Effective chronic pain management requires a structured approach to evaluation, diagnosis, and treatment.
When treating patients who are suffering from chronic pain, the diagnosis is critical, said Michael R. Clarke, MD, MPH, MBA, a psychiatrist and associate professor and director of the chronic pain treatment programs at the Johns Hopkins Medical Institutions.
“You don’t want to be driven by treatment modality; you want to design pain treatment plans based on a specific diagnosis,” he said. Although it may seem obvious that a diagnosis is needed before a patient can be treated, Clarke told the audience that he often sees patients who have been told that their pain is intractable or untreatable, yet they do not have a specific diagnosis.
During his presentation, “Chronic Pain Assessment,” delivered to a packed audience in Summerlin F at PAINWeek, Clarke discussed several tools that providers can use when assessing patients who are suffering from chronic pain. He noted that because nurses are often the clinicians who have the most hands-on contact with patients, in the acute setting all nursing admission assessment forms should have a section that addresses pain, and all flow sheets should have sections for pain documentation.
Clarke also briefly reviewed the hierarchy of importance of the various measures of pain intensity, identifying the patient’s self report of his or her pain using a pain scale as “the gold standard.” Clinical observation of the patient’s behaviors and actions and reports from family members are also useful, especially in young children and in elderly patients. Clarke said that physiologic measures are the least sensitive of all and warned that “although acute pain may elicit a change in a patient’s vital signs, clinicians shouldn’t be fooled by lack of change.”
There are a variety of widely available, easy-to-use scales that clinicians can use to assign a number to the patient’s pain intensity. Clarke also pointed to the visual analog pain scales, which “rate pain intensity along a continuum using anchor words,” noting that they are easy to use for patients who cannot give pain a number, but “are more difficult to use to assign pain intensity.” However, Clarke cautioned that no matter how good the scale is, they “cannot take the place of talking to the patient about his or her pain and asking him or her to describe its characteristics.”
When evaluating patients for pain, Clarke stated that clinicians should also look at a range of associated symptoms and factors. “It is critical that you ask patients about their ability to perform activities of daily living; ask them to outline a typical day and compare their answers from visit to visit,” he said. Other factors that should be assessed include changes in appetite and mood. Clarke reminded the audience that there is a common misperception that suicidal ideation is somehow “normal” among patients with chronic pain. “This is absolutely not the case,” he said, and any such talk should raise an immediate red flag for further assessment.
According to Clarke, all clinicians should learn to ask focused questions that elicit information from patients about their specific experiences. He advised the audience to also use a structured approach to pain assessment: “The better your assessment, the more complete your treatment plan will be."
Next, Clarke outlined a 10-step approach to long-term chronic pain management. Effective pain management begins with a comprehensive initial assessment and evaluation, the most important part of which is the patient history and physical exam. After also performing functional and psychological assessments and measuring pain intensity and impact on quality of life, clinicians should establish a diagnosis that confirms or excludes underlying causes for pain. “Most diagnostic tests don’t tell you much information with pain patients,” said Clarke. Clinicians must use their best judgment.
Once a diagnosis has been made, the clinician can establish medical necessity for the treatment plan they devise, assess the risk-benefit ratio, and establish goals for treatment. “You should have an internal rationale for all aspects of the treatment plan,” Clarke advised. After obtaining informed consent and agreement from the patient, the treatment plan can be implemented, with an initial dose adjustment phase (“start low and go slow,” Clarke recommended); a “stable dose phase,” during which the patient can be assessed for the “four As: analgesia, adverse side effects, activities of daily living, and aberrant behavior; and regular adherence monitoring. Then, treatment should be assessed for effectiveness.
Clarke summarized this approach to effective chronic pain management by reminding the audience to adopt a personalized “step approach” to pain assessment, identify pain tools that work for their practice, set realistic and achievable goals for pain reduction, utilize a comprehensive approach to pain management that includes pharmacologic and nonpharmacologic therapy, and minimize specialist referrals except when absolutely necessary.