EVALUATION OF THE PAIN PATIENT
● Reviewing psychiatric comorbidities, which may require co-treatment. ● Assessment of pain, including history, location, characteristics, severity, and impact.It is critical to gain as much information as possible about the specific complaint of pain. The SOCRATES acronym is a useful tool to remember key points to be collected when assessing a complaint of pain: 116 ● S ite: Where exactly is the pain? ● O nset: When did it start? Was it constant or intermittent? Was it gradual or sudden? ● C haracter: What is the pain like? Sharp? Burning? Tight? ● R adiation: Does the pain radiate or travel anywhere? ● A ssociations: Are there any symptoms associated with the pain such as sweating or vomiting? ● T ime course: Does it follow any time pattern? How long does it last? ● E xacerbating and relieving factors: Does anything make it better or worse? ● S everity: How severe is the pain? Consider using a visual analog scale or numeric rating scale to characterize the level of pain experienced by the patient. These scales allow patients to rate their pain between 0 (no pain) and 10 (worst pain imaginable). active psychological issues beyond their expertise. Clinicians should also probe for ways in which pain may be affecting the patient’s family system, work, or social activities. Pain can seriously erode these spheres of life. Evaluating these challenges and addressing them during treatment (for instance, by referral to a vocational counselor or social worker) is just as important as treating the more immediate medical issues that may be contributing to chronic pain. 118,119
It is critical to fully characterize both the patient’s pain condition and their potential for misusing or abusing controlled substances. Specifically, healthcare professionals must complete a comprehensive physical, medical, and social history and include an assessment of substance abuse and consideration of any special population requirements. Diligent healthcare professionals will look beyond the specific complaint and holistically evaluate the broader mental, cultural, and socioeconomic contexts in which the chief complaint is embedded. 116 A comprehensive history should be taken before a physical examination. A good medical history assessment is a test of the provider’s knowledge and communication skills. Depending on the mental state and reliability of the patient, a collateral history from a friend, relative, or caregiver may be required. It may be possible to gather this information before an in-person visit by using paper or online questionnaires. The history should include the following: 117 ● Past medical and surgical history to determine the etiology of pain and comorbidities that may affect therapy. ● A review of systems to evaluate the effects of pain. ● Social and family history, which helps elicit any issues pertaining to the development and treatment of pain. Psychosocial Evaluation Pain affects every aspect of a patient’s life. Therefore, it is vital to evaluate the ways pain may be affecting, or may be affected by, a patient’s mental health. Clinicians must be alert for signs of depression or anxiety, which are very common in patients suffering from chronic pain. Be particularly alert for suicidal thoughts; the risk of suicide is roughly doubled for patients with chronic pain. 118,119 Referral to a mental health professional is warranted if the clinician’s judgment suggests that the patient has
TREATMENT PLANS
● Individual differences in tolerance to pain become secondary to setting and monitoring treatment goals, since the patient’s perceived pain levels are not the focus in determining functionality. If a function-based approach is used, progress can be documented independently of subjective swings in reported pain. It is critical that the patient understands that progress may not be measured in days. Rather, gains may be incremental and occur over months or years. Further, some patients who begin showing solid progress may plateau. In these cases, consider reassessment. It may be beneficial to begin with more easily achievable goals to be replaced with more difficult goals after initial successes. This approach can be much more motivating than a plan resulting in early treatment failure. 120,121 As with most patient-provider documents, patients should be reminded of the potential risks and benefits of therapy even after obtaining informed consent. The realities of tolerance and physical dependence to controlled substances cannot be over-emphasized.
A comprehensive written plan should be developed to help both patients and providers work toward the patient’s pain management goals. Since the use of pain ratings alone to determine treatment goals can be problematic, one realistic approach may be to employ a function-based strategy. Using this method, the clinician does not measure efficacy as a patient’s progress in achieving pain relief, but rather by their ability to objectively achieve improved function. Potential post-therapeutic goals could include the ability to go to work, walk, enhanced sleeping, or simply improved social interactions. Possible functional scales could include one or two activities with minimal impact – for example, work enjoyment or pain-free walking – with intermediate steps interspersed. 120 Function-based goals offer two key advantages for managing medication use in patients with chronic pain 120,121 : ● Prescribing decisions are based on outcomes that can be objectively demonstrated to both the provider and the patient or caregiver.
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Book Code: CA23CME
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