


The pathophysiology of chronic pain is still a very topical issue and ongoing biomedical research aims to clarify our understanding of the mechanisms and issues involved in the initiation and maintenance of pain over a long period of time. Specialist physicians, neurobiologists, psychologists, psychiatrists, physiotherapists, dentists, gerontologists and nurses use research to expand knowledge of this complex condition. The biopsychopathological explanation of the basis of chronic pain development is complex and additional information is added on a daily basis. One of the most salient points to emerge recently is the neuroplasticity of the brain and how ongoing acute pain actually alters the functioning of some parts of the brain to embed pain and foster a chronic problem. This is supported by epidemiological studies, which demonstrate that people who suffer from chronic pain have lower pain thresholds and higher sensitivities to pain (Smith et al, 2006). For a thorough explanation of the chronic pain phenomenon, a pathophysiology textbook should be consulted.



CASE STUDY 8.1


This case study is used to show a typical professional approach to diagnosis and treatment of a person with chronic pain. It illustrates the importance of therapeutic communication and a holistic approach. The breakthrough in the management of this person is accurate diagnosis of the cause of the pain and pharmaceutical therapy associated with an understanding of the emotional turmoil of the person involved. The nursing role is a combination of diagnosis, support and education and continuing evaluation.



SOCIAL HISTORY


Mr B, a 69-year-old retired man living in north Queensland, is married with four grown children. His wife is very supportive of Mr B’s condition. He does not drink or smoke and has no significant family history.



RELEVANT MEDICAL HISTORY


Depression, anxiety, hypogonadism



PRESENTING PROBLEM


Mr B presented to a neurologist for investigation of left arm parasthesia and dysthesia of left thigh—chronic radiculopathy (spinal nerve root disease). He was diagnosed at that time with multiple sclerosis following positive results on Magnetic Resonance Imaging (MRI) and lumbar puncture. Prior to diagnosis Mr B developed recurrent left upper quadrant abdominal pain. This was diagnosed as pancreatitis and led to a distal pancreatectomy for a possible lesion on the tail of the pancreas with multiple subsequent operations for removal of collections. Sepsis followed.


This pain was extensively investigated in 1994, when Mr B had CT scans and endoscopic retrograde cholangio-pancreatography as well as pancreatic biochemistry tests. All resulted in ‘no abnormality detected’. Mr B was admitted to a private hospital for investigation of severe back pain a short time later.


Mr B was depressed to the point of considering suicide. His medications at this stage were:


• Baclofen 20 mg BD

• Prozac 20 mg daily

• Kapanol 50 mg BD

• Pethidine 150 mg Intramuscularly PRN Q4H

• Maxalon 10 mg PRN 4/24

An epidural catheter was inserted with an infusion of Marcain 0.25% and Fentanyl to provide pain relief. The catheter remained in situ for seven days before it was removed. It was believed that the pain may have been the result of plaque deposits on the spinal cord. Following this admission Mr B was transferred to the public hospital for implantation of an intrathecal catheter with a drug delivery pump. The overall goal was to reach a therapeutic level of drug administration where pain was kept at an acceptable level. Post-operatively some technical complications occurred while titrating the dose. (An intrathecal pump will not eliminate all pain but with it working at a therapeutic rate the pain will be decreased to a manageable level.) Pain management strategies developed in conjunction with allied health staff experts in pain management were implemented. As part of the team approach to his pain management Mr B was referred to a clinic psychologist. During his consultations it was uncovered that Mr B was grieving for the ‘life’ he had lost and his altered relationship with his wife. He felt that his condition was causing his relationship to break down because his wife needed to take on more of the day-to-day running of the household. He mourned the loss of responsibility and control that he had had at work prior to the chronic pain. He felt he could no longer make a difference at work.


By 2002, the pain was no longer at a manageable level and the intrathecal pump dose per day was titrated to 3.0 mg/day of morphine with clonidine added. Clonidine has an analgesic effect mediated at the alpha 2 adrenoreceptor sites, which are located in the superficial layer of the dorsal horn of the spinal cord (Murphy, 2006). It inhibits noradrenaline release from adrenergic nerve terminals and thus slows transmission across the synapses.


The prescription was changed numerous times and Mr B experienced exacerbations of his multiple sclerosis, which required admission into hospital or bolus doses of the morphine/clonidine that were programmed into the intrathecal pump by the pain management specialist. Mr B has now been on a stable dose of 11.5 mg/day of morphine, although he continues to experience some leg pain. MRI results show compromise of the bilateral neural foraminae at L5–S1.


The attending gastroenterologist now believes that Mr B’s presenting pain may never have been pancreatic pain but was much more likely to have been associated with the onset of the multiple sclerosis. Although Mr B’s pain levels have increased over the past ten years, he has used many positive management strategies to deal with it. With the assistance of his general practitioner and the pain management team he has been able to travel extensively around Australia by pre-arranging his pump refills in other centres across the country. Mr B has learned to manage his chronic malignant non-cancer pain and is enjoying a full life.



THE INCIDENCE AND IMPACT OF CHRONIC PAIN


The incidence of chronic pain was estimated at 17.1% (males) and 20% (females) of the adult Australian population, rising to 27% of adults over 65 years of age (Blyth, 2001). Chronic pain also affects significant numbers of children and adolescents, although population statistics are harder to come by for this group than the elderly. In Australia. with an estimated population of 2.7 million over the age of 65 years, 27% equates to 729,000 people (ABS, 2007) and in New Zealand, with an estimated population of 450,426 over 65 years, 121,615 (Statistics New Zealand, 2004). The incidence of chronic pain is of course underestimated because a number of people manage or endure the pain in their own way rather than seeking assistance and therefore avoid being registered as a ‘chronic pain’ statistic (Mayer et al, 2001). Moreover, Dewar (2006) makes the important point that the incidence of chronic pain rises with age and therefore the percentage of over 85s with chronic pain is higher than the 27% quoted above.


Chronic pain was estimated to cost Australian society somewhere in the region of $10 billion annually by Aoun, writing in 1998. This is only the monetary cost and does not take into account the social, cultural and intellectual contribution that is lost through the disengagement from the mainstream of work and social intercourse that can occur when people are stricken with disabling and chronic pain.



BEHAVIOURS AND EXPERIENCES ASSOCIATED WITH CHRONIC PAIN


Identifying the behaviours that lead to chronic pain is a complicated matter because chronic pain is classically associated with either no known cause, or a plethora of pathological conditions that result from illness or trauma. Without the power of hindsight there is little health advice that can be added to general messages to learn healthy habits from an early age in order to prevent a range of illnesses that may be associated with the development of chronic pain. In particular, healthy eating, regular exercise, good posture and avoidance of obesity, smoking and substance abuse may ward off illness or place a person in the best possible condition to cope with chronic pain should it develop. Trauma is another precursor to chronic pain; it is wise to follow health warnings and laws about wearing protective clothing and limiting alcohol consumption.


It is more usual to discuss behaviours that support the best possible management of chronic pain rather than prevention. Early interventions at the onset of chronic pain cover such things as learning how to manage pain and the effects and side-effects of analgesia, and how to continue to move and exercise in ways that do not exacerbate pain but keep muscles active and limbs flexible. Distraction, guided reflection and relaxation techniques may help some people and are a matter of personal choice. Nurses and other health professionals can reach an understanding of the psychological effects that chronic pain has on emotional wellbeing and the secondary effects of these on relationships with others by developing insight and self-understanding.


On a really practical note, navigating the maze of health information and choosing the best available therapies and therapists are increasingly becoming issues for health consumers. Nurses and other health professionals can facilitate learning and enable the person to discriminate.


Understanding the importance of psychological (cognitive and behavioural) factors in the development of chronic pain assists the person, their associates and health professionals to improve the care given to people who suffer chronic pain. Each person is different and will perceive and react individually to the insult of pain. How pain is perceived and the individual reaction to pain will often shape the experience of that pain. For instance, fear-avoidance (that is, the fear of injury due to movement, and avoiding movement), catastrophising (negative thinking and worry in response to pain) and depression are more likely to result in greater disability (Boersma & Linton, 2006). Catastrophising has been demonstrated to diminish with educational level, indicating that lower levels of formal education act as a risk factor for adverse pain outcomes (Edwards et al, 2006).


Negative emotions or emotional reactions to pain partially define the painful experience. Vulnerability to and the ability to regulate emotional experiences partially determine the reactivity of the person to their pain (Hamilton et al, 2007). Anxiety and depression are the major negative emotions that influence the pain experience. Anxiety stimulates the autonomic nervous system, leading to symptoms such as tachycardia, tachypnoea and elevated blood pressure. Over time, the autonomic arousal may result in symptoms perceived as pathological (e.g. headache, gastric upset) as well as the severe distress that accompanies ongoing anxiety. This results in more anxiety and avoidance of physical activity, which will eventually de-condition the person, leading to disability. Anxiety also affects cognitive function, such as memory and decision making (Dick & Rashiq, 2007).


Depression is considered a co-morbidity of chronic pain because of the significant overlap of brain regions affected by these two conditions. Many people with chronic pain develop depression and 65% of those with depression have pain as a symptom (Williams et al, 2006). Those people with chronic pain who do develop depression have greater associated disability with higher levels of reported pain, less physical activity, lower levels of psychosocial functioning, feelings of helplessness and loss of control, and poorer response to treatment (Adams et al, 2006).


Frustration, fear and anger are also typical emotions associated with chronic pain. Suffering is a combination of negative emotions (anxiety, depression, frustration, fear and anger) and negative ideation (that is, the inability to endure the pain, perception of the lifestyle interference, inability to reduce the pain and likelihood of not finding a cure) (Wade & Hart, 2002, p. 31).


Adolescents who live with chronic pain are often not able to work through the developmental tasks of their age group. Rather than striking out and establishing an independent lifestyle, those who live with chronic pain may remain dependent on their parents and in fact may increase their dependency. Their socialisation is also curtailed due to the inhibiting influence of pain, treatment and the associated psychosocial aspects of chronic pain, such as depression. Assessment is often difficult. The young person is often angry or embarrassed and may not be willing to share information with the healthcare professional.


Moral judgements may be made about the veracity of an individual’s pain that are based on the social and cultural context of the person’s response to pain. In the past (hopefully) this has led to labelling of individuals as fraudulent when they claim pain over time for which there is no medical explanation. This stigma, attached to those who report pain without an identifiable pathological basis, is greatly feared, in part because illness is defined by a society that values the medical model of healthcare. If medicine is unable to identify and treat the pain, either the person may be seen to be exaggerating for gain or the pain is seen as psychological. Patients with chronic pain are often very relieved if they can have a physical diagnosis of the cause of the pain as this is seen to ‘legitimate’ their pain. Although the incidence is low (Hill & Craig, 2004), there will always be those who ‘malinger’ (exaggerate their pain behaviour for some sort of personal gain). Determining the legitimacy of pain behaviour is a difficult clinical and ethical decision (Sullivan, 2004); it may also be a medico-legal question of whether the person is engaging in fraudulent behaviour for gain (Mendelson & Mendelson, 2004).


Case study 8.2 is a story of Paul S’s experience with chronic back pain. His was a long story of struggle for recognition and compensation. The story deals with trust, belief, self-stigma and emotions of fear and anger associated with chronic back pain. The style of this case study differs from that of Case study 8.1, which was presented from the point of view of a health professional. Case study 8.2 is taken from phenomenological study of the experience of chronic illness in rural Australia and gives the person’s view.



CASE STUDY 8.2


Paul S was on sickness benefits and had ceased work. He lived outside a regional city in Victoria and was booked in to have an operation in Melbourne. Before he was due to go to Melbourne the Department of Social Security sent him a letter, requiring him to present at the local office of the Department of Social Security on 9 April, which was a Friday. So, wanting everything to be right for the family while he was away, he went into the Department on the preceding Monday.


He was in the queue and recognised another man in the queue, whom he knew to be a ‘bludger’. He wanted to appear different from this man but how could he?—his back pain was not obvious to those around him. Paul resigned himself to the fact that he and the man looked remarkably similar. ‘I am here because I am sick,’ he cried inwardly, with enough passion to make his heart race and his back ache.


He shuffled from side to side, trying to ease the pain. There were no chairs anywhere; he could not take a walk around because he would lose his place and have to start queuing all over again.


After over half an hour, which seemed an eternity, his turn came. He held his letter out to the clerk behind the glass-fronted counter and before he could open his mouth to give the prepared apology for presenting earlier than the day stipulated in the letter, it was snatched from his outstretched hand. It disappeared under the hole in the glass screen. The clerk glanced at the letter and with a resigned look on his face said in a singsong tone, ‘This says to bring it in on Friday.’


‘I know,’ Paul replied mirroring his tone, ‘but Friday is Good Friday. There won’t be anyone here.’ Paul knew he had irritated the man.


‘Well, you can’t bring it in today.’


‘That is okay,’ Paul said, ‘when shall I bring it in?’


The clerk thought about this and said, ‘Tuesday after.’


Now the frustration was beginning to well up inside Paul. He described it, ‘The pain in my back was like two hard bricks pressing down, my stomach ached and my teeth were clenched.’ He really wanted to cry but that was unthinkable—that, or reach through the glass hole and throttle his tormentor. People were shifting in the queue behind Paul. He explained that he was going away to Melbourne on Sunday.


‘Well, take it to an office in Melbourne,’ the clerk responded.


‘I will be in hospital,’ Paul replied. ‘Gotcha!’ he thought. ‘Can I bring it here on Thursday?’ he asked.


‘No,’ was the clerk’s belligerent reply.


Paul asked for the manager but there was not one. He tried asking for the clerk’s name but he would not give it to him. Paul felt that the people in the queue were enjoying the scene; he had to give up but before he did so he clenched his fist tightly and shot it towards the clerk’s jaw. Stopping just at the glass, he opened both hands and placed them flat on the glass which divided them. The man looked scared and Paul was ashamed, defeated, disgusted and so angry. His hands slipped slowly down the glass and dejectedly he walked to his rickety old ute for the 20-km jolting journey through the bush with nothing to offer his family.

Related posts:

  1. Stigmatisation of people living with a chronic illness and/or disability
  2. Palliation in chronic illness
  3. Cancer
  4. Principles of practice for supportive care: diabetes

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Mar 13, 2017 | Posted by in NURSING | Comments Off on Management of chronic pain

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