1. The Basics of Good Pain Control: Understanding and Assessment Dr. Leah Steinberg

3. On Monday you go to work: Meet Mr. Peters 52 yr old patient with lung cancer Holding his chest “It feels like I’m being squeezed and it is burning” “I can’t sleep…” His wife is crying at his side…

4. Your Learning Objectives: 1.Appreciate the prevalence of pain in patients with advanced cancer and other medical illnesses; 2.Describe the basic mechanism of pain; 3.Define the elements of a complete pain assessment;

5. How common are symptoms? Pain 84% Fatigue 69% Weakness 66% Anorexia 65% Dyspnea 50% Nausea 36% Delirium 21% Walsh et al, Supportive Care Cancer 2006 N= 922 patients with advanced cancer

6. What about non-malignant illness? Congestive Heart Failure Emphysema (COPD) ALS Renal failure Advanced liver disease PAIN FATIGUE ANOREXIA DYSPNEA

7. Objective 2: What is pain? An unpleasant sensation – a feeling Created by stimulation of receptors on nerve endings -- nociceptors

9. Mechanism of pain transmission: Cancer damages tissue Releases neurotransmitters Pain signal We now know: Cancer itself releases inflammatory mediators Inflammatory mediators trigger pain receptors Don’t always “see” damage on imaging; size doesn’t matter

10. Types of pain simplified: Nociceptive pain Intact nervous system Visceral - describe? Somatic – describe? Neuropathic pain Damaged nervous system Describe? If it sounds weird…

11. Back to Mr. Peters: Sitting in front of you, looking for help… What have we learned so far?

12. We now know: Common His disease is causing pain signals But before we know what to do for him, we need a good assessment

13. Objective 3: How do we assess pain? Thoughts?

14. How do we assess pain? Physical Domain + Psychosocial Domain TOTAL PAIN

15. Physical Domain: find etiology Location of pain Timing of pain Nature (quality): ache, dull, burning, skin Radiation of pain Aggrevating/Relieving factors Severity (use a pain rating scale) Treatment so far and effect

16. Past/current medical status May assist or complicate assessment: Assist: Location of cancer: pain syndromes, neuropathic Complicate: Delirium, dementia, infection, renal function, chronic pain

17. Mr. Peters: Physical Domain Now you can start asking some questions!

18. Physical Domain: Another example Mrs. C. presented with pain from locally advanced breast cancer -- Her physical domain assessment: Sharp, burning, chest wall pain Started 4 days ago Worse with movement of arm, dressings Redness increased PMH: LABC x 4 yrs, no other illnesses

19. Mrs. C: What is her pain from? What is our going on in this case?

20. How do we assess pain? Physical Domain + Psychosocial Domain TOTAL PAIN

21. Psychosocial Domain Understanding of disease Fears, ideas, expectations History of depression/anxiety Fears of opioid use Family support/awareness Cultural/religious factors Affects how your patient perceives and expresses his pain

22. Mr. Peters: Psychosocial domain Now you can ask more questions!

23. Psychosocial Domain: Another example 90 yr old female with bony metastatic disease to manubrium (lung ca) Clearly bone (somatic) pain Clearly uncomfortable Always said pain was acceptable, never wanted pain medication – family quite upset Assessment revealed fear of sedation and confusion – therefore under expressed pain

24. Why it is important? Or, how I understand TOTAL PAIN NOCICEPTION PERCEPTION EXPRESSION Pain receptors and neurotransmission; this is where opioids work Thalamus and cortex Psychosocial Domain

25. Total Pain Our patients express pain Opioids work and they work well But, remember, it is EXPRESSION of PAIN If you are having trouble with managing pain with opioids, think about the other inputs…

26. Complete Assessment Physical understanding: –Gives you likely etiology and medical complications Psychosocial understanding: –Gives you understanding of how your treatments will likely work and what other components you need to add to have effect

27. Summary Prevalence of pain Mechanisms of pain First (and hardest) step in treatment: A good pain assessment Once you have that, you know the path to treatment