EVALUATING PAIN
Take a history The patient’s self-report is the most reliable indicator of pain. 18 Physiological and behavioral signs of pain (e.g., tachycardia, grimacing) are neither sensitive nor specific for pain and should not replace patient self- report unless the patient is unable to communicate. Therefore, talking to patients and asking them about their pain (i.e., obtaining a “pain history”) is integral to pain assessment. The pain history usually is obtained as part of the patient history, which includes the patient’s past medical history, medications, habits (e.g., smoking, alcohol intake), family history, and psychosocial history. Obtaining a comprehensive history provides many
potential benefits, including improved management, fewer treatment side effects, improved function and quality of life, and better use of health care resources. Assessing the impact of pain on functional status and sleep and screening for mental health conditions potentially related to pain or treatment adherence (e.g., depression, anxiety, and memory issues) may provide useful information for pain management. 19 Depression in older patients, for example, sometimes presents with somatic complaints of pain. Pain complaints may resolve when the underlying depression is treated. Patients can also be screened for known risk factors for OUD (see below). Brief pain inventory The Brief Pain Inventory (BPI) is used frequently in clinical trials to assess pain. Specifically developed for patients with chronic pain, the BPI more fully captures the impact of pain on patient function and quality of life than simple VAS scales. 21 By including a pain map, the BPI allows tracking of the location of pain through the course of management. The BPI is self- administered but somewhat time-consuming, which may limit its role in a busy clinical practice. PEG scale The PEG scale (Pain average, interference with Enjoyment of life, and interference with General activity) is a three-item tool based on the BPI and is practical for clinical practice (Figure 3). Zero-to-10 scales are used to assess pain, enjoyment of life, and general activity. PEG can be self-administered or done by the clinician and is relatively brief. 22
TOOLS
Many tools have been developed to document and assess pain. Initial approaches to assessing pain severity use a numerical rating scale (NRS) rating pain from 0 (no pain) to 10 (worst pain you can imagine) (some scales use a 0 to 100 scale). Such scales are often used in clinical trials of pain therapies, and the minimal clinically important difference using these scales is generally considered a 20%-30% change from baseline (i.e., 2-3 points on a 0-10 scale or 20-30 points on a 0-100 scale). 20 Multidimensional tools, such as those described below, include questions relating to quality of life and participation in daily activities. Such tools can provide a more comprehensive approach to assessing pain and response to treatment. The selection of a pain assessment tool must balance the comprehensiveness of the assessment obtained with the time and energy required to use the tool in a real-world practice setting.
Figure 3: PEG scale 22 What number best describes your pain on average in the past week? 0 1 2 3 4 5 6 7 8 9 10 No pain
Pain as bad as you can imagine
Assessing acute pain Acute pain intensity can be assessed with unidimensional tools such as the VAS and the Wong- Baker FACES Pain Rating Scale (faces depicting increasing levels of pain). While useful for a quick assessment, these scales alone may not appropriately identify patients with pain-related suffering driven by functional limitations, worry, or other factors, and may not detect some patients with clinically significant pain. 23 Although developed for patients with chronic pain, the BPI is also applicable to patients with acute pain. Completed by the patient, the BPI captures ways that pain impacts function and quality of life, although, like most multidimensional questionnaires, it requires more time (about 10 minutes) and concentration to complete, which may limit its utility in some elderly patients. 21
Pain in patients with dementia Although patients with mild-to-moderate dementia can report their pain and its location, those with severe dementia are often unable to communicate their pain experience or request medication. In these patients, physicians need to observe pain behaviors, including facial expressions, verbal cues, body movements, changes in interpersonal interactions, activity patterns, and mental status. Caregiver observations and reports are critical to appropriate assessment and management of chronic pain conditions. 24
Book Code: MDAZ1124
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