Thursday, May 25, 2017

Strategies for Evaluating the Patient with Chronic Pain

A comprehensive evaluation of the patient with chronic pain is rarely straightforward, and it begins with the recognition that a complete cure is unlikely. The patient’s pain experience may be complicated by numerous factors, including lack of an obvious pathological cause, concomitant anxiety and depression, and a downward spiral of inactivity and lowered self-esteem. Often, medications used to treat the pain may themselves cause side effects that contribute to the patient’s reduced function.

The skillful clinician will work with the patient, incorporating time-efficient tools to determine a treatment plan that combines a variety of modalities and may or may not include the use of opioids. With chronic pain patients, the evaluation is key: Failure to identify all the factors that contribute to the pain can lead to ineffective treatment, further deterioration, and mutual frustration, not to mention legal and regulatory consequences. A seasoned clinician listens carefully to validate the patient’s pain without allowing elaborate descriptions to derail the timing and purpose of the visit. For most patients with persistent pain, the goal of treatment is not the complete relief of pain, but rather improvements in the patient’s physical and mental functioning that result in an improved quality of life as he or she takes increasing responsibility in his or her own therapy. Patient and clinician may be a traveling a long and bumpy road, but the outcome can be meaningful and beneficial for both.

The Assessment Process

There are numerous guidelines for managing the patient with chronic pain (1-4). Having a routine for the evaluation ensures that relevant data are captured. The clinician should evaluate and document the patient’s pain history including the nature, location, intensity, and duration of the pain; current and prior pharmacological and nonpharmacological treatments; factors that worsen or improve the pain; underlying or coexisting conditions; and (importantly) the effect of the pain on the patient’s life. An assessment of function should include the impact of the pain on the patient’s family and social life, employment, and sleep, and provide a baseline for follow-up evaluations. The clinician should also be alert to signs that the patient is minimizing or maximizing the subjective reports of the pain or, in cases of cognitive impairment, lacks the proper resources to describe it (3).

As the noted clinician Sir William Osler stated, it is more important to consider what kind of patient has the disease, rather than what kind of disease the patient has. The treatment of the patient with chronic pain proves time and again the truth of of his aphorism. Thus, I include questions about depression, anxiety, posttraumatic stress disorder, and other factors that might impact pain, including stress levels at home or at work. I consider the patient’s capacity for chemical coping, or the likelihood of using pain medication to cope with life’s stresses. And, of course, any evaluation that may lead to a trial of opioids should include an assessment of the patient’s risk for opioid misuse, but it also should include a qualitative assessment of the patient’s goals. What are the patient’s functional goals? How does the patient define functionality? What are simple, concrete things the patient wants to do in the next 30 days? How can treatment help the patient reach her goals?

When reviewing the pharmacological history, I attempt to ascertainwhether the pain is a part of the history or consumes the history. I ask which medications has the patient tried: nonsteroidal anti-inflammatory drugs (NSAIDs), serotonin norepinephrine reuptake inhibitors (SNRIs), nerve cell membrane stabilizers (anticonvulsants), and/or opioids. I like to think of these as the four pharmacologic pillars of pain relief, which often yield salutary results when used in combination. Is the patient equally balanced on all four pillars, or is he leaning on just one?

A comprehensive evaluation may take some time, but several strategies can be used to work within the time constraints of the office visit, especially in primary care practice. A comprehensive questionnaire can be filled out by the patient before the initial appointment, providing key historical information even before the patient enters the exam room. Self-reporting pain scales and screeners, such as the Brief Pain Inventory (BPI) (5), also can help consolidate information and maximize the time before the visit. I often bring the patient back in a week or two, or see the patient more frequently in the beginning of the treatment plan, to continue the initial evaluation. When dealing with a pain patient who may be considered difficult because he has lost the ability to cope with life, it is tempting to try to rush the evaluation. But most such patients have complex issues and histories that require a commitment on the clinician’s part to take the time to unravel them.

The clinician should perform a focused physical examination based on the patient’s history and carry out appropriate diagnostic testing. Quantitative measurements of the patient’s capacity for successful opioid treatment can be obtained from urine drug screens, electronic databases, and standard tools for risk stratification, such as the Opioid Risk Tool (6) and the revised version of the Screener and Opioid Assessment for Patients with Pain (SOAPP-R) (7). In addition, the Sheehan Disability Scale (8) and the WHO-5 (9) are very helpful to assess functionality and wellness (a predictor of resiliency). The PHQ-9 (10) is a useful scale for depression, which often co-exists with chronic pain and will impact the patient’s care.

Treatment Considerations

The patient-clinician relationship is best viewed as a collaborative partnership; whereas patient demand should not determine the choice of a therapy, it should inform the choice. Many patients want to combine complementary and alternative medicine options with pharmacological therapy, and the assessment will help determine which therapy will provide greatest benefit. If the patient has issues with gait and balance, for example, physical therapy can improve functionality and decrease the potential for falls. We would also recommend other strategies such as fall-proofing the home, and learning ‘tricks’ for safe and less painful walking. For patients with localized neuropathic pain, dry needling techniques may be effective. Massage, either alone or combined with topical treatments such as NSAID-based gel, may ease musculoskeletal and soft tissue pain.

Most complex pain patients will be taking multiple medications, so I try to maximize their effectiveness during treatment. For example, switching a patient who is already taking a selective serotonin reuptake inhibitor (SSRI) to an SNRI will often provide additional analgesia. I try to prescribe treatments that will ‘multitask;– give multiple therapeutic effects from one molecule. Another example: if lack of sleep is an issue, I usually give gabapentinoids at night. Of course, opioids may also be required, if the risk/benefit ratio is appropriate, and non-opioid therapies alone have failed.

Treating patients with chronic pain can be challenging, but I have developed strategies for dealing with some of the frustrations. I talk with my colleagues, keep up to date with legislation and CME, and, most importantly, I trust my clinical judgment–especially when I am confident that my evaluation has been comprehensive and has involved collaborating with the patient. I am comfortable treating my patients with chronic pain, even when they become angry and disagree with the treatment decision. Because I have laid the proper groundwork, I view this not as a treatment failure, but as an opportunity to strengthen the therapeutic relationship.

References

  1. Irving G, Squire P. Medical evaluation of the chronic pain patient. In: Fishman SM, Ballantyne JC, Rathmell JP, eds. Bonica’s Management of Pain. 4th Baltimore, MD: Lippincott Williams & Wilkins; 2010:208-223.
  2. Fishman SM. Responsible Opioid Prescribing: A Physician’s Guide. Washington, DC: Waterford Life Sciences; 2007:13-29.
  3. American Geriatrics Society Panel on the Pharmacological Management of Persistent Pain in Older Persons. Pharmacological management of persistent pain in older persons. J Am Geriatr Soc. 2009;57(8):1331–1346.
  4. Chou R, Fanciullo GJ, Fine PG, et al., for the American Pain Society- American Academy of Pain Medicine Opioids Guidelines Panel. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009;10(2):113-130.
  5. Cleeland CS, Ryan KM. Pain assessment: global use of the Brief Pain Inventory. Ann Acad Med. 1994;23(2):129-138.
  6. Webster LR, Webster RM. Predicting aberrant behaviors in opioid-treated patients: Preliminary validation of the Opioid Risk Tool. Pain Med. 2005;6(6):432–442.
  7. Butler SF, Fernandez K, Benoit C, Budman SH, Jamison RN. Validation of the revised Screener and Opioid Assessment for Patients with Pain (SOAPP-R). J Pain. 2008;9(4):360–372.
  8. Leon AC, Olfson M, Portera L, Farber L, Sheehan DV.. Assessing psychiatric impairment in primary care with the Sheehan Disability Scale. Int J Psychiatry Med. 1997;27(2):93-105.
  9. Bech P. Measuring the dimensions of psychological general well-being by the WHO-5. QoL Newsletter. 2004;32:15-16.
  10. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606-613.

This story originally appeared in The Pain Practitioner, Spring 2014.

 

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About W. Clay Jackson, MD, DipTh, Vice President of the Board