Pain assessment may be challenging in the context of reduced consciousness. Signs of discomfort include more rapid breathing or heart rate. Rectal and transdermal routes can be especially valuable at the end of life when the oral route is precluded because of reduced or absent consciousness, difficulty swallowing, or to avoid nausea and vomiting. 100 Managing Chronic Noncancer Pain To apply best practices in chronic noncancer pain treatment, HCPs should recognize and treat pain promptly, involve patients in the pain care plan, reassess and adjust the pain care plan as needed, monitor patient progress toward treatment goals, monitor patient adherence to any treatment agreements, and document all pain management outcomes in the patient medical record. The goals of treatment should be meaningful to the patient and contain measurable outcomes of improvement that include pain relief, functionality, quality of life, and activities of daily living. 23,64,86 Even patients with pain conditions or injuries that make complete cessation of pain unlikely can set goals such as sleeping through most nights, returning to work, walking a set distance, or participating more fully in family activities. The self-efficacy involved in collaborating on these goals can help patients gain greater control over their pain and their lives. Choices in medications are based on pain diagnosis and severity; comorbidities as established through medical history, physical exam, relevant diagnostic procedures; patient response; and a risk-benefit assessment to increase the likelihood that benefits outweigh risks. It is important to differentiate between nociceptive and neuropathic pain and to thoroughly evaluate the patient to aid in an accurate diagnosis, identifying the generator of pain whenever possible. Neuropathic pain can be difficult to manage and generally requires a combination of pharmacologic and nonpharmacologic approaches. 26 Choices of medications for neuropathic pain that provide the most relief include anticonvulsants, antidepressants, or local anesthetics. NSAIDs are not considered effective treatments for neuropathic pain, and opioids should be reserved for patients who did not respond to other therapeutic options. 26,64 For osteoarthritis, ACET and NSAIDs are considered first-line and second-line medications, respectively, and many guidelines recommend NSAIDs and ACET as first-line therapies for low-back pain. 64
Corticosteroid generally recommended for hip and knee osteoarthritis. 101 Expert guidelines usually now recommend against ongoing opioid therapy for nonspecific back pain, headaches, and fibromyalgia. 23 Whenever possible, nonpharmacologic injections are therapies and self-management strategies should be optimized. 30 Noninvasive interventions in specific conditions that have sustained small improvements in pain and function for one month or longer post treatment without serious harms are shown in Table 4. 30 A trial of opioids, when indicated, should be part of a comprehensive treatment approach, typically in combination with one or more treatment modalities. 2 Assessing Pain A patient’s initial visit for evaluation of a pain problem should include a physical exam and a patient interview to gather and document medical history and pain assessment. One should obtain a complete history of current and past substance use and misuse to include prescription drugs, illegal substances, alcohol, and tobacco. Social history is also relevant and includes employment, marital history, and family status. 78 Women should be screened for contraceptive use and pregnancy or breastfeeding status or intent. 64 Previous treatment records, including any pertinent clinical notes of treatments tried, and laboratory and imaging results should be reviewed whenever possible and retained in the current patient record. Pain should be assessed by its severity (to include pain intensity, pain-related distress, and interference with daily activities), its temporal characteristics (to include onset, duration, whether it is continuous, has recurrent episodes with painless intervals, or is continuous with times of pain exacerbation). Psychological and social factors can contribute to the pain experience, which is why these issues should be included in the patient interview and documented in the record. Recording these factors will assist with documenting what special pain management needs a patient has as well as what level of disability. 26 Good questions to ask the patient include what relieves or increases the pain, how it affects their daily lives and functioning, and what goals they have for pain relief and improved function.
A number of evidence-based, pain assessment tools are available for clinical practice: • The Visual Analogue Scale (VAS) and Numerical Rating Scale (NRS) are quick tools to measure pain severity that are sensitive, validated, and widely used. 102 • The Brief Pain Inventory (BPI) has good sensitivity, reliability, and validity for pain severity and interference-with-function items, including assessments of mood and sleep. 103,104 • The Pain, Enjoyment of Life, and General Activity Scale (PEG) was created to assist management of chronic pain in primary care settings. 105 It is based on the BPI and has rating scales to measure past-week pain, pain interference, functional components, and quality of life. • The McGill Pain Questionnaire (MPQ) assesses pain descriptors (sensory, evaluative, and affective). 102 With good validity and reliability, the MPQ is useful for helping patients describe their subjective pain experience but requires a good vocabulary when self-administered. The MPG is also available as a short form. • The Multidimensional Pain Inventory has been validated for multiple chronic pain conditions for categorizing how well patients cope with chronic pain as adaptive, dysfunctional, or interpersonally distressed. 106,107 Numeric pain scales, such as the VAS or NRS, have limitations in that they provide only a snapshot of the pain on a given day and do not necessarily reflect the impact of pain on the patient’s life. One should also consider other clinical signs and symptoms and to make treatment decisions to further therapeutic goals meaningful to the patient rather than basing treatments solely on a pain scale number. HCPs should also screen and monitor patients for factors associated with poor outcomes and substance abuse, such as sleep disturbance, mood disorder, and stress. HCPs are encouraged to consider use of a scale such as the Defense and Veterans Pain Rating Scale (DVPRS) (Figure 3). 3,108 The DVPRS is a graphic tool with a numeric rating scale in which each pain level has descriptive word anchors, facial depictions of pain, and color coding that coincides with pain severity categories. The DVPRS also includes supplemental questions for general activity, sleep, mood, and level of stress.
Table 4. Noninvasive, Nonpharmacologic Treatments for Specific Pain Conditions 33
Pain Condition
Treatment
Chronic low back pain
Exercise, psychological therapies (primarily cognitive behavioral therapy), spinal manipulation, low-level laser therapy, massage, mindfulness-based stress reduction, yoga, acupuncture, multidisciplinary rehabilitation, tai chi
Chronic neck pain Knee osteoarthritis Hip osteoarthritis
Exercise, low-level laser, Alexander technique, acupuncture
Exercise, ultrasound
Exercise, manual therapies
Fibromyalgia
Exercise, cognitive behavioral therapy, myofascial release massage, tai chi, qigong, acupuncture, multidisciplinary rehabilitation
Chronic tension headache
Spinal manipulation
13
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