Proper Patient Assessment
Chronic pain refers to a wide spectrum of diseases and conditions with causes that are multifactorial in nature. Chronic pain may include physical, psychological, social, and spiritual components, while physical pain may be further classified as either somatic, visceral, or neuropathic. Chronic pain refers to a pain state which is persistent, typically 3 months or more, and exists beyond an expected time for healing. The cause of the pain may not be removable or otherwise treated. It may persist despite generally accepted medical treatments. This type of pain may be associated with end-of-life pathology involving cancer or organ failure. Pain is a very personal and subjective experience in which a multitude of factors such as past pain experiences, expectations, social or environmental factors, and personal beliefs and values can affect 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 practice treatment options.
Opioid therapy should be de-emphasized, and utilized only as a last resort and never the sole therapy for treating patient's pain. Opioid medication therapy can result in 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
Consider exploring how pain affects the patient's life. 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.
NIH Medline Plus. Chronic Pain: Symptoms, Diagnosis, & Treatment. Spring 2011. Volume 6 (1). pp 5-6.
- CDC Guideline for Prescribing Opioids for Chronic Pain
- HHS Announces Guide for Appropriate Tapering or Discontinuation of Long-Term Opioid Use
- Patient-Centered Reduction or Discontinuation of Long-term Opioid Analgesics The HHS Guide for Clinicians - summary
- Dealing With Chronic Pain? Get Your WebMD Score.