Simple approach to PAIN

Pain is ubiquitous in medicine and often overlooked. Despite a thorough definition, 'an unpleasant, sensory and emotional experience associated with actual or potential tissue damage', it is impossible to really understand someones pain unless you have felt it yourself. It is a highly diffuse symptom with a massive impact on patient well being and quality of life (it may even be much more diffuse than believed). It is an all encompassing entity which if you take Dame Cicely Saunders concept of 'total pain' concerns not only physical aspects but also social, spiritual and emotional aspects. 

If you take cancer pain, it is the most frequent presenting symptom and present overall in the majority of cancer patients. Shockingly pain is reported in a minority of cancer medical records, it would seem that many oncologists dont assess pain, probably fixating on battling the cancer itself (one of the toughest battles in medicine to add). Pain should be considered a disease entity itself and if it is properly assessed, addressed and treated, it could go a long way to enhance patient quality of life.

Here is a simple approach to pain you should consider whenever a patient says they are in pain:

First ASSESSMENT:

ABCDE 

A is for Ask: Ask about the pain: use the OPQRST approach:

• Onset
• Provoking factors 
• Quality of pain
• Region and Radiation of pain
• Severity 
• Timing and history 

When assessing severity use the NRS or VAS technique; "on a scale of zero to ten, where ten is the worst pain imaginable and zero is no pain, how would you describe your pain severity" (this is NRS, VAS is the application of a mark on a 10cm line to indicate pain severity in the same way).

score of 1-3 is mild  (VAS would be 1-3cm)

score of 4-6 is moderate pain (4-6cm mark)

score of 7-10 is severe pain (7-10cm mark)

One really important thing to think about after you have taken a thorough history is "what is causing the pain?"

B is for Believe the patient, don't dismiss them.

C is for Control: choose and appropriate pain control method, best way to apparoch pain treatment is with the WHO pain treatment ladder, which can be applied to all pain and not just cancer pain. move up the steps if pain is not well managed or still present.

• 1st step: PARACETOMOL (to treat mild pain)
• 2nd step: WEAK OPIOIDS (for example tramadol or codiene, these are opioids with a ceiling effect where inceasing drug dosgae will not improve effect from a certain point)
• 3rd step: STRONG OPIOIDS (consider for mod-severe pain). (for all opioids "start low and go slow"
• at any point you can add adjuvants to the ladder: NSAIDS, corticosteriods, antidepressants, anticonvulsants, benzodiazepines.

D is for Deliver pain control in a timely manner

E is for Empower the patient in pain control, patient education is so important. 

Second MANAGEMENT:

The four A's:

• Optimize ANALGESIA
• Optimize ACTIVITIES of daily living
• Minimize ADVERSE EFFECTS due to treatment
• AVOID unnecessary  drug taking

Third REASSESSMENT:

Simply, reassess often!

Summary: ABCDE OPGRST AAAA Reassess!

AA Gill Faces Up To His Cancer

Yesterday the prolific writer and restaurant reviewer AA Gill died. 2016 has been a torture to many and just when you thought it couldn’t get worse, it took away another loved human being. The cycle of life and death is of course inevitable but even that resounding truth doesn’t make it any better. (someone please please put Sir David Attenborough in a bubble or something).

I actually first came across AA Gill when I was quite young and had just moved to the UK, my mom would read the Sunday times leave it lying on the dining room table after she finished. I would come in and pick through the various smaller newspapers and magazines in search for sports, motoring or kids sections and briefly read about the rugby scores or some fantastic gadget that will come out in the future (can you believe this iPhone gadget!). As I was flicking through the pages looking at the pictures of far off paradises in the travel section and the contrasting war torn battlegrounds in the Sunday Times magazine as I usually would, my mom came in once and pointed out I should actually READ the paper and not just look at the pictures. Of course I wasn’t interested in Tony Blair or The Foot and Mouth crisis but defiantly I decided to read something and one of the many articles I read that day was by the late great AA Gill.

Today I read his final piece in the Sunday Time magazine, a fantastically written and honest piece about his cancer and experiences with the NHS. I highly recommend reading it. 

The article: “More life with your kids, more life with yourfriends, more life spent on earth — but only if you pay” AA Gill.

He points out that the UK shockingly has some of the worse cancer survival rates in Europe, a third the percentage as Sweden in some instances. This is primarily due to the late diagnosis of cancer propagated by waiting times and turtle paced referral. The NHS, The jewel of the british isles, the pride the UK, might not be so brilliant after all, AA Gill writes:

“We say it’s the envy of the world. It isn’t. We say there’s nothing else like it. There is. We say it’s the best in the West. It’s not. We think it’s the cheapest. It isn’t. Either that or we think it’s the most expensive — it’s not that, either. You will live longer in France and Germany, get treated faster and more comfortably in Scandinavia, and everything costs more in America.”

RIP Mr Gill 

Picture: pic.twitter.com/A7WI9o8jWX @jenbalcombe