Targeting Pain - Communication is Key

Pain – has an Element of Blank –
It cannot recollect
When it begun – or if there were
A time when it was not

Emily Dickinson

We have all experienced pain of varying degrees throughout our lives. Be the pain short-lived or long-lasting, agonizing or somewhat less profound, it’s source has marked our memory bank indelibly. The labor of childbirth, a hammer on a thumbnail, kidney or gall stones, a broken bone, a car accident, an icy slip and fall… we generally don’t forget the associated sensations.

With intense pain, there is nothing more welcome than its relief. In most cases of pain, its cause can be identified. Medications may work to alleviate the discomfort. You get better, you feel better. The experience lives on only as a memory. Unfortunately, this is not the case for everyone.

Those who suffer from chronic pain experience physical anguish that doesn’t go away. According to the American Pain Foundation (APF), chronic pain persists, fiendishly, uselessly; pain signals keep firing in the nervous system for weeks, months, even years. The person may be able to identify the initial cause of the pain, but they have long recovered and yet the pain remains - surrounding them, overcoming them and in some cases making daily living intolerable.

The number of people who suffer from chronic pain is reaching epidemic proportions in North America. According to the APF, more than 50 million Americans live with serious chronic pain that interferes with day-to-day functioning in their personal, social and work lives. Chronic pain is the third leading cause of physical impairment in the United States, and up to 86 percent of Americans suffering from chronic pain experience breakthrough pain – sudden flare of discomfort - even when the day to day pain is well managed.

Despite the incredible number of people who deal with pain on a daily basis, it remains poorly understood, and its treatment is inconsistent across the medical profession. It is estimated that only one in four of the over 50 million Americans who suffer from chronic pain receive proper treatment. And it costs the economy an estimated $100 billion every year. For family members and friends of those with chronic pain, the affect it has on their lives can be extensive.

Amputation and Chronic Pain

For amputees, it is important to differentiate between the types of chronic pain that can be experienced. Residual limb pain occurs in all persons following an amputation. It is the pain associated with the trauma to the remaining limb, including bone spurs, scarring, poor fitting prostheses, for example, explains Dr. Robert H. Meier III, who has rehabilitated amputees for more than 30 years. After surgical incisions are healed, residual limb pain may present itself in the post-operative healing period.
But for some amputees, residual limb pain can become a chronic pain syndrome that needs assessment and further treatment. Residual limb pain is very different from what is known as phantom limb pain. Phantom limb sensations/pain are thought to occur in virtually all people with amputations as well. For some, these painful sensations last long after the initial surgery. It may be mild to severe in intensity, and may completely disrupt the function and quality of an individual’s life. It is important to be able to differentiate between these two types of pain when seeing your health care provider. There’s a tendency among amputees suffering from phantom limb pain to choose not to disclose the sensations to their physicians, surmising that the doctor will perceive the complaint as “all in their head.” It’s important for the amputee to be forthcoming about all pain problems.
When appointments with physicians can be weeks and sometimes months apart, it is challenging to remember and accurately describe more severe pain episodes – or episodes of breakthrough pain. We all have a tendency to live in the moment, and when visits to the doctor coincide with “better days”, it is harder to describe the pain, its location, possible influences, medications that relieved or didn’t relieve the pain, and other questions asked.

Fighting against Chronic Pain

To tackle the reporting problem, the American Pain Foundation has launched the TARGET CHRONIC PAIN initiative to close the gap between the actual pain that patients experience and what is reported to healthcare providers. Successful pain management requires effective communication and an ongoing partnership between pain patients and healthcare providers. The initiative encourages better communication between these two partners to improve pain management.

The program acknowledges that clinicians receive little education on pain management during their medical training. Simultaneously, patients don’t always know how to describe their pain and often don’t recall how their pain has varied over time. Together, these lead to difficulties in assessing and managing pain. The TARGET CHRONIC PAIN initiative addresses this predicament by providing resources for both the patient and the provider to focus on a common language to distinguish and describe the components of chronic pain.

Studies have shown that chronic pain patients describe their pain in many different and personal ways, and are often unconcerned with specific clinical descriptions. They have difficulty communicating the difference between increased levels of persistent pain versus breakthrough pain. The tools help patients identify and describe the pain more effectively and efficiently. “We hope to improve the success of pain management for patients by making it easier for them to describe their pain and get the help they need to achieve relief, and to improve their ability to function on a day-to-day basis,” says Claudia Campbell, BSN, RN, CCRN, Manager of Pain Services at Intermountain Healthcare in Salt Lake City, Utah, and contributor to the TARGET initiatives.


The Target Chronic Pain Notebook

How many times do we go to the doctor and forget to tell them something, or we get home and forget an important piece of information they may have given us? The Target Chronic Pain Notebook is designed to help describe chronic pain. The book serves as a diary to record daily pain experience, and the treatments tried. It allows for self-reflection and records that information in words and graphs. Diagrams of the human body allow a person to mark exact locations of pain. The Target Chronic Pain Notebook is a valuable tool for people with chronic pain to more accurately assess their own pain on a scale from one to ten. The diary works to bridge the gap between appointment times by allowing the person to record their daily pain and activity levels.

It encourages day to day, and long term comparisons of pain and activity levels to determine progress in pain management and areas of need. It also empowers the patient, positioning him or her as an active participant in assessing and treating their pain. It can be a starting point for patient education as pain triggers can be identified and discussed – sleeplessness, stress and fatigue, depression, anxiety, the effects of alcohol, medications and cigarettes on pain. Taking this notebook to a physician provides the him or her with valuable information to better understand, assess, and treat their patient’s pain.

The notebook is available by order from the American Pain Foundation by calling 1-888-615-PAIN (7246) or through the web site at www.painfoundation.org where the book can be downloaded directly from the site.


Target Chronic Pain Card for Clinicians

The APF has also designed a corresponding card for physicians who see patients with chronic pain. It is designed to ensure that patients and providers are using a common vocabulary. TARGET is an acronym for Talk to your patients about their pain; Ask about current treatments; Rate pain intensity and get details; Get details about breakthrough pain; Evaluate limitations on activities; and Treat side effects. It is the first assessment tool designed for physicians by the APF and is based on the organization’s belief that clear and consistent two-way communication between patient and provider is essential to good pain management.

The card features key questions to ask patients about pain, tips on treatment strategies based on accepted principles of pain management, and charts that can be used as visual aids to explain the components of chronic pain to patients. The Target Chronic Pain Card is available by calling the APF at 1-888-715-PAIN (7246) or through the website at www.painfoundation.org.


Pain - The 5th Vital Sign

According to James Campbell, MD, “If pain was assessed with the same zeal as other vital signs are, it would have a much better chance of being treated properly. We need to train doctors and nurses to treat pain as a vital sign. Quality care means that pain is measured and treated.” Campbell’s call to action prompted the phrase “pain as the 5th vital sign” and served as the impetus for a toolkit developed by the Veteran Health Administration (VHA) to make an individual’s “pain” more visible.

Screening for pain can be administered quickly and routinely as health care providers take temperature, pulse, breathing rate and blood pressure. As with these other vital signs, a positive pain score should trigger further assessment, treatment and follow up assessment of the pain after treatment.

With these new initiatives in communicating and assessing pain, people who live with chronic pain have new tools to help them be better understood, better assessed and in turn better served. Although they may never be pain free, they may reach “comfortable” pain levels that allow them to lead more productive, happier lives.




Pain Defined

Persistent pain is continuous pain that is present for most of the day, persists for more than three months and is usually treated with medication taken around-the-clock.

Breakthrough pain is a sudden flare of pain that “breaks through” the relief by around-the-clock medication used to treat persistent pain.

Residual limb pain is pain felt in the remaining section of the amputated limb.

Phantom limb pain is a neurogenic disorder. It is pain perceived in the amputated or absent part of the body.


Sources: The American Pain Foundation; Veterans Health Administration: Pain as the 5th Vital Sign Toolkit;

Functional Restoration of Adults and Children with Upper Extremity Amputation (Robert H. Meier, MD, Diane J. Atkins, O.T.R)