Few things affect a patient’s general quality of life as adversely as pain does. It can have severe effects on their mood, appetite, personal interactions, sleep and overall behaviour. Before you can determine what type of pain management regimen should be prescribed, it is important to first thoroughly assess the type of pain that a patient is presenting with.
CORRECTLY ASSESSING PAIN
While pain is a very widespread symptom of a great number of medical conditions, it must be kept in mind that the final arbiter of the degree of pain a patient is experiencing is the patient themselves. This is both because there is hardly any way to accurately determine the degree of pain a patient experiences, and because pain can be a highly subjective experience.
According to online medical educator Dr John Campbell, pain is, “whatever the experiencing person says it is, existing wherever they say it does, at the level they say it exists at.” Pain should be assessed to see whether it is different when the patient is moving versus when they are resting. Postoperative patients, for example, could experience no pain while lying motionless in their hospital beds, but experience extreme pain while moving or coughing.
A simple way of asking patients to self-assess their pain would be to ask them to rate their pain on a scale of 1 to 10, where 10 is the worst pain they have ever experienced. Separate conditions that cause pain in the same patient should be assessed separately and any treatment strategies that are applied to separate conditions should be checked to ensure no adverse interactions occur.
A useful tool for the assessment if pain is the PQRST evaluation.
The first step to properly managing pain is to carry out an individualised pain assessment. This not only helps to chart a course of treatment for a patient, but also psychologically reassures them. The psychological factor is an extremely important part of pain management. It has been proven, for example, that minimising a patient’s expectation of pain serves to reduce it.
Anxiety and stress can increase the severity of pain. Anxiety and stress often increase in direct correlation with a patient’s perceived lack of control over their condition. It is, therefore, very important to let patients feel like they are in charge or have the higher ground when it comes to their condition. To manage anxiety directly, many combination pain therapies will include both an analgesic and an anxiolytic, for example paracetamol/codeine-meprobamate combinations.
For many forms of acute pain, non-pharmacological therapies including physiotherapy, acupressure, aquatherapy, massage, hypnosis, meditation and exercise can greatly help alleviate symptoms (depending on the severity of the pain, of course). But in many cases of acute pain some form of analgesic therapy will be called for, and it will be the norm for the treatment of chronic pain.
In South Africa, the commonly prescribed analgesics are paracetamol, ibuprofen and tramadol. Very few analgesics have negligible adverse effects, especially during long-term use for chronic pain, and patients must be made aware of this. Research has also found that analgesics work best when they can be self-administered, since this helps the patient feel like they have the upper hand.
A WORD ON GOUT
Gout is a form of arthritis that can be extremely painful. Essentially, it occurs when excess uric acid finds its way into the joints. Gout is a chronic condition typified by frequent acute attacks of pain. Patients with gout can respond well to decreased alcohol intake, proper diet and moderate exercise. However, in many patients the best way to manage gout pain is to take anti-inflammatory agents (usually NSAIDs) and xanthine oxidase inhibitors like allopurinol and febuxostat. It is vital to treat gout as early as possible because it can eventually cause damage to bone and cartilage, as well as kidney stones.