Assessing Pain When the Patient Cannot Self-report

   Pain is completely subjective, and the gold standard of pain assessment is self-report by the patient. Several assessment tools can facilitate determining the patient's assessment of pain intensity, and hospitals nationwide have implemented policies and procedures outlining the use of these instruments.

   The most commonly used self-report tools in patients who are able to quantify their pain are the 0-10 numerical pain rating scale and the 0-10 Wong-Baker FACES pain rating scale or the Faces Pain Scale-Revised; many patients who can self-report pain but are unable to quantify it may be able to select the face that best characterizes their pain on a faces pain rating scale. However, not all patients are able to report pain using customary assessment tools, and this presents a significant challenge for the healthcare team who must ensure that pain is recognized and treated appropriately.

   For patients unable to report pain through traditional methods, an alternative approach based on the Hierarchy of Pain Measures is recommended (Table). The key components of the hierarchy are as follows:

- Attempt to obtain self-report;
- Consider underlying pathology or conditions and procedures that might be painful;
- Observe behaviors;
- Evaluate physiologic indicators; and
- Conduct an analgesic trial.

Table. Hierarchy of Pain Measures

   1. Attempt to obtain the patient's self-report, the single most reliable indicator of pain. Do not assume that a patient cannot report pain; many cognitively impaired patients are able to use a self-report tool, such as the Wong-Baker FACES Scale, Faces Pain Scale-Revised, or Verbal Descriptor Scale.

   2. Consider the patient's condition or exposure to a procedure that is assumed to be painful. If appropriate, assume pain is present (APP) and document APP when approved by institution policy and procedure.

   3. Observe behavioral signs (eg, facial expressions, crying, restlessness, and changes in activity). Many available behavioral pain assessment tools will yield a pain behavior score and may help to determine whether pain is present. However, a behavioral score is not the same as a pain intensity score. Pain intensity is unknown if the patient is unable to provide it. A surrogate who knows the patient well (eg, parent, spouse, or caregiver) may be able to provide information about underlying painful pathology or behaviors that may indicate pain.

   4. Evaluate physiologic indicators with the understanding that they are the least sensitive indicators of pain and may signal the existence of conditions other than pain or a lack of it (eg, hypovolemia, blood loss). Patients may have normal or abnormal vital signs in the presence of severe pain. The absence of elevated blood pressure or heart rate does not mean the absence of pain.

   5. Conduct an analgesic trial to confirm the presence of pain and to establish a basis for developing a treatment plan if pain is believed to be present. An analgesic trial involves administration of a low dose of nonopioid or opioid and observing patient response. The initial low dose may not be enough to elicit a change in behavior and should be increased if the previous dose was tolerated, or another analgesic may be added. If behaviors continue despite optimal analgesic doses, other possible causes should be investigated. In patients who are completely unresponsive, no change in behavior will be evident and the optimized analgesic dose should be continued.

Pain Assessment Options in the Absence of Self-report

   Evidence-based guidelines recommend against the rating of pain intensity by anyone other than the person who is experiencing the pain. The importance of relying on self-report has been underscored by research over the years, which has shown a lack of correlation between the patient's perception of pain and that of nurses and other members of the healthcare team. Furthermore, the greatest discrepancies often occur at the highest pain levels.

   Various explanations for such discrepancies have been proposed, including care provider experience, patient gender, language barriers, and ability to distinguish pain behaviors from other behaviors. A principle of pain management is that the patient is the authority on pain intensity, and if he or she cannot report the intensity, then it is unknown.

   Estimation of pain by others. Research has shown that individuals who know the patient well (eg, parents, caregivers) often overestimate or underestimate the patient's pain. Discrepancies are influenced by a various factors, including the presence and level of cognitive impairment in the patient, caregiver gender, perceived burden of caregiving, preconceived ideas of acceptable pain relief, and fear of analgesic side effects. A concern has been raised that discrepancies occur when pain is more severe. Although individuals who know the patient should not be asked to rate pain intensity, they can facilitate assessment by providing the healthcare team with information about underlying painful pathology or behaviors that may indicate the presence of pain.

Exposure to painful procedures.

   When self-report cannot be obtained, the Hierarchy of Pain Measures calls for consideration of any potentially painful underlying conditions or procedures that the patient might be experiencing (Table). In this case, the patient has sustained painful traumatic injuries. He is also being subjected to endotracheal intubation, mechanical ventilation, and suctioning, all of which have been identified as painful procedures. However, he cannot report pain and is unable to demonstrate pain behaviors.

   According to the Hierarchy of Pain Measures, pain should be assumed to be present in such patients and treatment should be initiated with recommended starting doses of appropriate analgesics. The subanesthetic doses of propofol that are used for goal-directed sedation produce negligible analgesia. This underscores the importance of co-administering appropriate analgesics, such as nonopioids and opioids. Reassessing analgesic treatment may yield no change in behavior in unresponsive patients; therefore, the optimized analgesic dose should be continued.

   The patient's ability to self-report or the appropriateness of using a behavioral pain assessment tool should be evaluated regularly (eg, every shift). The decision to switch from assessment based on assumption of painful pathology to the use of behavioral tools or the patient's report of pain always depends on the patient's ability to demonstrate pain behaviors or report pain.

Patient behaviors.

   Patient behaviors often provide clues about whether a patient has pain. For example, facial expressions, restlessness, bracing, and changes in activity have been shown to be indicators of pain. Behavioral pain assessment tools facilitate pain assessment. One of the most commonly used tools in the ICU setting is the Critical-Care Pain Observation Tool (CPOT), which has been shown to be reliable and valid in a variety of critically ill patient populations. The tool requires evaluation of the following 4 categories:

   - Facial expression;
   - Body movements;
   - Muscle tension; and
   - Compliance with ventilator (intubated patients) or vocalization (extubated patients).

   A score of 0-2 is assigned to each category, depending on the degree of the patient's response. The maximum total score is 8. A limitation of many of the behavioral tools, such as the CPOT, is that they designate specific behaviors that must be observed, making it essential for nurses to carefully evaluate each patient for the patient's ability to demonstrate the requisite behaviors in the tool. In patients such as the one described above, behaviors are absent, rendering behavioral tools ineffective.

   Although it is tempting to rely on physiologic indicators, such as heart rate and blood pressure, vital signs have been shown to be the least sensitive indicators of pain and are known to be influenced by a variety of factors other than pain (eg, hypovolemia, blood loss, hypothermia, and anesthetic and analgesic agents).

Outcomes of Pain Assessment

   The healthcare team caring for this patient used the Hierarchy of Pain Measures as a framework for pain assessment. The patient was unresponsive, unable to self-report pain, and did not demonstrate any pain behaviors. As directed by the Hierarchy, those caring for him assumed that he had pain on the basis of his underlying painful pathology (eg, head trauma and ulnar fracture) and painful procedures (eg, endotracheal intubation, mechanical ventilation, and suctioning). A continuous IV morphine infusion at 2.5 mg/hour was initiated. Bolus doses of 1 mg IV morphine were administered before painful procedures. In addition, scheduled doses of IV acetaminophen and IV ibuprofen were administered around-the-clock.

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Universal HIV Screening Recommended by USPSTF

   The US Preventive Services Task Force (USPSTF) strongly recommends that clinicians screen all people aged 15 to 65 years for HIV infection, according to a draft recommendation statement posted online November 20. The statement also recommends HIV screening for all pregnant women, including those who present at the time of labor, and for younger adolescents and older adults who are at increased risk.

   "The draft recommendation reflects new evidence that demonstrates the benefits of both screening for and earlier treatment of HIV," task force member Douglas K. Owens, MD, said in a USPSTF news release. "Because HIV infection usually does not cause symptoms in the early stages, people need to be screened to learn if they are infected. People who are feeling well and learn they are infected with HIV can begin treatment earlier, reduce their chances of developing AIDS and live longer and healthier lives."

   Although US prevalence of HIV infection is nearly 1.2 million and annual incidence is about 50,000, nearly one quarter of those infected are unaware that they are HIV-positive. Since the first reports of AIDS in 1981, more than 1.1 million people have been diagnosed with AIDS and nearly 595,000 have died from it.

   Combined antiretroviral therapy (ART) has been shown to reduce the likelihood of HIV transmission, and earlier initiation of treatment lowers the risk for AIDS-related complications.

In issuing this recommendation, the task force hopes to improve and maintain the health of persons who are already infected with HIV, to delay the onset of AIDS, and to lower the risk for HIV transmission. The USPSTF is offering the public an opportunity to comment on this draft recommendation until December 17 and will consider all public comments when writing its final recommendation.

   Clinicians should screen adolescents and adults aged 15 to 65 years for HIV infection, as well as younger adolescents and older adults who are at increased risk (grade A recommendation).

Although evidence is insufficient to define optimal time intervals for HIV screening, the statement suggests that a reasonable strategy would be 1-time screening of adolescent and adult patients to identify those who are already HIV-positive and repeat screening of those known to be at risk for HIV infection, those who are actively engaged in high-risk behaviors, or those living in a high-prevalence setting.

   Clinicians should screen all pregnant women for HIV, including those of unknown HIV status who present in labor (grade A recommendation).

Evidence and Rationale

   The USPSTF updated their 2005 review on the benefits and harms of HIV screening in adolescents and adults by searching MEDLINE (2004 - June 2012) and the Cochrane Library (through the second quarter of 2012). Inclusion criteria were English-language randomized trials and observational studies comparing HIV screening approaches and reporting clinical outcomes, assessing the effect of initiating ART at different CD4 cell count thresholds and long-term harms, or reporting the effect of interventions on transmission risk.

   "Previous studies have shown that HIV screening is accurate, targeted screening misses a substantial proportion of cases, and treatments are effective in patients with advanced immunodeficiency," the USPSTF task force writes in its systematic review. "New evidence indicates that ART reduces risk for AIDS-defining events and death in persons with less advanced immunodeficiency and reduces sexual transmission of HIV."

   Evidence was convincing that standard and rapid HIV antibody tests are both highly accurate in diagnosing HIV infection.

   Evidence also was convincing that identifying and treating HIV infection in individuals with immunologically advanced disease (CD4 count <200 cells/mm 3) is associated with a substantially lower risk for progression to AIDS, AIDS-related events, and death.

   Evidence was adequate that starting ART earlier (at CD4 counts of 200 - 500 cells/mm 3) is associated with a lower risk for AIDS-related events or death.

   Finally, evidence was convincing that ART is associated with a markedly lower risk for transmission from HIV-positive persons to uninfected heterosexual partners and that identifying and treating HIV-positive pregnant women substantially lowers rates of mother-to-child transmission. Therefore, there are significant overall benefits of screening for HIV infection in adolescents, adults, and pregnant women.

   Although evidence is convincing that individual antiretroviral drugs, drug classes, and combinations are all associated with short-term adverse events, many are transient or self-limited, and there are often effective alternatives. Long-term use of certain antiretroviral drugs is linked to a small increase in risk for cardiovascular and other adverse events.

   "The overall harms of screening for and treatment of HIV infection in adolescents, adults, and pregnant women are small," the task force writes in its draft guidelines.

   "The USPSTF concludes that there is high certainty that the net benefit of screening for HIV infection in adolescents, adults, and pregnant women is substantial."

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Lung Screening May Encourage Smoking Cessation CME

News Author: Damian McNamara

CME Author: Charles P. Vega, MD, FAAFP Faculty and Disclosures

CME Released: 11/08/2012; Valid for credit through 11/08/2013

CLINICAL CONTEXT
There are more than 200,000 new cases of lung cancer diagnosed annually in the United States. However, effective screening strategies for lung cancer have remained elusive. Two major studies have recently evaluated the efficacy of lung cancer screening programs, and Barry and colleagues provide a review of this research. The Prostate, Lung, Colorectal and Ovarian Cancer (PLCO) trial did not find a difference in the rate of lung cancer mortality in comparing a screening group receiving annual chest X-rays with a control group. However, the National Lung Screening Trial demonstrated that individuals receiving lung cancer screening with computed tomography experienced a 20% reduction in the risk for mortality compared with adults screened with chest X-ray alone.

Smoking is the most important risk factor for lung cancer, and previous research suggests that false-positive screening tests for lung cancer are associated with a higher rate of cessation from smoking. The authors of the current study examined variables associated with smoking outcomes in the PLCO study.

STUDY SYNOPSIS AND PERSPECTIVE
Former smokers are more likely to relapse if they are young; black or Hispanic; less educated; unmarried; have a lower income, lower body mass index, and no family history of lung cancer; or have smoked light or ultralight cigarettes, according to a secondary analysis of participants in the PLCO Screening Trial.

Of the 31,694 self-reported former smokers at baseline in the PLCO, 3.3% relapsed and reported on follow-up that they currently smoked, report Samantha A. Barry, BA, from the Prostate Cancer Decision Making and Quality of Life Research Department at Georgetown University Medical Center, Washington, DC, and colleagues in an article published online October 26 in the Journal of the National Cancer Institute.

In addition, long-term smokers and recent quitters were statistically significantly more likely to relapse (both P < .001), according to this secondary analysis of PLCO trial data.

"This relapse prediction model may be useful for identifying former smokers who may benefit most from relapse prevention interventions," the authors note.

Of the 6807 people who reported smoking at baseline, 65.2% said they still smoked on their subsequent questionnaire a median of 8.5 years later (range, 4 - 14 years). Those who were younger, black or Hispanic, or had a lower income or a lower body mass index were more likely to have continued smoking.

"Continued smoking was also more likely among heavier smokers, smokers of light or ultralight cigarettes, and those with greater secondhand smoke exposure," the authors write. "However, current smokers with higher body mass index or new tobacco-related diseases and smokers of unfiltered cigarettes were less likely to continue smoking. These characteristics may be useful in identifying smokers who are most in need of a smoking cessation intervention."

In terms of trial variables, only participation in the PLCO trial for a shorter time was associated with continuation of smoking (odds ratio, 0.85; 95% confidence interval, 0.82 - 0.88). The trial group randomization (screening vs control), screening center, and screening result were not significant factors.

Participants were approximately 60 years old, 50% were men, 90% were white, and about 50% had 2 or more comorbidities. They started smoking at an average age of 18 or 19 years. In addition, 10% reported receiving at least a single false-positive screening result, defined as a positive chest X-ray at 1 or more of the 4 annual assessments that was not followed by a lung cancer diagnosis within 3 years.

Receipt of a false-positive screen was not significantly associated with lower likelihood of smoking relapse or greater likelihood of smoking cessation, however, "suggesting that screening results may have only a short-term effect on smoking behavior," the authors note. "However, we found that being diagnosed with a new noncancer, tobacco-related disease was inversely associated with continued smoking, suggesting another possible teachable moment for altering smoking behaviors: Upon receiving a new diagnosis, smokers may be motivated to quit smoking and become more amenable to formal cessation programs."

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Smoking and Risk on Women’s Mortality Rates

CLINICAL CONTEXT
Smoking is widely recognized as the most important modifiable risk factor in preventing adult mortality in Western countries, but there has been little attention paid overall to sex-based differences in health outcomes of smokers. Huxley and Woodward addressed this issue in a systematic review comparing cardiovascular outcomes associated with smoking among women and men. Their results, which were published in the October 8, 2011, issue of the Lancet, demonstrate that the risk for cardiovascular events associated with current smoking was more profound among women compared with men. There was no sex-based difference in the cardiovascular risk of former smokers.

Long-term data analysis on the health risks of smoking among very large groups of women has only recently been possible. The current study reports on mortality outcomes based on cigarette use in the Million Women Study.

STUDY SYNOPSIS AND PERSPECTIVE
Women who smoke lose at least 10 years from their lifespan. In particular, women who continue smoking past the age of 40 years have 10 times the hazards of those who quit smoking before that age.

Kirstin Pirie, MSc, from the Cancer Epidemiology Unit at the University of Oxford in the United Kingdom, and colleagues presented results from the Million Women Study in an article published online October 27 in the Lancet. Women were recruited for the study between the ages of 50 and 65 years and were followed up for between 9 and 15 years. The women in the study had a relatively low absolute death rate, possibly because various previous illnesses were excluded and possibly because the study included relatively healthy volunteers.

The study examined women in the United Kingdom and found that smoking accounted for two thirds of all deaths of smokers in their 50s, 60s, and 70s. Women smoking at baseline had a 12-year mortality rate of 2.76 (95% confidence interval, 2.71 - 2.81) when compared with never-smokers. For smokers younger than 70 years, the probability of death was 24% compared with 9% for never-smokers of the same age (absolute difference, 15%).

Women who stopped smoking by age 30 years avoided more than 97% of the lifetime hazard from smoking. Women who smoked until age 40 years and stopped had substantial hazards but were able to avoid more than 90% of the excess mortality caused by continuing to smoke. Women who stopped smoking at age 50 years avoided approximately two thirds the excess mortality seen in women who continue smoking at a later age. Women who quit smoking at the age of 40 years still have a mortality rate 1 to 2 times that of the never-smokers, however, and this increased mortality rate lasts for the next few decades of life.

Smokers typically experienced excess mortality from lung cancer, chronic lung disease, heart disease, and stroke, as well as other neoplastic, respiratory, or vascular conditions. For many of these diseases, the study identified a proportional excess risk in smokers that was even higher than that identified in previous studies.

The UK population was useful for studying because it includes a generation of women who smoked through adult life and reached old age. The authors seek to use the data from this study to predict the effect of smoking on female mortality outside the United Kingdom.

In a linked comment, Rachel Huxley, DPhil, from the University of Minnesota in Minneapolis and Mark Woodward, PhD, from Johns Hopkins University in Baltimore, Maryland, write, "The substantial hazards of smoking and the remarkable benefits of stopping now being seen among women in the UK emphasise the need for effective sex-specific and culturally-specific tobacco control policies that encourage adults who already smoke to quit and discourage children and young adults from starting to smoke."

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