Proper Patient Assessment
Chronic pain is defined as pain persisting longer than 12 weeks and can arise from an original injury or be secondary to co-occurring medical condition. Pain is a very personal and subjective experience, in which a multitude of factors such as childhood background, mental aptitude, social environment, and personal beliefs and values can effect perceptions of pain.
The goal of chronic pain management is to safely and effectively reduce pain and improve function and quality of life. Complete eradication of chronic pain is an unrealistic expectation and should not be a goal for the patient or the medical provider. Multi-modal treatment therapies addressing the bio-psycho-social-spiritual needs of the patient should be employed as safe best practices.
Opioid therapy should be de-emphasized, utilized only as last resort and never as the sole therapy. Opioid medication therapy can cause opioid-induced hyperalgesia, which is a paradoxical effect that causes a hyper-sensitization of the pain receptors and a lower threshold of pain perception through prolonged use of opioid medications. In essence, the patient's pain gets worse by treating with opioid pain medications and normally benign stimuli can be perceived as noxious and painful. Further, opioid medication therapy introduces significant morbidity and mortality risks, complications of tolerance and dependence requiring sustained escalating doses to achieve original effectiveness, iatrogenic addiction, and public health threats such as diversion, addiction by secondary users, and overdoses in the community. Opioids are not clinically indicated for treatment of back pain without radiculopathy, migraines, inflammatory disorders (rheumatoid arthritis or osteoarthritis), or neuropathic pain syndromes (peripheral neuropathy or fibromyalgia) and should not be prescribed for these conditions. In fact, most of these conditions are worsened by opioid medication therapy.
Here are three helpful steps to assist with the assessment of pain:
- Step 1: Take Extra Time
For chronic pain patients, finding the sources of their pain (locations, intensity, duration, etc.) takes considerable time. Clinicians must do the detective work necessary for these patients, despite the inclination to move difficult patients along.
- Step 2: Focus on the Patient, Not the Pain
In addition to investigating the sources of pain, clinicians need to find out how pain affects their patients' lives. The collateral damage caused by chronic pain can take the forms of nausea, depression, fatigue, anxiety, and other problems. Learning these aspects of patients' lives will help clinicians understand the "true dimensions" of their patients' pain (Fishman, 2007).
- Step 3: Try Reflective Listening
Reflective listening is a widely recommended patient assessment technique.
From the Providers' Clinical Support System for Opioid Therapies (PCSS-O), a video resource guides providers through a patient interview using CDC Guidelines for Prescribing Opioids for Chronic Pain.
Fishman, MD, Scott M. Responsible Opioid Prescribing: A Physician’s Guide. Washington, DC: Waterford Life Sciences, 2007. pp. 16–17.
Passik, PhD, Steven D., and Pamela Squire, MD, CCFP “Current Risk Assessment and Management Paradigms: Snapshots in the Life of the Pain Specialist” Pain Medicine. 10 (2009): S101–S114.
Lee, M., Silverman, S., Hansen, H., Patel, V., and Manchikanti, L. (2011). A Comprehensive Review of Opioid-Induced Hyperalgesia. Pain Physician. 14, 145-161.
- Model Policy for the Use of Controlled Substances for the Treatment of Pain [PDF – 44KB]
- CDC Guideline for Prescribing Opioids for Chronic Pain
- Implementing the CDC Guideline for Prescribing Opioids for Chronic Pain
- painACTION , a resource to help people manage their pain.
- Dealing With Chronic Pain? Get Your WebMD Score.