The management of acute and chronic pain in the community

2 February, 2002

Ruth Day, MA, RN.

Nurse Consultant, Pain Management, Luton and Dunstable NHS Trust Hospital, Luton, Bedfordshire and the University of Luton

In her story about living with, and in, pain Judith Thwaite wrote: 'Thank God it is not possible to relive the acuteness of pain' (Thwaite, 1998). And Albert Schweitzer's experiences led him, back in 1937, to write 'Pain is a more terrible Lord of Mankind than Death itself' (Schweitzer, 1937). Whether we like it or not, pain is an experience that almost everybody will have at some time. Many will manage it themselves but a significant number will seek advice from their GP, a nurse or the local pharmacist. This paper will look at the broad areas of pain in the community and, through specific examples, suggest some ways that nurses can help patients manage their pain. The area of pain relief in cancer will not be covered, although the approaches covered here could be applied in that field.

Acute pain
Acute pain is defined by the International Association for the Study of Pain (IASP) as: 'Pain of recent onset and probable limited duration. It usually has an identifiable temporal and causal relationship to injury and disease' (IASP, 1986). Presentation of acute pain in the community can often mean a visit to the accident and emergency (A&E) department (for acute abdominal pain or cardiac pain) but there are a number of clinical situations in which the acute pain is best managed by the primary care team. A good example would be that of simple, or mechanical, back pain.

Acute back pain
It is estimated that 80% of people in the UK will develop back pain at some point in their lives. Of these, 90% will improve within 12 weeks. Patients coming to see the GP with back pain need careful screening to ensure that nerve root pain or any suspected serious pathology is not present. However, Waddell states that 93% of patients who present with back pain will fall into the category of mechanical, musculoskeletal back pain (Waddell et al, 1999; Bartley and Coffey, 2001). The Royal College of General Practitioners has published guidelines to assist in the management of these patients (Waddell et al, 1996). This document should be readily available in every GP surgery.

A possible timetable for the management of these patients is set out in Table 1.

Once the diagnosis of acute simple back pain is made, practice nurses can provide reinforcement of the key messages to patients, as follows:

- Backache is very common and the patient need not worry

- There is no sign of serious damage or disease and full recovery should be expected in days or weeks (although time will vary)

- No permanent weakness will result but recurrence is possible (that does not mean re-injury)

- Activity is helpful; too much rest is not. The fact that the patient's back is hurting does not mean harm is being done.

Patients may ask for treatment advice and there is evidence that regular (not 'when required') paracetamol is effective and can be supplemented with non-steroidal anti-inflammatory drugs (NSAIDs) if further analgesia is required. Sometimes the addition of a muscle relaxant such as diazepam is beneficial. The input of manipulative therapies can provide short-term improvement and the risks are low. Evidence for these therapies can be found in Waddell et al (1999), Chambers et al (2001) and Bartley and Coffey (2001). These publications seek to present an evidence-based approach.

Chronic pain
Chronic, non-malignant pain is particularly challenging and an analysis undertaken by Potter in 1990 showed that, of 1000 consultations with a GP, 11.3% were for pain that had lasted more than three months. The IASP defines it as 'pain lasting for a long period of time. It usually persists beyond the time of healing of an injury and there is frequently no identifiable cause' (IASP, 1986). Chronic pain includes not only low back pain but also conditions such as arthritis, diabetic neuropathy, trigeminal neuralgia, post-surgical pain and ischaemic pain. It is clearly beyond the remit of this paper to consider all these and many will benefit from specialist input from a pain clinic.

Chronic pain in arthritis
Osteoarthritis is the most common form of arthritis and is a leading cause of disability in older people. Rheumatoid arthritis is an inflammatory condition of the joints and tendons but it also has systemic features. Table 2 compares and contrasts these two forms of arthritis.

Although treatment choices are frequently made by the GP or specialist, nurses are in a position to be able to support the patient, either while waiting for surgery or while undergoing treatment. Patients may ask about non-pharmacological interventions. Transcutaneous electrical nerve stimulation (TENS) can be used in a number of painful conditions. The evidence surrounding its use in osteoarthritis of the knee suggests that it is more effective than placebo, although more studies are needed (Osiri et al, 2001). There is also a growing interest in herbal remedies. An example of a herbal prescription for osteoarthritis can be found in Vickers and Zollman's clinical review (1999). The evidence for these treatments needs further exploration and nurses need to be aware of the possibility of interactions between herbal medicines and conventional drugs. However, a Cochrane review indicated that 'avocado or soybean unsaponifiables' (herbal extracts) may be beneficial in the treatment of osteoarthritis (Little et al, 2001).

Team working
Nurses need to be aware of the input of other health-care professionals in the treatment of these conditions. Physiotherapists, occupational therapists, chiropractors and others can all play some part in the management of pain in patients in the community. Part of working as a multidisciplinary team involves understanding each other's roles - therefore enabling appropriate referrals. The emotional support that nurses can give this patient group is immense and an integral part of their pain management. On occasions input from a psychologist is appropriate and valuable (Eccleston, 2001).

Analgesia
Frequently, advice may be sought from the nurse about painkillers. Both chronic and acute pain are often dealt with using a variety of analgesic drugs and nurses need to develop skills in assisting patients in making sound choices in the use of their medicines. A multi-modal, or balanced, approach to analgesic therapy is often the best (Day, 1998).

The WHO ladder This well-known tool advocates a step-like approach to pain management (Figure 1). (See McCaffery and Pasero, 1999 for details of the World Health Organization pain ladder.) Alongside the choice of an appropriate analgesic the nurse needs to be able to give advice on taking the medication (regularly or as needed), the role of adjunctive medications (for example antidepressants may be used for nerve pain), the need for some medications to counter adverse effects (for example laxatives for opioids) and to answer general concerns the patient may have about his or her medications.

The role of opioids in the treatment of chronic pain is an area under debate at present and nurses should be aware of the key points (Collett, 2001). The choice of medications is always expanding and nurses need to be aware of, for instance, the differing side-effect profiles of some of the new, 'cleaner' NSAIDs. Further information on this can be found at www.jr2.ox.ac.uk/bandolier - the internet journal Bandolier.

Conclusion
It is clear that the nurse is in a key position to make a sound pain assessment and to suggest therapies which may cross professional boundaries. As pain is a multi-modal experience it should come as no surprise that effective pain management needs a multi-professional approach.

In order to be effective the nurse must:

- Understand different types of pain

- Have some knowledge of what causes the pain for that patient

- Be able to assess pain in an holistic manner - not just the character of the pain but the meaning it has for the patient, the concerns he or she may have about pain management and the restrictions that the pain puts on the patient's daily life (Dunn, 2000)

- Be able to advise on appropriate pharmacological interventions

- Know who to approach for multidisciplinary, non-pharmacological pain management techniques

- Be able to offer psychological support to patients.

This is no easy task and nurses must be willing to use a variety of resources. The Internet sites listed in Box 1 can provide useful information to both professionals and patients.

- Back pain will be discussed specifically in the March 2002 edition of Professional Nurse.

Bartley, R., Coffey, P. (2001) Management of Low Back Pain in Primary Care. Oxford: Butterworth-Heinemann.

Chambers, R., Hawksley, B., Smith, G., Chambers, C. (2001) Back Pain Matters in Primary Care. Oxford: Radcliffe Medical Press

Collett, B.-J. (2001) Chronic opioid therapy for non-cancer pain. British Journal of Anaesthesia 87: 133-143.

Creamer, P (1999) Osteoarthritis. In: Wall, P.D., Melzack, R. (eds). The Textbook of Pain (4th edn). Edinburgh: Churchill Livingstone.

Day, R. (1998) Methods of effective pain management in adults. Community Nurse June, 41-42.

Dunn, V. (2000) The holistic assessment of the patient in pain. Professional Nurse 15: 12, 791-793.

Eccleston, C. (2001) Role of psychology in pain management. British Journal of Anaesthesia 87: 144-152.

International Association for the Study of Pain. (1986) Classification of chronic pain: descriptions of chronic pain syndromes and definitions of pain terms. Pain (suppl 3) S1-S226.

Jayson, M.I.V (1999) Rheumatoid arthritis. In: Wall, P.D., Melzack, R. (eds). The Textbook of Pain (4th edn). Edinburgh: Churchill Livingstone.

Little, C.V., Parsons, T., Logan, S. (2001) Herbal therapy for treating osteoarthritis (Cochrane Review) In: The Cochrane Library 3. Oxford: Update Software.

McCaffery, M. Pasero, C. (1999) Pain: Clinical manual (2nd edn). St Louis, Mo: Mosby.

Osiri, M,. Welch, V., Brosseau, L. et al. (2001) Transcutaneous electrical nerve stimulation for knee osteoarthritis (Cochrane Review) In: The Cochrane Library 3. Oxford: Update Software

Potter, R.G. (1990) The frequency of presentation of pain in general practice: an analysis of 1000 consecutive consultations. Journal of the Pain Society 8: 112-116.

Roland, M., Waddell, G., Klaber, X. et al. (1997) The Back Book. London: The Stationery Office

Schweitzer, A. (1937) On the Edge of the Primeval Forest. London: A&C Black.

Thwaite, J. (1998) Pain lashes out: a personal story of pain. In: Carter, B. (ed.). Perspectives on Pain: Mapping the territory. London: Arnold.

Vickers, A., Zollman, C. (1999) ABC of complementary medicine: herbal medicine. British Medical Journal 319: 1050-1053.

Waddell, G., Feder, G., McIntosh, A. et al. (1996) Clinical Guidelines for the Management of Acute Low Back Pain. London: Royal College of General Practitioners.

Waddell, G., McIntosh, A,. Hutchinson, A. et al. (1999) Low Back Pain Evidence Review. London: Royal College of General Practitioners.

World Health Organization. (1986) Cancer Pain Relief. Geneva: WHO.