Pain assessment is a critical component of optimum nursing care to enable effective pain management.1
Advances in the understanding of pain mechanisms and management, as well as increasing concerns regarding an opioid crisis in the developed world, have brought the importance of accurate, valid and reliable pain assessments into focus for the future. The pivotal role of nurses in conducting pain assessment needs to be explored in response to the revised, universally accepted definition of pain by the International Association for the Study of Pain (IASP) in 2020 and evolving perspectives on opioid analgesia in acute pain management.
IASP definition of pain
The IASP definition of pain has been broadly supported and accepted in the pain field by researchers, educators and practitioners since 1979 and states pain is “An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage”.2 The revised IASP definition from 2020 now states pain is “An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage”.2 This updated definition reflects recent advances in pain medicine, where it is understood pain may derive from nociceptive, neuropathic or nociplastic sources and that pain may be multi-mechanistic, creating a complex pain presentation requiring multifactorial management.2,3,4 The revised IASP definition of pain also aims to reinforce the importance of assessing for pain in patients where verbal description is not the sole behaviour or mode available to express their pain, which may include neonates, the elderly, intubated or critically ill patients, persons with an intellectual disability or others incapable of verbal self-reporting their pain.2
Pain management in Australia
Chronic pain impacts 3.24 million Australians and 20% of the population worldwide.5 Chronic pain is projected to have an increased burden to five million Australians by 2050, which is likely to result in an increased demand for health services and nurses to provide expanded care delivery, including patient support, pain education, and to be an integral component of redesigning and implementing innovative, integrated pain service delivery.6,7
Australia has an ageing population that is projected to increase the burden on healthcare resources and result in an incongruity with the supply and demand of acute care nurses in the future.8 The prevalence of chronic pain combined with an ageing population will generate a greater reliance on accurate and reliable pain assessments to underpin the demand and advancements in pain management practice.
Chronic non-malignant pain (CNMP) is often poorly responsive to opioid therapy, is associated with a risk of long-term health issues and opioid misuse, abuse, addiction and overdose.9 The opioid epidemic and associated mortality rates in the United States of America (USA) since 1999 reflect 44 Americans dying every day from opioid-related deaths in 2016.9,10
In 2018, opioids accounted for just over three deaths per day in Australia- an annual total of 1,123 deaths, with a greater proportion of these occurring in regional areas and with pharmaceutical opioids contributing to a greater number of deaths in females than males.11,12 Multi-disciplinary pain programs with nurse involvement effectively manage chronic pain by generating improved postoperative pain, mitigating analgesic use, reducing psychological distress and improving physical functioning and satisfaction with the patient’s health.7,13
The efficacy of pain self-management interventions and cognitive behavioural therapy (CBT) used in chronic pain management are well substantiated by current evidence, with the execution of such programs delivered by nurses due to their insights, experience and patient-centred approach.6,13,14
Opioid analgesia in pain management
The use and clinical indication for opioids has shifted due to escalating problematic opioid use over the past 20 years, with the Faculty of Pain Medicine (FPM) releasing a statement regarding the use of opioids in 2020 on the management of CNMP.15 The FPM statement identifies that opioid analgesia should only be used for severe pain for which “other treatment options have failed, are contradicted, not tolerated or are otherwise inappropriate to provide sufficient management and which has shown to be opioid responsive”.15 This guidance on the appropriate use of opioids from the FPM highlights the importance of an effective and comprehensive pain assessment to determine the potential nature and source of a patient’s pain, to subsequently identify and differentiate the mechanism of pain from nociceptive or neuropathic, as well as the acute, persistent or chronic source of pain.
The FPM statement relies on an effective, consistent pain assessment being undertaken consistently for individuals to ensure that implemented pharmacotherapeutic treatments are evaluated to determine ongoing pain management plans and identify whether the use of opioids is considered appropriate and effective.16
The FPM are involved in training and accrediting medical pain specialists and are affiliated with the Australian and New Zealand College of Anaesthetists (ANZCA), which released its own statement in 2018 on the role of slow-release opioids in acute pain management. This statement declared slow-release opioids are not recommended for use in the management of acute pain and “The use of slow-release opioids for the treatment of acute pain can be associated with a significant risk of respiratory depression, resulting in severe adverse events and deaths”.17,18 Acute pain can transition into chronic pain if untreated or poorly treated, from neuroplastic changes in the nervous system. Timely and effective treatment of acute pain is essential to prevent transition to chronic pain, with accurate, valid and reliable pain assessment fundamental to effective pain treatments.5,16
Nurses’ role in pain assessment
The evolving demand on pain management care for the future and safety of the Australian population will require a greater reliance on nurses to have a sound understanding and knowledge of pain concepts. Robust and insightful knowledge of pain mechanisms and pain management interventions underpins an accurate pain assessment. With a revised definition of pain by the IASP, due to advancing perceptions and understanding of pain mechanisms, nurses need to consider their role and application of pain assessment into their clinical practice for the benefit of their patients. There are a number of validated and reliable pain assessment tools available for nurses to implement a comprehensive pain assessment, many of which have been used for decades and include assessment of verbal, non-verbal and functional expressions of pain.16,19,20
The importance of the nurse’s role in providing patient and clinician education has been recognised in current literature.21 Nurses play a pivotal role in disseminating best practice recommendations, providing education, mentoring and engagement with interdisciplinary team members to produce sustainable and innovative changes. Nurses’ contributions to the achievement of effective pain management are robustly supported by current literature, with expanded and ongoing pain education fundamental to the development of nurses’ and clinician knowledge, understanding and assessment of pain.22,23,24 Nurses are in a principal position to work in partnership with patients to optimise safe and effective pain management and identify self-care and nonpharmacological strategies individuals can use to manage their pain sustainably.25
The definition of pain has changed, the focus of pain management is evolving, and prioritising pain assessments is a key focus for the future. The role of opioid analgesia in acute management is an area of contention and discussion in the pain field, where their clinical use demands a greater reliance on valid and accurate pain assessments. Nurses have a crucial role in leading and undertaking reliable and appropriate pain assessments to advocate for optimal and evidence-based pain management strategies delivered to patients.
1 Issa M, Awajeh A, Khraisat F, Rasheed A, Amirah, M., Hussain, A, et al. Impact of an educational program on the knowledge and attitude about pain assessment and management among critical care nurses. DCCN. 2019; 38(5): 271-277. doi: 10.1097/DCC.0000000000000375.
2 International Association for the Study of Pain. IASP announces revised definition of pain [internet]. IASP; 2020. Available from https://www.iasp-pain.org/PublicationsNews/NewsDetail.aspx?ItemNumber=10475#:~:text=The%20definition%20is%3A%20%E2%80%9CAn%20unpleasant,pain%20for%20further%20valuable%20context.
3 Raja S, Carr D, Cohen M, Finnerup N, Flor H, Gibson S, et al. The revised International Association for the Study of Pain definition of pain: concepts, challenges, and compromises. Pain. 2020; 00, 1-7. Doi.org/10.1097/j.pain.0000000000001939
4 Pergolizzi J, Raffa R. The WHO Pain Ladder: Do we need another step?. Practical Pain Management. 2015; 14(1).
5 Pain Australia. What is chronic pain? [Internet]. Pain Australia; 2020. Available from https://www.painaustralia.org.au/about-pain/what-is-chronic-pain
6 Hogg M, Gibson S, Helou A, DeGabriele J, Farrell M. Waiting in pain: a systematic investigation into the provision of persistent pain services in Australia. Med J Aust. 2012; 196: 386-390. https://doi: 10.5694/mja12.10140
7 Sonneborn O, Miller C. Pain Nurse Practitioner and Pain Nurse’s views on opioid management in Australia: a national questionnaire survey. Pain Manag Nurs. 2021; 15(26): 1-7. https://doi.org/10.1016/j.pmn.2021.05.002
8 Health Workforce Australia. Australia’s future health workforce: nurses-detailed report [Internet]. Health Workforce Australia; 2019. Available from https://www1.health.gov.au/internet/main/publishing.nsf/Content/34AA7E6FDB8C16AACA257D9500112F25/$File/AFHW%20-%20Nurses%20detailed%20report.pdf.
9 Chaudhary S, Compton P. Use of risk mitigation practices by family nurse practitioners prescribing opioids for the management of chronic non-malignant pain. Subst Abuse. 2017; 38(1): 95-104. DOI: 10.1080/08897077.2016.1265038
10 Muench U, Spetz J, Jura M, Guo C, Thomas C, Perloff J. Opioid prescribing outcomes of medicare beneficiaries managed by nurse practitioners and physicians. Med Care. 2019; 57(6): 482- 489. DOI:10.1097/MLR.0000000000001126
11 Australian Bureau of Statistics. 3303.0- Causes of death, Australia, 2018. Australian Bureau of Statistics; 2019. Available from https://www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/3303.0~2018~Main%20Features~Opioid-induced%20deaths%20in%20Australia~10000
12 Pennington Institute. (2020). Australia’s annual overdose report 2020. Retrieved from https://www.penington.org.au/publications/2020-overdose-report/6 Pennington report
13 Schoenwald A, Windsor C, Gosden E, Douglas C. Nurse practitioner led pain management the day after caesarean section: A randomised controlled trial and follow up study. Int J Nurs Stud. 2018; 78: 1-9. https://doi:10.1016/j.ijnurstu.2017.08.009
14 Kaasalainen S, Wickson-Griffiths A, Akhtar-Danesh N, Brazil K, Donald F, Martin-Misener R, et al. The effectiveness of a nurse practitioner-led pain management team in long-term care: A mixed methods study. Int J Nurs Stud. 2016; 62: 156-167. https://doi:10.1016/j.ijnurstu.2016.07.022
15 Faculty of Pain Medicine. PS01 (PM) Statement regarding the use of opioid analgesics in patients with chronic non-cancer pain [Internet]. Faculty of Pain Medicine; 2020. Available from https://www.anzca.edu.au/getattachment/7d7d2619-6736-4d8e-876e-6f9b2b45c435/PS01(PM)-Statement-regarding-the-use-of-opioid-analgesics-in-patients-with-chronic-non-cancer-pain
16 Schug S, Palmer G, Scott D, Halliwell R, Trinca J. Australian and New Zealand College of Anaesthetists acute pain management: scientific evidence [Internet]. ANZCA; 2020. Available from https://www.anzca.edu.au/getattachment/4c3b03b7-52bf-4c10-9115-83d827c0fc38/Acute-Pain-Management-Scientific-Evidence.aspx
17 Australian and New Zealand College of Anaesthetists. Prescribing slow-release opioids can be fatal leading college warns [Internet]. ANZCA; 2018a. Available from https://www.anzca.edu.au/resources/media-releases/2018-media-releases/prescribing-slow-release-opioids-4-april-2018#:~:text=%E2%80%9CSlow%2Drelease%20opioids%20are%20not,its%20Faculty%20of%20Pain%20Medicine.
18 Australian and New Zealand College of Anaesthetists. Position Statement on the use of slow-release opioid preparations in the treatment of acute pain [Internet]. ANZCA; 2018b. Available from https://www.anzca.edu.au/resources/professional-documents/statements/sr-opioid-statement-with-disclaimer-20200825
19 Freyd M. The Graphic Rating Scale. J Educ Psychol. 1923; 14(2): 83-102. https://doi.org/10.1037/h0074329
20 Haifeli M, Elfering A. Pain assessment. Eur Spine J. 2005; 15: S17-S24. doi: 10.1007/s00586-005-1044-x
21 Ingadóttir B, Zoëga S. Role of patient education in postoperative pain management. Nurs Stand. 2017; 32(2): 50-63.
22 Burke A, Denson L, Mathias J, Hogg M. An analysis of multidisciplinary staffing levels and clinical activity in Australian tertiary persistent pain services. Pain Med. 2015; 16: 1221-1237. DOI: 10.1111/pme.12723
23 Kaasalainen S, Ploegg J, Donald F, Coker E, Brazil K, Martin-Misener R. Positioning clinical nurse specialists and nurse practitioners as change champions to implement a pain protocol in long-term care. Pain Manag Nurs. 2015; 16(2): 78-88. DOI: 10.1016/j.pmn.2014.04.002
24 Cui C, Wang L, Li Q, Zaslansky R, Li L. Implementing a pain management nursing protocol for orthopaedic surgical patients: Results from a PAIN OUT project. J Clin Nurs. 2017; 27: 1684-1691. https://doi.org/10.1111/jocn.14224
25 Sonneborn O, Bui T. Opioid induced constipation management in orthopaedic and trauma patients: treatment and the potential of nurse-initiated management. Int Journal of Orthop Trauma Nurs. 2019; 34; 16-20. DOI:10.1016/j.ijotn.2019.03.002
Olivia Sonneborn MN, PerianNurse, RN is a Lecturer in the School of Nursing, La Trobe University and a Pain Clinical Nurse Consultant at Alfred Health, Melbourne Victoria Australia.
Annie Williams, MScMed (Pain Management) is a Clinical Nurse Consultant, Department of Anaesthesia, Box Hill Hospital, Box Hill Victoria Australia
Nicole Gauthier, MScMed (Pain Mgt), BSN, CCRN, is a Clinical Nurse Consultant at Northern Health Pain Service, Epping Victoria Australia