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Treatment Planning

Two doctors confer in the hallway
“Zero” pain is neither achievable nor desirable.

A patient’s pain score is just one of several measurements of success.

Small reductions in pain can be deemed major successes if they lead to increased function.

Functional objectives should be set collaboratively between doctor and patient. They should be realistic and revisited at regular intervals.

Each patient has a unique set of functional milestones. (Fishman, 2007)

The one thing a chronic pain patient understands is the constant existence of pain that prevents the patient from engaging the basic activities of life, such as work, sleep, or eating. The patient’s foremost objective in visiting the doctor is to make the pain go away (sooner, rather than later). Unfortunately, finding the right treatment regimen is a long-term, sometimes difficult, process. The patient can be discouraged by treatment setbacks in the forms of side effects (excessive sedation) from opioid analgesics or the recurrence of high levels of pain.

Doctors treating chronic pain patients often use quantitative tools to measure patients’ treatment progress. But, simple zero-to-ten scales, happy-sad faces, or x’s on a drawing of a body don’t necessarily offer objective or quantitative information. Different patients have different levels of pain tolerance; one person’s “3” is another’s “7.” Also, a less-than-candid patient could over-report levels of pain.

Therefore, in addition to the scales and the drawings, the clinician needs to find individualized, objective measures for each pain patient. Pain experts recommend a function-based treatment strategy that focuses on restoring some or all of the pain patient’s normal activities. The clinician should learn what activities a patient has stopped doing as a result of chronic pain and then establish weekly or monthly objectives for restoring these activities with the help of pain medication. In collaboration with the patient, the clinician can create a scale where the lowest end is the patient’s ability to engage in only one of his normal activities—sleeping—and the highest end would be all of his activities—sleeping, eating, working, recreation, etc.

Reference

Fishman, MD, Scott M. Responsible Opioid Prescribing: A Physician’s Guide. Washington, DC: Waterford Life Sciences, 2007. pp. 31–44.