Detecting, Documenting, and Dealing with Pain

Third in a Series.

We know pain when we feel it.  But do we know pain when we see it?

Caring for someone who is in serious pain if the individual refuses to is always difficult, but it can become extremely complicated acknowledge or treat the offending pain.  Sometimes, our loved ones won’t admit pain because they feel it is a sign or personal weakness; sometimes they deny pain to avoid its treatment; and at other times, they deny pain so as not to worry us.

Caregivers need to be alert for non-verbal symptoms of pain, such as:
 

• Grimacing or wincing with movement
• Avoiding movement, including staying in bed or not dressing
• Difficulty finding a comfortable position, resting or sleeping
• Declining interest in regular activities
• Decreased appetite
• Crying, anger, or anxiety without apparent reason.

When the individual is unwilling to acknowledge pain, it is hard to get them to agree to take medication that will decrease their pain and increase their enjoyment in daily activities.  Some individuals will accept treatment only when their caregivers share their specific observations; some will seek treatment when they understand that pain is not an indication of weakness but a consequence of the situation (surgery, cancer treatments, or an injury).   Others agree to treatment simply to pacify the caregiver.  If resistance to treatment persists, the intervention of a health care professional is often an effective option to clarify any concerns the individual may have regarding the use of the medications. 

Only those who suffer can decide the degree of pain they are willing to tolerate.  But as a caregiver, what can you do to help?

• Encourage the individual to take medications as prescribed.  Pain should be treated before it becomes intolerable.  Often individuals are asked to rate their pain on a scale of 0 (no pain) to 10 (worst pain imaginable)  In my experience, pain is relieved more effectively if it is treated when it is in the 5-7 range, rather than waiting for it to max out at 10.  Pain medication should not be withheld for " when the pain gets really bad".Uncontrolled pain is harder to treat, tales longer to subside and reduces the effectiveness of pain medications.

• Pre-medicate before an activity that is likely to cause or increase pain. For example, if pain increases with bathing and dressing in the morning, giving the pain medication with a small snack or breakfast 30-45 minutes beforehand may decrease the anxiety and pain level.

• Be aware that the first 1 to 2 days of narcotic pain medications may make the individual sleepy or mentally cloudy; this is usually temporary.  This sleepiness is not a rationale for not medicating someone in pain.  If it persists contact the physician for further advice.

• Be prepared for side effects of the medication, which often can be prevented.  Constipation is the most common side effect of pain medications.  The initiation of a stool softener, increasing fluid intake or increasing daily consumption of fruits, vegetables and salads can prevent this problem.  Increasing activity will also help.  Nausea or other stomach upsets can often be avoided by giving the medication with a small snack or milk. 

Keeping a pain journal is very helpful to the individual, the caregiver and the health care professional.  Write down when it hurts, where it hurts, and how it hurts.  Does anything seem to initiate or worsen the pain?  Does the pain radiate (move)?  What makes it subside?  How long does it hurt?  The journal also is a safeguard for the caregiver.  When there is more that one caregiver in the home or if the individual is sleepy or confused, a pain journal can prevent mistakes.  Document when the medication was given, and what dose and whether it was effective.   Is there anything else that makes the pain better?  The information in the journal will also help when contacting the physician for concerns related to pain management.  It is also important to notify the physician’s office if side effects occur and before the last doses of the medications are being given.

There are other, non-medication therapies that can help with the control of pain:

• Maintain a quiet, calm, comfortable room that would allow the individual to relax and the medication to take effect.  Soft music is often effective too.
• Diversion can help.  Watching a movie, playing a game, or reading may decrease the focus on the pain and the waiting period until the medicine begins to work.
• Human touch is effective in decreasing pain-related distress.  Holding a hand or a gentle massage is especially effective for cancer pain, often described as a deep gnawing pain.
• Relaxation exercises also soothe.  Deep breathing, prayer, and meditation are helpful to many.
• Complementary therapies of yoga, tai chi, exercise, acupuncture decrease pain by releasing the bodies own pain killers, endorphins.  Other things also release these ‘feel good’ endorphins, like chocolate and chili peppers. 

Many individuals and their caregivers express concerns regarding tolerance, physical dependence and addiction to pain medications.  Many misconceptions exist and often stand in the way of pain control.

• Tolerance refers to the fact that when a medication is taken over a long period of time the body can become used to the effects produced and the medication may need to be increased until pain relief is obtained.  This is not a sign of addiction.  This needs to be evaluated by a health care professoinal and any changes should only be made under their direction.

• Physical dependence is characterized by withdrawal symptoms when the drug is stopped suddenly as the body has become accustomed to the effects the drug provides. These symptoms can be prevented by slowly tapering the use of the medication over time.  This is not a sign of addiction. 

•  Addiction is characterized by the compulsive use of a narcotic (opioid) medication for its psychological effects. Addiction is a compulsive physiological and psychological need for a habit-forming substance.  Addiction is also identified by active drug-seeking and drug-taking behaviors.