Chapter 1 FAILURE of clinicians to ask patients about their pain and to accept and act on patients’ reports of pain are probably the most common causes of unrelieved pain and unnecessary suffering. Basic pain assessment is a simple but, unfortunately, infrequently performed task. Even when appropriate assessments are made, clinicians do not necessarily accept the findings and might not take appropriate action. Some of the misconceptions that cause this are listed in Table 1-1, and these and others are discussed later in this chapter and in other chapters in Section II. Table 1-1 Misconceptions: Barriers to the Assessment and Treatment of Pain *These misconceptions are discussed in this section, along with appropriate references. From Pasero, C., & McCaffery, M. Pain assessment and pharmacologic management, p. 17, St. Louis, Mosby. Pasero C, McCaffery M. May be duplicated for use in clinical practice.
Underlying Complexities of Pain Assessment
Misconception*
Correction
The best judges of the existence and severity of patients’ pain are the physicians and nurses caring for the patients.
Patients are the authorities on their pain. Patients’ self-reports are the most reliable indicators of the existence and intensity of pain.
Clinicians should use their personal opinions and beliefs about the truthfulness of patients to determine patients’ true pain status.
Allowing each clinician to act on personal beliefs presents the potential for different pain assessments by different clinicians, leading to different interventions by each clinician. This results in inconsistent and often inadequate pain management. It is essential to establish the patients’ self-reports of pain as the standard for pain assessment.
Clinicians must believe what patients say about pain.
Clinicians need not believe the patients’ reports of pain, but clinicians must accept and respect patients’ reports of pain and proceed with appropriate assessment and treatment. Clinicians are always entitled to their personal opinions, but those opinions cannot be allowed to guide professional practice.
Comparable noxious stimuli produce comparable pain in different people. The pain threshold is uniform.
Findings from numerous studies have failed to support the notion of a uniform pain threshold. Comparable stimuli do not result in the same pain in different people. After similar injuries, one person may suffer moderate pain and the other severe pain.
There is no reason for patients to hurt when no physical cause for pain can be found.
Pain is a new and inexact science, and it would be foolish of us to think that we will be able to determine the cause of all the pains that patients report.
Patients should not receive analgesics until the cause of pain is diagnosed.
Pain is no longer clinicians’ primary diagnostic tool. Symptomatic relief of pain should be provided while the investigation of cause proceeds. Early use of analgesics is now advocated for patients with acute abdominal pain.
Visible signs, either physiologic or behavioral, accompany pain and can be used to verify its existence and severity.
Even with severe pain, periods of physiologic and behavioral adaptation occur, leading to periods of minimal or no signs of pain. Lack of pain expression does not necessarily mean lack of pain.
When it is time to reassess patients’ pain following an analgesic and the patients are sleeping, it is not necessary to awaken them.
Sleep does not mean the absence of pain, and not all patients who appear to be sleeping are actually sleeping. Until patients’ responses to analgesics are established as being effective and safe, patients should be awakened to obtain a pain rating. This should be explained to patients. However, if the same analgesic dose has been administered before and has produced effective pain relief, and patients are not aroused by simple stimuli such as calling their names in a normal tone of voice, patients with acceptable respiratory status may be allowed to sleep. If patients’ pain is relatively constant and the analgesic effect is known to wear off after a certain time, e.g., 4 hours, consider awakening patients for the next dose before pain awakens the patients. Discuss this option with the patients.
Anxiety makes pain worse.
Anxiety is often associated with pain, but the cause-and-effect relationship has not been established. Pain often causes anxiety, but it is not clear that anxiety necessarily makes pain more intense.
Patients who are knowledgeable about opioid analgesics and who make regular efforts to obtain them are drug seeking (addicted).
Patients with pain should be knowledgeable about their medications; use of opioids for pain relief is not addiction. When patients are accused of drug seeking, it may be helpful to ask, “What else could this behavior mean? Might these patients be in pain?”
When patients report pain relief after a placebo, it means that the patients are malingerers or that the pain is psychogenic.
About one third of patients who have obvious physical stimuli for pain (e.g., surgery) report pain relief after a placebo injection. Therefore, placebos cannot be used to diagnose malingering, psychogenic pain, or any psychologic problem. Sometimes placebos relieve pain, but why this happens remains unclear.
The pain rating scale preferred for use in daily clinical practice is the Visual Analog Scale (VAS).
For patients who are verbal and can count from 0 to 10, the Numeric Rating Scale (NRS) is preferred for adult patients. It is easy to explain, measure, and record, and it provides numbers for setting pain-management goals. The VAS is a straight line with anchors at each end and no numbers or adjectives in between.
Cognitively impaired older patients are unable to use pain rating scales.
When an appropriate pain rating scale (e.g., 0 to 5) is used and patients are given sufficient time to process information and respond, many cognitively impaired elderly people can use a pain rating scale.
Cognitively impaired patients, especially those who are unable to self-report, do not experience as much pain as those who are cognitively intact.
Recent studies examining mechanisms and differences in pain transmission and perception in older adults with dementia document that the pain transmission process is unaltered, but these adults may respond with behaviors that are different from those of cognitively intact adults. In other words, cognitive impairment may result in less pain being reported, but there is no evidence that cognitive impairment reduces the ability to feel painful stimuli.
Critically ill patients, especially those who appear to be unconscious or have received a neuromuscular blocking agent, do not feel pain and do not recall painful episodes in intensive care units (ICUs).
Levels of consciousness are difficult to determine, and patients who are thought to be unconsciousness in the ICU often recall moderate to severe pain. Patients under the influence of neuromuscular blocking agents may still be fairly alert and able to feel pain. Patients with endotracheal tubes are unable to self-report verbally but may be able to provide self-reports if attempts are made, such as establishing head nod, pointing, or eye blink in response to questions about a pain.
Persons with intellectual disabilities (IDs) or mental retardation are either insensitive to pain or have greater tolerance for it.
This perception appears to be based on observations that behavior following a potentially painful event is delayed or unconventional. These observations are often valid but do not necessarily indicate insensitivity to pain or indifference to it. Measurements of sensitivity to pain using heat-pain thresholds indicated greater sensitivity to pain than is experienced by normal controls. Behavioral responses to pain may not occur in some individuals with IDs because of physical disabilities such as cerebral palsy.
Schizophrenic patients’ reports of pain are commonly expressions of the mental illness.
For some time, decreased reactivity to pain in some patients with schizophrenia has caused clinicians to believe they were experiencing insensitivity to pain. Some patients with schizophrenia fail to report pain until it becomes severe. As a result, these patients seek medical care at a later stage of the physical disease and may suffer complications as a consequence. Postoperative pain is a risk factor for postoperative confusion and should be treated with analgesics. The appearance of insensitivity to pain by schizophrenic patients is poorly understood but may be the result of abnormal processing of sensory input. In one study of experimental pain, it was noted that individuals with schizophrenia had difficulty focusing on their pain. Furthermore, pain is rarely a hallucination. Recently, studies have suggested that absence of pain reactivity does not mean absence of pain sensitivity.
Patients with posttraumatic stress disorder (PTSD) show low sensitivity to acute pain and rarely have chronic pain.
Although a few studies have shown that patients with PTSD are less sensitive to very brief painful stimuli, chronic pain is commonly present in patients with PTSD and, conversely, patients with chronic pain often have PTSD, although both of these co-occurences are underdiagnosed.
