What is “Total Pain”?

(Excerpt from Pain Management in End-of-Life Care, Leleszi JP,DO; Lewandowski JG, MD; J Am Osteopath AssocMarch 1, 2005 vol. 105 no. 3 suppl 6S-11S

Total pain is the sum of four components: physical (pain), emotional discomfort, interpersonal conflicts, and nonacceptance of one’s own dying. These four components may individually or in combination affect a patient’s perception of their total pain. Lack of understanding of the influence of each of these four components may result in less-than-optimal pain management at the end of life.

The “gold standard” of pain management is constant pain assessment. Pain is whatever the patient

says it is. Simply asking patients about their pain is the best way to obtain this information. Patients describe non-physical components of pain as “discomfort.” Dr. Ira Byock wrote that in dying persons, pain is never purely physical. Things related to when and how they will eventually die influence their pain. These things include being abandoned; becoming undignified in terms of what they do, how they look, and how they smell; being a burden to their families—not only a physical strain, but also a financial hardship; and dying in pain alone. Any one of these concerns causes individuals to suffer and therefore must be addressed to provide good management of pain symptoms.

Physical pain is not universal with every death, but some discomfort is usually present.

1. TOTAL PAIN – PHYSICAL PAIN Physical pain is the most familiar component of the total pain concept for physicians. Pain assessment includes eliciting a history of presenting symptom(s) as well as conducting the appropriate physical examination of the patient. Laboratory and imaging studies may be used to further understand the patient’s pain.

Physical pain can be categorized in terms of its temporal nature (ie, acute or chronic) and delineated as to three types based on neurophysiologic mechanisms (ie, somatic, visceral, and neuropathic). Regardless of mechanism, breakthrough and incident pain may occur.

Acute Pain 

Acute pain results from nociceptor stimulation, usually is time-limited, and often responds to

analgesic medications or osteopathic manipulative treatment. Pain perception is usually the result of an acute injury such as a surgical intervention and can occur at end of life. 

Chronic Pain

Determination of chronic pain is based on duration of pain beyond 3 months after an acute injury. Acute pain can be resolved, but chronic pain must be managed and presents an entirely different challenge to both patient and physician. The two goals of treating patients with such pain are reduction of related symptoms and restoration of maximal function. Chronic pain is often multifactorial, sources being as diverse and additive as that from migraine headache, osteoarthritis, dental caries, diabetic neuropathy, and cancer—all of which may occur in the same patient. Delineating and targeting treatment for each symptom allows for optimal symptom relief and better global functioning.

Somatic Pain

Somatic pain results from stimulation of nociceptors (receptors for pain in the skin and deep

musculoskeletal tissues. It is described as being a well-localized “deep aching feeling” with tenderness to palpation. Common sources of somatic pain are arthritic joints, osteopathic lesions, fractures, and abscesses.

VISCERAL PAIN

Visceral pain occurs from stretching or activation of nociceptors (receptors for pain) in the linings of organs. In contrast to somatic pain, visceral pain is difficult to localize. Visceral pain is described as “deep pressure,” “cramping,” “spasms,” or “squeezing.” Nausea, diaphoresis, and emesis are frequently present. Palpation over the site may elicit an accompanying somatic pain.

Neuropathic Pain 

Neuropathic pain results from damage to the peripheral nervous system or the central nervous system

(CNS), or both. It is described as “sharp,” “electric,” or “burning” pain, singly or in combination, and is usually found in the same distribution pattern as a sensory peripheral nerve. Pain resulting from trauma to the central nervous system that partially or completely separates the central nervous system from the peripheral nervous system is termed deafferentation pain.

Central pain may be the result of a cerebral vascular accident and is

characterized as “vicelike” or “throbbing,” or both; headaches are described as “dull” and “never-relenting.”

Breakthrough Pain and Incident Pain

Breakthrough pain is characterized as a temporary increase in pain from the basal, acute, or chronic pain level. It is frequently described as worsening pain at the latter part of the regularly scheduled analgesic-dose interval. Incident pain can occur during daily routine activities as when passing flatus. Patients should have the appropriate comprehensive pain management in place for each type of pain.

Pain Scales:

*(Example of a common pain scale) 

Pain scales are universally used for patients to convey the intensity of their pain throughout treatment.. Using a particular pain scale is not as important in the care of patients as the consistent use of the same pain scale. Patients’ perception of an acceptable pain level should be the endpoint of the therapy. The endpoint of therapy should be the patient’s perception of an acceptable pain level.

2. TOTAL PAIN – ANXIETY : The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Text Revision (DSM IV-TR) defines anxiety as the apprehensive anticipation of future danger or misfortune accompanied by a feeling of dysphoria or somatic symptoms of tension.(Pg. 820) The focus of anticipated danger may be internal or external.

Anxiety may be due to many organic causes and may occur in the course of pain management if patients are not receiving adequate pain control.Anxiety may also be preexisting and should be managed as any other comorbid medical condition.

Even when patients are adequately treated, the thought that pain relief will not be available at the end of life causes some to have great anxiety. Abandonment by their physicians, families, or friends, as well as fear of dying alone, is another source of symptomatic anxiety at the end of life.

3. TOTAL PAIN – INTERPERSONAL INTERACTIONS:

An interpersonal conflict influences the development of pain as much as any other aspect of total pain. Families and individuals who coped well before end of life may require little additional support, but patients in families with marital discord or other conflicted relationships may experience total pain. Mounting financial stress along with family discord may cause additional disharmony. The loss of status within the workplace or in the family can intensify pain symptoms. Whereas analgesic medication and anxiolytics cannot quell the pain of interpersonal conflict, counseling often can be of assistance. Patients at the end of life can achieve comfort and a sense of completion in personal relationships by addressing Dr. Ira Byock’s five key points:

“I forgive you.”

“Forgive me.”

“Thank you.”

“I love you.”

“Goodbye.”

4. TOTAL PAIN – NON-ACCEPTANCE : Acceptance at the end of life is the self-acknowledgment of the imminence of death. Buckman’s Three-Stage Model of the Process of Dying offers a guide for physicians to anticipate how patients accept their finality in terms of personal spirituality. In the initial stage, the patient has awareness of the definitive reality that the disease process will possibly result in death. Reactions to such awareness are characteristic of the individual’s basic personality and may include fear, shock, anger, guilt, and vacillation between hope and despair. In the middle stage, most patients resolve their anger and denial. Depression is common in this stage as individuals are aware they will indeed die, but they do not view death as immediate. Supportive family and friends are helpful if the dying persons do not have negative interpersonal conflicts. Others in this intermediate stage have an intensified positive emotional resolve.

The third stage is defined by dying individuals’ acceptance of the imminence of their death. Nonacceptance is evidenced by intense distress with the proximity of death and is a source for increased total pain. This model is helpful for those who may anticipate the need for support of patients at the end of life

Spirituality is a function of personal values, not specific religious tenets. Hay provides a spiritual model that is compatible with medical constructs for good end-of-life care. There are four versions of individual spirituality according to Hay:

Spiritual suffering is the presence of interpersonal or intra-psychic pain.

Inner resource deficiency is defined as having diminished spiritual capacity.

Belief system problem is a lack of conscious awareness within a personal-meaning system.

Specific religious requests that are made by some individuals at the end of life assist them in obtaining a sense of spiritual well-being.   Effective pain management at the end of life applies the concept of total pain. An assessment is required to determine the nature of the pain. They must treat patients for reversible physical causes and address interpersonal and spiritual pain. Analgesics will be most effective if all components of total pain have been explored. Opioids are often the medication of choice for end-of-life pain. They are safe and effective for the treatment of patients with moderate to severe pain, and they have side effects that can be managed effectively.

Pain management at the end of life:  Effective pain management at the end of life applies the concept of total pain. An assessment is required to determine the nature of the pain. They must treat patients for reversible physical causes and address interpersonal and spiritual pain. Analgesics will be most effective if all components of total pain have been explored. Opioids are often the medication of choice for end-of-life pain. They are safe and effective for the treatment of patients with moderate to severe pain, and they have side effects that can be managed effectively. Myths continue to limit the use of opioids. Patients and their families may delay the use of opioids fearing their use foretells imminent death, and patients may fear that opioid use early in their care will diminish the effectiveness of such medication. It is the responsibility of physicians to counsel patients that this result will not be allowed to occur. Dose adjustment, appropriate monitoring, and management of adverse reactions must continue for all patients. Nausea, sedation, and pruritus, are common temporary side effects of opioids and usually resolve in 3 to 5 days. Antihistamines such as diphenhydramine and hydroxyzine are effective for treating patients for nausea and pruritus. The elderly may experience confusion, hallucinations, and cognitive impairment with opioid use. A different opioid at a lower dose may help; however, advancing disease (*Such as in the case of brain metastasis –spreading of disease– in some types of cancer) may be the cause of confusion in a patient. Constipation is the most frequent side effect with sustained opioid therapy and should be anticipated and prevented. Constipation may cause bowel obstruction. The liberal use of laxatives, hydration, and exercise facilitate bowel function with ongoing opioid therapy. (*Constipation can also be the cause of nausea, vomiting, confusion and other symptoms, especially in the elderly. Please see Symptom Management information on this Home page under “Education” for more information.)

When someone is terminally ill and taking pain medications/opioids for relief, opioid overdose is rare. *(HOWEVER: Caution must be used when taking pain medications as well as when administrating them! Always administer all medications as prescribed. If pain becomes uncontrolled on present dose, contact the patient’s hospice nurse and/or physician immediately. Never increase the dose without the doctor’s orders.) Signs of opioid toxicity include myoclonus (*Spasmodic  contractions of groups of muscles) and respiratory depression (Breathing slows or stops). One should consider opioid toxicity when the patient’s level of consciousness declines and respirations are fewer than 6 breaths per minute. These conditions may also represent disease progression or active dying (*Patient is getting closer to death.)  Other physical signs of opioid toxicity are myoclonic twitching, constricted pupils, and skeletal muscle flaccidity with cold or clammy skin. End-of-life care is the rational therapy that allows for reduction of pain symptoms and facilitation of as much function as possible. Good pain management at the end of life need not be daunting for patients and physicians. Physicians will encounter patients at end of life regardless of their type of specialty practice. Knowledge of total pain concepts incorporated into end-of-life pain management offers much to patients and their caregivers.

*Added by Vaishnavas CARE Editor