A clearer picture of pain
Helping patients to identify their pain and its triggers is the first step in alleviating it
Helping patients to identify their pain and its triggers is the first step in alleviating it, says the RCN’s Amanda Cheesley
Detecting whether someone is experiencing pain is not as straightforward as it may seem. Pain is surprisingly complex and it is different for everyone; what is clearly intolerable to one person may barely register with another.
Nurses need to be aware of this complexity and work with the patient to carefully unpick what their pain is, where it is, what it feels like, how it makes them feel and what helps.
Pain presents in many different ways. It can have physical, emotional or mental triggers.
Many people remain unaware that emotional pain can manifest as physical pain and, if left untreated, can cause great distress to the individual and those they live with.
Pain is categorised in two ways: neuropathic and nociceptive.
Pain pathways working as expected
Nociceptive pain, when the body’s pain pathways are working as you’d expect, can often be managed effectively compared with other pain. As an example, if a patient experiences pain after an operation, specific pain relief can be administered over a few days until the source of the pain heals.
The same principle applies to pain resulting from an injury, which transmits pain messages through the body.
‘Nociceptive and neuropathic pain are not mutually exclusive and patients may experience a mix of the two’
Nursing staff play an essential role in identifying and alleviating pain. This is more difficult to do when the nervous system becomes damaged or isn’t functioning as usual – which is particularly true of neuropathic pain.
Affected by chronic disease
Neuropathic pain is prevalent in chronic disease. It can affect people with diabetes (painful diabetic neuropathy), older people, patients who have had shingles (post-herpetic neuralgia), those who have had chemotherapy (chemotherapy-induced peripheral neuropathy) and patients who have undergone an amputation (phantom pain).
Nurses should consider a neuropathic component of pain if a patient describes a burning or stinging sensation, ‘pins and needles’ or a painful numbness.
Nociceptive and neuropathic pain are not mutually exclusive and patients may experience a mix of the two. Indeed, the relationship between the two classifications prompted the International Association for the Study of Pain to approve a third mechanistic descriptor, ‘nociplastic pain’.
There are a number of reputable screening tools nurses can use with patients who have persistent, non-malignant pain. The first tool to be widely used was S-LANSS, which remains a reliable way to identify neuropathic pain. For lower back pain, painDETECT is a common screening tool. The DN4 questionnaire is mainly used in research but is applicable to any setting.
‘When pain is difficult to describe or identify, nurses may feel that just when they’ve found a solution, another barrier emerges’
Although it can be difficult to recognise, there are tested methods of treating neuropathic pain. The Scottish Intercollegiate Guidelines Network (SIGN) produced a helpful reference guide that outlines the importance of a compassionate patient-centred approach and several treatment options. NICE guidance includes amitriptyline, duloxetine and soon-to-be-controlled substances gabapentin and pregabalin as initial treatment. Other treatments might involve desensitisation therapy. SIGN also produced an algorithm that nurses can use to familiarise themselves with the pathway for managing patients with neuropathic pain.
Effect on patients and families
No one should have to live with untreated pain. When pain is difficult to describe or identify, nurses may feel that just when they’ve found a solution, another barrier emerges. Pain with no observable cause can still become so debilitating that patients are left immobile or restricted in daily life, prevented from going about their day-to-day activities and spending time with their friends and family.
We mustn’t forget the burden on loved ones of witnessing someone in pain and the feeling of helplessness that comes with this. An emerging body of research means we’ll certainly see advances in the way neuropathic pain is diagnosed, but before then nurses must do everything they can to alleviate it, so patients and their families can enjoy the best quality of life possible.
Amanda Cheesley is RCN professional lead for long-term conditions and end of life care