Managing and treating pain

The treatment and management of pain should be based on the findings of a pain assessment.

Treatment approaches vary according to the type of pain, but all involve a combination of pharmacological and non-pharmacological approaches.

Coordinated, multidisciplinary treatment strategies are sometimes required, particularly if pain persists and does not respond to conventional treatment.

The National Pain Strategy (2010)¹ , which is currently under review, recommends a multidisciplinary pain management plan that includes a combination of medical approaches, physiotherapy, environmental and psychological interventions based on Cognitive Behavioural Therapy (CBT).

Identify the pain

Classify the pain to inform treatment planning.Most chronic pain may be classified as:

• nociceptive - pain that arises from actual or threathened damage to non-neronal tissue and is due to the activation of nociceptors. This could include post-operative and inflammatory arthropathy (such as arthritis or gout) and may be described as dull, aching or throbbing.
• neuropathic - to describe pain caused by a lesion or disease of the somatosensory nervous pain, it is often described as burning and may be associated with tingling, pins and needles, numbness or itching.

Some types of pain can be both nociceptive and neuropathic (cancer pain)

• Treat pain without a pain score when the older person is not able to focus or use a pain rating scale or is visibly in pain².
• Always consider the possibility of pain in all contacts with older people.
• Ask older patients about pain routinely and be aware of behaviours that might indicate underlying pain.
• Regularly record assessment results to facilitate ongoing care.

Manage the pain

Follow your hospital policies and procedures and pathways for pain management.

Consider pharmacological and non-pharmacological approaches:

A pharmacological approach requires an understanding of the mode of action, common side effects and common drug interactions. Medication dose, administration, monitoring and adjustment must be carefully considered, taking into account age-related changes in drug sensitivity, efficacy, metabolism and side effects. Analgesic treatments should be tailored to individual needs.

• Consider pre-emptive analgesia prior to any medical procedure (IV cannulation, dressing change), or rehabilitation procedure (physiotherapy exercises) likely to cause significant pain.
• Consider patient-controlled analgesia post-operatively.
• Chronic pain is best managed with around-the-clock analgesia. Medications should be given, even if the person doesn’t have pain at the time the medication is due.
• Monitor regularly for any side effects following pain treatment (such as nausea, vomiting, sedation, constipation or dizziness)
• Address opiophobia:
  • Many older people with pain respond well to opioid therapy, particularly if nociceptive pain. Opioids should not be denied because of fears of addiction.
  • It is reasonable for a person with severe pain to seek and/or be offered analgesia.
  • Addiction, also known as psychological dependency, is manifested by opioid-seeking behaviours for reasons other than pain relief. Psychological dependency should be differentiated from physical dependency.
  • Physical dependency occurs after a person has been on certain medications for some time, including opioid analgesics, and is manifested as withdrawal symptoms if the drug is suddenly stopped. Chronic opioid therapy should therefore not be abruptly stopped.
  • Opiophobia by health care staff may contribute to persistent unrelieved pain.
• Simple analgesia, such as regular paracetamol, is well tolerated and can provide a background level of analgesia. If the person's pain is not well controlled the addition of opioids provided regularly and/or as required can be an effective strategy to manage a person's pain.
• Some medications that are not typically used for pain may also be helpful for its management. Examples of these include tricyclic or SNRI antidepressants and gabapentinoids. These may improve the quality of opioid analgesia and limit the development of opioid tolerance.

Non-pharmacological approaches include psychological approaches (cognitive behavioural therapy, relaxation, education), physical therapies (physiotherapy, occupational therapy, superficial heat and cold, TENS, gentle exercise, hydrotherapy), and complementary and alternative therapies (acupuncture, massage, other supplements).

• Encourage the older person to move regularly around the ward if they are capable and it is appropriate.

Refer the patient for an inpatient management assessment or to an outpatient multidisciplinary pain clinic on discharge if their pain persists after pharmacological and non-pharmacological therapies.

Re-assess pain regularly

• Interventions introduced to manage pain should be regularly re-assessed.
• Re-assess pain levels every one to two hours until the pain episode is under control (for example, post-procedural pain).
• Increase the frequency of pain assessments if:
  • pain is poorly controlled, that is, if the patient is experiencing moderate pain, scores 5/10 on a measurement scale or the pain stimulus or intervention alters. Consider the potential for undiagnosed serious pathology, including ischaemia.
  • an analgesic infusion is in progress, which indicates a higher intensity of pain and appropriate safety monitoring occurs.
• Reassess pain after analgesic treatment to determine if:
  • the treatment was effective
  • further treatment is necessary
  • any side effects have occurred as a consequence of the treatment (for example, nausea, vomiting, constipation and sedation).
• Wear badges and use stickers on care plans as visual reminders to regularly assess and report pain.

Assess and document the pain assessment outcome and pain management treatment provided^{2 3}.

¹ National Pain Summit Initiative, National Pain Strategy: Pain Management for all Australians, 2010.

² The Victorian Quality Council, Acute pain management measurement toolkit, 2007, Rural and Regional Health and Aged Care Services Division, Victorian Government, Department of Human Services: Melbourne.

³ Herr, K., Pain assessment in the older adult with verbal communication skills, in Pain in Older Persons, S. Gibson and D. Weiner, Editors. 2005, IASP Press: Seattle. p. 111-133.