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APOS PSYCHOSOCIAL
POCKET GUIDE

A quick reference resource for psychosocial professionals

The information contained in this guide does not constitute medical advice and is not intended to replace a healthcare provider’s independent medical judgment regarding the treatment or management of individual patients.

Table of Contents

Home 5 Table of Contents 5 Psychological Disorders, Psychosocial Concerns, & Evidence-Based Interventions 5 Pain & Discomfort

Pain & Discomfort

Author(s): Laura Porter, PhD, Scott Ravyts
Editor(s): Beth Gardini Dixon, PsyD, Sharla Wells-DiGregorio, PhD

Introduction 

    Pain is an unpleasant sensation that can range from mild discomfort to excruciating suffering. Despite advances in treatments for cancer pain, the prevalence of pain remains high, particularly for patients with advanced disease. Almost two-thirds of patients with advanced cancer report pain, and half report pain of moderate to severe intensity.

    Pain is a complex, multidimensional experience that impedes patients’ ability to perform valued activities and increases the risk of psychological distress. Pain is often inconsistent in nature, fluctuating in frequency, intensity, and sensory qualities. This unpredictability can make it challenging for patients to manage, leading to a perceived lack of control. In addition to having a biological basis, pain also affects and is affected by psychological and social factors. Thus, recent models maintain that cancer pain is best understood and treated using a biopsychosocial model that accounts for thoughts, emotions, behaviors, and the social context.

     

    Guidelines

    1. NCCN Guidelines Adult Cancer Pain Guidelines V.2.20241

    https://www.nccn.org/home

    1. National Cancer Institute Cancer Pain (PDQ®)–Health Professional Version: https://www.cancer.gov/about-cancer/treatment/side-effects/pain/pain-hp-pdq
    2. World Health Organization Guidelines for the Pharmacological and Radiotherapeutic Management of Cancer Pain in Adults and Adolescents: https://www.who.int/publications/i/item/9789241550390

    Screening/Risk Factors

    • Numerical Rating Scale: pain severity rated from 0 (no pain at all) to 10 (worst pain possible) (https://www.va.gov/PAINMANAGEMENT/docs/Pain_Numberic_Rating_Scale.pdf)
    • PEG: three items (pain severity, interference with enjoyment of life, and interference with general activities, each rated from 0 to 10) (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2686775/)
    • The Faces Pain Rating Scale – Revised (https://wongbakerfaces.org/wp-content/uploads/2016/05/FACES_English_Blue_w-instructions.pdf) – nonverbal assessment of pain severity

     

    Psychosocial Risk Factors

    • Pain Catastrophizing Scale – assesses catastrophic thinking related to pain, which is highly predictive of pain severity and distress (https://painbc.ca/sites/default/files/events/materials/Pain_Catastrophizing_Scale.pdf)
    • Self-efficacy for pain scale- 10 items assessing patients’ confidence in managing pain and its effects; https://novopsych.com.au/wp-content/uploads/2021/03/pseq_pain-self-efficacy-questionaire-pdf-template.pdf
    • Kinesiophobia (fear of movement) (https://novopsych.com.au/wp-content/uploads/2020/05/tsk_assessment.pdf)
    • Factors related to undertreatment of pain (From NCCN guidelines):
      • elderly; women
      • minorities (language, cultural barriers)
      • history of substance use problems, psychiatric illness, neuropathic pain
      • fear of addiction.
    • Pre-existing chronic pain
    • Other significant medical conditions that may contribute to pain
    • Social support – availability of family or others to provide emotional and/or practical support. Is anyone assisting patient with pain management and medications at home?

    Evaluation and Diagnosis

    Pain Severity and Interference

    McGill Pain Questionnaire

    (https://journals.lww.com/pain/Abstract/1975/09000/The_McGill_Pain_Questionnaire__Major_properties.6.aspx)- includes 3 major classes of word descriptors (sensory, affective and evaluative) that are used by patients to specify subjective pain experience

    • Ask about pain at rest and with movement

    Pain history (From NCCN Guidelines)1

    • When did it start?
    • How long has it been present?
    • Has it changed in any way?
    • Is it intermittent or constant?
    • Do you have other symptoms?
    • What makes the pain worse? Better?
    • What has been tried to treat the pain? Has it helped? Are there side effects? What are the scheduled doses?

    Pain-Related Problems

     

    Cultural Considerations

    Racial disparities in pain have been well-documented with individuals from underserved backgrounds being more likely to receive less aggressive treatments for their pain despite reporting greater levels of pain than their White counterparts. Implicit bias from medical providers and barriers to access for healthcare for underserved populations are believed to drive these disparities in pain. An understanding of a patient’s culture and its influence on pain communication, coping, and acceptability of different treatments allows for patient-centered, culturally-sensitive, treatment interventions. Additionally, adhering to established clinical guidelines for pain management can reduce individual discretion and minimize implicit bias affecting patient outcomes.

     

    Treatment

    Table 1. Non-Pharmacological Pain Management Strategies

    Pain Education

    Providing information about the biopsychological model of pain shifts one’s conceptualization away from viewing pain purely as a marker of tissue damage.

     

    Pros: Pain education can enhance patients’ motivation to utilize non-pharmacological coping skills.

     

    Cons: If not explained clearly, pain education may be misinterpreted by patients as the pain being “all in their head.”

     

    How to choose: Should be standard for all patients. The amount and complexity of information presented can be tailored to the patient’s level of understanding.
    Relaxation Training

    Relaxation exercises, such as progressive muscle relaxation, requires individuals to tense and then relax muscle groups throughout the body one by one. This skill promotes relaxation and increases one’s awareness of muscle tension which can exacerbate pain.

     

    Pros: Pain relaxation can decrease stress and muscle tension.

     

    Cons: Pain relaxation training, such as progressive muscle relaxation, can take up to 20 minutes and should be practiced regularly for optimal effects.

     

    How to choose: Helpful for most patients. Some patients respond positively to this on the first try while others will need repeated practice to derive benefits. Brief relaxation exercises can be demonstrated in the medical setting, with encouragement to practice regularly.
    Imagery

    Relaxation focused on a pleasant image. Individuals are encouraged to incorporate all five senses to make the image as vivid and relaxing as possible. Imagery redirects one’s attention away from pain while improving mood.

     

    Pros: Imagery is one of the few coping skills that is not focused on the breath or body.

     

    Cons: Imagery may be more challenging for patients who do not enjoy visualization.

     

    How to choose: Most patients find this enjoyable and helpful. Patients who are unable or dislike to visualize images will typically state this upfront and should be encouraged to use alternative strategies.
    Mindfulness Meditation

    Mindfulness encourages individuals to bring their awareness to their present moment experiences in non-judgmental way. Mindfulness meditations vary in length and style with individuals being asked to focus on either their breath, emotional experience, or physical sensations.

     

    Pros: Mindfulness mediation can change patients’ relationship to their pain and decrease pain catastrophizing. Even 5-10 minutes per day of meditation can be helpful.

     

    Cons: Mindfulness meditation may not be suitable for some patients with trauma histories. It also should be practiced regularly for optimal effects.

     

    How to choose: Suitable for most patients except those with trauma histories and those who tend to dissociate.
    Distraction

    Focusing one’s attention away from pain and towards other activities, such as reading or listening to music, can improve mood and promote adaptive coping.

     

    Pros: Distraction is a simple strategy that can be effective for coping with acute pain flare-ups.

     

    Cons: Distraction is primarily effective in the short-term.

     

    How to choose: Most effective in coping with acute pain (e.g., procedural) or with pain flares.
    Cognitive Restructuring / Coping Thoughts

    Identifying negative automatic thoughts related to pain (e.g., “there is nothing I can do to manage my pain”) and replacing them with thoughts that promote coping (e.g., “my pain may be high now but there are things I can do to manage my pain”).

     

    Pros: Cognitive restructuring can decrease pain catastrophizing.

     

    Cons: Cognitive restructuring can be challenging for patients who have difficulty differentiating thoughts from emotions.

    How to choose: Most helpful for patients who are high in pain catastrophizing, or are experiencing significant levels of pain-related depression and/or anxiety.
    Pleasant Activity Scheduling

    Scheduling pleasant or meaningful activities redirects one’s attention away from pain while enhancing one’s mood.

     

    Pros: Pleasant activity scheduling can promote movement and provide structure to one’s day.

     

    Cons: Pleasant activity scheduling may be impeded by environmental or financial barriers.

     

    How to choose: All patients can benefit from this.
    Activity Pacing

    Alternating between brief periods of activity and brief periods of rest promotes movement which can improve physical functioning while limiting overactivity or underactivity.

     

    Pros: Activity pacing can assist patients in maintaining some activities which they previously enjoyed by modifying them to incorporate rest.

    Cons: Activity pacing may need to be used several times before the optimal activity and rest periods are identified.

     

    How to choose: Most helpful for patients who are very inactive, or who are overdoing activities which leads to pain flares
    Managing Depression and Anxiety

    Unmanaged depression and anxiety can increase pain. Adaptive coping skills such as relaxation exercises, cognitive restructuring, and pleasant activity scheduling can improve mood symptoms and enhance one’s ability to cope with pain.

     

    Pros: Improved mood may increase overall quality of life.

     

    Cons: Pharmacological treatments may be needed to supplement behavioral strategies for depression or anxiety.

    How to choose: Any patient who is experiencing clinically significant psychological distress.

     
    Managing Sleep Disturbance

    A poor night’s sleep can exacerbate next-day pain. Making the environment conducive to sleep and avoiding non-sleep activities in the bed/bedroom, including limiting the amount of time spent awake in bed, can promote better sleep.

     

    Pros: Improved sleep can lead to secondary improvements in both pain and mood.

     

    Cons: Behavioral strategies to improve sleep can temporarily cause sleep to worsen before sleep improves long-term.

     

    How to choose: Any patient who is experiencing sleep disturbance (whether or not it is related to pain).
    Involving Caregivers

    Providing feedback to caregivers about ways in which they can assist with pain management (e.g., setting reminders to take medicine, encouraging appropriate activity), as well as feedback about what is not helpful (e.g., over-focusing on pain, solicitous responses, minimizing pain experiences).

     

    Pros: Involving caregivers can decrease interpersonal stress contributing to pain and muscle tension and provide reinforcement for positive pain coping behaviors.

    Cons: Some caregivers may be less amenable to feedback.

     

    How to choose: Any patient who has a family caregiver involved in their care.

    Click here to view table as PDF

    Conclusion

    While recommended by guidelines, nonpharmacological approaches to pain management are currently underutilized.  They have a number of advantages including:

    • Can be used in combination with pain medication and potentially lead to decreased need for pain medication
    • Not associated with negative side effects common to pain medication (e.g., constipation, drowsiness)
    • Can address psychosocial and behavioral factors (e.g., psychological distress, social support, inactivity) that both impact and are impacted by pain.
    • Can address patients’ primary goals which include performing valued tasks and activities, maintaining important relationships, and preserving a sense of control and independence.

    Resources

    1. Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelinesâ) for Adult Cancer Pain V.2.2024. ã National Comprehensive Cancer Network, Inc. 2024. All rights reserved. Accessed April 3,2024. To view most recent and complete version of the guideline, go online to NCCN.org.

    https://www.nccn.org/home

     

     

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