Assessment

Contents Introduction Recommendations Overview Patient-centred care Screening Assessment

Self-management Pharmacological Mx Non-pharmacological Mx Practice improvement Resources Opioid formulations References

Information on authorship and revision

Page last modified: 13 May 2019 07:40:38

Author(s): Australian Adult Cancer Pain Management Working Group

Assessment

Evidence-based recommendation

A1. Complete a comprehensive assessment if either of the following apply: • a new patient reports a pain score of 2 or more on self-reported numerical rating scale of zero to 10 or pain score is 3 or more on the Abbey Pain Scale (see Screening) • an existing patient reports a new pain or a sudden, unexpected change in intensity of pain.(Consensus) Assess all the following to determine the individual’s pain management needs: • Disease status and treatment (Consensus) The Working Group considered this information to provide necessary context for other assessments • Pain severity (using a validated tool) (NCCN, SIGN) • Pain experience (location, interference, timing, description, aggravating and relieving factors) (ESMO, NCCN, NHS, SIGN) • Current and previous management of pain (ESMO, NCCN, NHS, SIGN) and other symptoms (Consensus) • Pain meaning for the person and their beliefs and knowledge (NCCN, NHS, SIGN), including concern about pain and its treatment (e.g. perceived addictiveness of opioids) (NICE) • Psychosocial status (ESMO, NCCN, NHS, SIGN), including risk factors for opioid misuse (NCCN) • Cognitive functioning (Consensus) The Working Group considered this information to provide necessary context for other assessments • Physical examination and, where needed, further investigations (NCCN, NHS, SIGN) • Functional status (ESMO) • Risk factors for poorly controlled pain (NCCN) • Patient and family preferences (goals and expectations for comfort, advance directives) (NCCN) • Factors suggesting an oncological emergency. (NCCN) Reassess whenever there is a change in pain or a new pain is reported.

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Assessment checklist [ ] Disease status and treatment [ ] Record the person’s disease status: • Cancer type • Site/s [ ] Record current cancer treatments, including: • Chemotherapy (agents, doses) • Radiotherapy (site, dose) • Other treatments (including complementary and alternative) [ ] Record previous and previous cancer treatments, including: • Chemotherapy (agents, doses) • Radiotherapy (site, dose) • Other treatments (including complementary and alternative) [ ] Record treatments for any health problems other than cancer. Anticancer treatments that may cause peripheral neuropathy Taxanes Platinum agents Eribulin Vincristine Navelbine Lenolinamide Bortezomib Thalidomide Comments Back to top [ ] Pain severity [ ] Record pain severity in detail, using a self-reported validated pain assessment instrument (e.g. the Brief Pain Inventory short form (BPI-SF) recommended by NCCN and SIGN) Comments Back to top [ ] Pain experience If the person has more than one pain, number each and complete all assessments for each pain (including any pain not caused by cancer). Comments [ ] Location [ ] Assess and record: • Location (see the Change Pain website for an interactive and printable body diagram) • Presence of radiating pain Comments Back to top [ ] Interference with activities [ ] Assess and record whether and how pain is interfering with the person’s daily activities (e.g. walking , sleeping), using a validated assessment tool (e.g. the Brief Pain Inventory short-form (BPI-SF) recommended by NCCN and SIGN) If pain is impairing the person’s ability to perform activities of daily living, consider referral to a physiotherapist or occupational therapist for further assessment. Comments Back to top [ ] Timing [ ] Assess and record the timing of pain, including: Onset Duration Change in pain over time Pain during particular movements or activities Whether pain is persistent or intermittent Whether pain is generally controlled by medication but recurs at certain times or at end of dosing interval. Aim to establish whether timing of pain is predictable or random and whether breakthrough analgesia might be needed preemptively. Comments Back to top [ ] Description (type: neuropathic or nociceptive – see comment below) [ ] Assess and record the quality of pain. Allow the patient to describe his/her pain, prompting with the descriptors listed below if needed. Characteristic of nociceptive pain Characteristic of neuropathic pain Aching Hot-burning Cramping Cutting-lacerating Gnawing Pins and needles Pressure Pricking Sharp Tingling Stabbing Tight-stretched Throbbing Numb Electric shocks Jumping-bursting Radiating Stabbing-shooting Descriptive terms for neuropathic pain have been taken from: Bennett M. The LANSS Pain Scale: the Leeds assessment of neuropathic symptoms and signs Pain 2001 May;92(1-2):147-57. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11323136 Comments Back to top [ ] Aggravating and relieving factors [ ] Assess and record factors that either make pain worse or relieve pain. Comments Back to top [ ] Current and previous management of pain and other symptoms [ ] Ask the patient which pain medications he or she: is currently taking has taken in the past. [ ] Ask the patient which medications for other symptoms he or she: is currently taking has taken in the past. [ ] For each medication, ask about: when it was taken (currently/ past month/before past month) duration of use dose efficacy adverse effects who prescribed it self-reported adherence reason for stopping (if applicable). [ ] Ask the patient if he or she has used any non-pharmacological methods for managing pain (e.g. relaxation, massage, herbal medicine). [ ] For each non-pharmacological pain management method, ask about: reason for use duration of use efficacy adverse effects reason for stopping (if applicable). Comments Back to top [ ] Other symptoms [ ] Assess and record the presence of other symptoms and attempt to diagnose the cause and mechanism of each. Comments Back to top [ ] Pain meaning, beliefs and knowledge [ ] Assess and record the meanings the person’s pain has for them and their family or carers. [ ] Assess and record any concerns the person has about the pain and its treatment such as fear of addiction, tolerance, side effects and fear that prescription of opioid means the final phase of illness. Provide education tailored to patients’ and families’ knowledge, beliefs and attitudes about pain and pain treatment. Suggested questions to ask person: What do you think is causing the pain? Has someone else in the family had cancer pain? Is there anything you are afraid of related to the pain or its management? Is there anything that worries you about the treatment of pain? Source: Kissane D, Bultz B, Butow P, Finlay I, editors. Handbook of communication in oncology and palliative care. Oxford: Oxford University Press; 2010. Comments   Back to top [ ] Psychosocial assessment [ ] Assess and record psychosocial status, including anxiety and depression. [ ] Record psychiatric history, including previous or current substance abuse. [ ] Assess risk of opioid misuse. [ ] Assess and record relevant spiritual, religious or existential beliefs affecting pain and its management. Suggested questions to assess risk of opioid misuse: At any time in your life, have you ever used alcohol, cannabis, other drugs, or any substance that can lead to dependence, including a medicine normally prescribed by a doctor? [For each substance named] Do you think your use of [substance] was out of control? Never or almost never Sometimes Often Always or nearly always Did the prospect of missing a drink/fix/dose of [substance] make you anxious or worried? Never or almost never Sometimes Often Always or nearly always Did you worry about your use of [substance]? Never or almost never Sometimes Often Always or nearly always Did you wish you could stop? Never or almost never Sometimes Often Always or nearly always How difficult did you find it to stop or to go without [substance]? Not difficult Quite difficult Very difficult Impossible Has anyone in your immediate family (e.g. a parent, brother or sister) ever been addicted to or dependent on any substance, including alcohol, other substances (such as cannabis or other drugs), or a medicine normally prescribed by a doctor? Adapted from: Gossop M, Darke S, Griffiths P, et al. The Severity of Dependence Scale (SDS): psychometric properties of the SDS in English and Australian samples of heroin, cocaine and amphetamine users. Addiction 1995; 90: 607–14. Available from: www.ncbi.nlm.nih.gov/pubmed/7795497 Suggested questions to assess contribution of spiritual beliefs to pain and its management Do you have spiritual beliefs that help you cope? What importance does your faith or belief have in your life? How does your faith or belief affect the way you think about your pain? Where psychosocial concerns are identified, refer to the following guideline for advice on further assessment, referral and management - National Breast Cancer Centre and National Cancer Control Initiative. Clinical practice guidelines for the psychosocial care of adults with cancer. Camperdown, NSW: National Breast Cancer Centre; 2003. Available from: http://canceraustralia.gov.au/publications-resources/cancer-australia-publications/clinical-practice-guidelines-psychosocial-care Comments Back to top [ ] Cognitive functioning [ ] Record whether cognitive impairment is present. If self-reporting of pain intensity is difficult due to cognitive impairment, use a tool validated for this population such as the Abbey Pain Scale Comments Back to top Physical examination and further investigations [ ] Perform a thorough physical examination [ ] Consider whether there are indications for imaging or laboratory studies. A sudden change in the type or intensity of pain warrants further investigations. Comments Back to top [ ] Functional status [ ] Assess and record functional status, using a systematic approach. Consider using one of the following: The Eastern Cooperative Oncology Group (ECOG) Performance Status Scale The Australia-modified Karnofsky Performance Status (AKPS) scale If pain is contributing to functional impairment, consider referral to physiotherapist, occupational therapist, social worker or palliative care team. Comments Back to top [ ] Risk factors for poorly controlled pain [ ] Assess and record whether the person has any risk factors for poor pain control: high pain score cognitive impairment elderly history of substance use first language other than English membership of a cultural minority group neuropathic pain. If self-reporting of pain intensity is difficult due to cognitive impairment, use the Abbey Pain Scale For patients whose ability to communicate with the treating team may be affected by a language barrier, use a healthcare interpreter. The Brief Pain Inventory is available in many community languages (listed on the MD Anderson Cancer Center website). Comments Back to top [ ] Preferences for care based on individual’s goals and expectations for comfort [ ] Assess and record person’s goals for comfort. Suggested questions to ask person What are you hoping to do with improved pain relief which you can't do now? (e.g. sleep better, be more active) What aspects of daily life are you most hoping pain management can help with? Comments Back to top [ ] Oncological emergencies [ ] Consider whether pain is related to an oncological emergency, e.g: bone fracture (or high risk of imminent fracture) brain metastasis epidural metastasis leptomeningeal metastasis infection obstructed or perforated abdominal organ.

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References

Bennett M. The LANSS Pain Scale: the Leeds assessment of neuropathic symptoms and signs Pain 2001 May;92(1-2):147-57.

Gossop M, Darke S, Griffiths P, et al. The Severity of Dependence Scale (SDS): psychometric properties of the SDS in English and Australian samples of heroin, cocaine and amphetamine users. Addiction 1995; 90: 607–14.

Kissane D, Bultz B, Butow P, Finlay I, editors. Handbook of communication in oncology and palliative care. Oxford: Oxford University Press; 2010.

National Breast Cancer Centre and National Cancer Control Initiative. Clinical practice guidelines for the psychosocial care of adults with cancer. Camperdown, NSW: National Breast Cancer Centre; 2003. Available from: http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/cp90.pdf

National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology. Adult cancer pain. Version 2.2015: NCCN; 2015. Available from: http://www.nccn.org

National Health Service Quality Improvement Scotland. Best practice statement. The management of pain in patients with cancer. Edinburgh: NHS Quality Improvement Scotland; 2009. Available from: http://www.palliativecareguidelines.scot.nhs.uk/documents/PAINCANCERREV_BPS_NOV09.pdf

National Institute of Health and Care Excellence Guideline Development Group. Opioids in palliative care: safe and effective prescribing of strong opioids for pain in palliative care of adults. NICE clinical guideline 140. Manchester: NICE; 2012. Available from: http://www.nice.org.uk/nicemedia/live/13745/59285/59285.pdf

Ripamonti CI, Bandieri E, Roila F, ESMO Guidelines Working Group. Management of cancer pain: ESMO clinical practice guidelines. Ann Oncol 2011; 22(Suppl 6): vi69-vi67. Available from: http://annonc.oxfordjournals.org/content/22/suppl_6/vi69.long

Scottish Intercollegiate Guidelines Network. Control of pain in adults with cancer. A national clinical guideline [Version amended 18 July 2011] Edinburgh: SIGN; 2008. Available from: http://www.sign.ac.uk/pdf/SIGN106.pdf
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Appendices

Appendix: The Eastern Cooperative Oncology Group (ECOG) Performance Status scale

Grade	Person’s function
0	Fully active, able to carry on all pre-disease performance without restriction
1	Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work
2	Ambulatory and capable of all self-care but unable to carry out any work activities. Up and about more than 50% of waking hours
3	Capable of only limited self-care, confined to bed or chair more than 50% of waking hours
4	Completely disabled. Cannot carry on any self-care. Totally confined to bed or chair
5	Dead

Source: Eastern Cooperative Oncology Group (Chair: Robert Comis) Oken MM, Creech RH, Tormey DC, et al. Toxicity and response criteria of the Eastern Cooperative Oncology Group. Am J Clin Oncol 1982; 5:649-655. Available from: http://www.ecog.org/general/perf_stat.html.  

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Appendix: The Australia-modified Karnofsky Performance Status (AKPS) scale

Score (Category)	Person’s function
100 (A)	Normal; no complaints; no evidence of disease
90 (A)	Able to carry on normal activity; minor signs or symptoms
80 (A)	Normal activity with effort; some signs or symptoms of disease
70 (B)	Cares for self; unable to carry on normal activity or to do active work
60 (B)	Requires occasional assistance but is able to care for most of his needs
50 (B)	Requires considerable assistance and frequent medical care
40 (C)	In bed more than 50% of the time
30 (C)	Almost completely bedfast
20 (C)	Totally bedfast and requiring extensive nursing care by professionals and/or family
10 (C)	Comatose or barely arousable
0	Dead

Source: Abernethy AP, Shelby-James T, Fazekas BS, et al. The Australia-modified Karnofsky Performance Status (AKPS) scale: a revised scale for contemporary palliative care clinical practice SRCTN81117481]. BMC Palliat Care 2005; 4: 7. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1308820/?tool=pubmed.

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