By Carol S. Blecher, RN, MS, AOCN, APNC

The International Association for the Study of Pain (IASP) and the American Pain Society (APS) define pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” While this definition identifies the complex nature of pain with its physiological and psychosocial components, for those of us in clinical practice, it is more common to use the definition put forth by pain management expert Margo McCaffery, MS, RN, FAAN, (1968) which states that “pain is whatever the experiencing person says it is, existing whenever he says it does.” This definition coincides with the current expectations outlined by regulatory agencies such as The Joint Commission, The Commission on Accreditation of Rehabilitation Facilities (CARF), and the National Committee on Quality Assurance (NCQA), as well as the clinical practice guidelines published by the American Pain Society, Acute Pain Management Panel, Management of Cancer Pain: Clinical Practice Guideline-Agency for Healthcare Policy and Research, and, most recently, the National Comprehensive Cancer Network Adult Cancer Pain Guideline.

Most people seek health care because they are in pain, and it is the responsibility of the entire medical team—including physicians, nurses, and pharmacists—to treat the pain as well as its underlying cause. However, in order to effectively treat pain, it must first be adequately assessed, as all pain should not be treated in the same fashion.

Pain Assessment
Studies show that many clinicians consistently underestimate a patient’s pain level by making an assessment based on their perception of the patient’s pain, usually derived from the patient’s appearance (smiling vs. grimacing). However, based on McCaffery’s widely accepted definition, the only reliable indicator of pain is the patient’s self report. Therefore, in order to best assess pain, the patient should be asked several questions about the pain they are experiencing, including:

1. Where the pain is located and what the intensity of the pain is (using a standardized scale, usually zero to10)
2. What the present level of pain is, and what has been the worst and best level of the pain since its onset
3. What the pain goal is (usually rated as zero, implying pain free)
4. What the qualities of the pain are (e.g., sharp, stabbing, shooting, hot, cold, prickly, aching, etc), which can help indicate the type of pain that is being experienced, such as bone pain which may present as dull and/or achy or neuropathic pain which may present as shooting, hot, cold and/or prickly

In addition, questions related to the onset, duration, variations, and rhythms of the pain will help decipher what causes or relieves the pain. Keep in mind that the patient’s expression of pain may be affected by cultural factors as well as religious beliefs. It also is important to ask the patient how the pain is affecting their life in relation to Activities of Daily Living and their psychosocial relationships. Once pain has been assessed, an effective plan of care designed to meet the specific needs of the pateint can be
formulated.

Assessing and managing pain involves a team effort that includes input from doctors, nurses, and pharmacists. As part of that team effort, pharmacists should be evaluating the patient’s adherence to the medication regimen, assuring that the medication is refilled at the appropriate time, and questioning the patient about their pain and the effectiveness of the pain management protocol.

Pharmacological Management of Pain
The pain management team needs to work together to help patients gain control of their pain using combinations of medications to achieve the best possible pain control. When treating pain we use the WHO (World Health Organization) pain ladder as a guide (see Figure 1). This three-step approach was designed to help health care providers manage cancer pain with medications in a systematic way, and is now the basis for all pain management situations. It uses combinations of non-opioids, adjuvants, and opioids in a progressive fashion to achieve adequate analgesic effects. Initially, we use drugs such as Tylenol and NSAIDs with or without adjuvants such as Elavil, Neurontin, and Lyrica for neuropathic pain or a bisphosphonate or steroids for bone pain. If the non-opioid medications are ineffective in managing the individual’s pain even in combination with the adjuvant medications, opioids such as oxycodone, morphine, methadone, or dilaudid will be added. Short-acting opioids are used at first, and once the patient’s pain has stabilized, they are switched to long-acting opioids such as MS Contin, OxyContin, methadone, or fentanyl patches—avoiding the peaks and valleys inherent in the short-acting medications. Short-acting medication would then only be used for breakthrough pain.

The pain management team needs to be aware of the maximum tolerable doses of various medications when making decisions; drugs like Tylenol have a maximum dose beyond which there is potential for liver damage. Practitioners often forget about the Tylenol in drugs like Percocet, and if the patient is taking two Percocet 5/325 every four hours around the clock, that patient is receiving a total of 3,900mg of Tylenol in 24 hours, very close to the maximum 4 gram daily dose. It is important for the pharmacist on the team to remind clinicians of this issue so that pure opioids are ordered as opposed to combination drugs. It also is important for the pharmacist to inquire about stool softeners when the prescription for an opioid is filled due to the constipating effects of opioids. If the prescriber has forgotten to add the stool softener, pharmacists can save the patient from unnecessary problems by suggesting the need for one. Most prescribers also rely on the pharmacist to reinforce the education they have given the patient regarding the medications as well as the instructions for use of the medications.

Conclusion
No one should ever have to live or die in pain when we have such effective pain management agents at our disposal. By taking a team approach to evaluating and treating the patient, we can help them most effectively manage their pain. As the medication experts, pharmacists play a valuable role in this team approach, helping to ensure that the patient is using pain medications that make the most sense for their condition.

Carol S. Blecher, RN, MS, AOCN, APNC, is an advanced practice nurse and clinical educator at Trinitas Comprehensive Cancer Center in Elizabeth, New Jersey. Carol also is a member of the adjunct faculty at Trinitas School of Nursing, Union County College and at Rutgers University in Newark, New Jersey. She received her BS in nursing from New York University, and her MS in nursing from Rutgers University.