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Pain Assessment

Proper assessment of pain guides effective treatment. The assessment should involve a multidimensional approach, and include physiological tests, as well as an evaluation of the patient’s mental and emotional health. This includes vitals, proactive pain tests (eg, straight leg raising for low back pain), and reflex/balance tests. Additional tests, such as imaging, laboratory, as well as motor and nerve signal tests may also be indicated.1,2

The patient’s mental and emotional health can be assessed through general health surveys or questionnaires. Short-form surveys on daily activity and lifestyle can be a way to gauge recent mood and anxiety levels, work productivity, exercise, and other parameters.3 These do not replace a full psychological evaluation if there are any serious mental health concerns.4

Pain assessment hinges heavily on a patient’s self-report, however if a patient is unable do so, then pain can be objectively assessed based on behavior, facial expressions, muscle tension, upper/lower limb movement, limping or bracing, and other parameters.5,6,7 In cases of chronic pain, pain should be reassessed over follow-up appointments, focusing on improvements in movement and mobility, as well as quality of life.8 If there are pharmacologic treatments, pain reassessment should also include specific treatment goals. Pain should be reassessed prior to and after any procedures as well. Assessment should ascertain the temporality, quality, severity/intensity and region/location of the reported pain.9

Temporality

Pain can be categorized by its temporality into acute or chronic, or by pain patterns, for example, if there are recurrent flares, or if the pain is constant or fluctuating. Evaluating constancy of pain can be determined by asking the patient how many hours in the day or what percentage of the day the patient is experiencing pain.10 One way to overcome any inaccuracies in the patient’s memory of pain is to use the Day Reconstruction Method, which asks patients to recall the previous day’s activities, their emotions, and pain level during that time.10 Patients with chronic pain may also be asked to keep a pain diary to track pain triggers or the time of day pain occurs.11

Quality

The quality of the pain can be determined through a patient’s description of its characteristics, and questionnaires can help articulate this. A patient might describe the pain using specific words like burning, tingly, achy, or cramping, or they can choose these words from a list.12 These descriptors can indicate the type of pain—a sharp or throbbing pain might indicate nociceptive pain, while a burning, tingly or shooting pain is likely neuropathic.13,14

Severity and intensity

There are many methods to assess the severity and intensity of pain, including a numerical rating scale (NRS), categorical scales, such as mild/moderate/severe, and a visual analog scale (VAS).10 For young children, a Faces Pain Scale may be used.15 There are also scales which take into account pain over the past 24 hours, week, or month.

The McGill Pain Questionnaire (MPQ) is one of the most commonly used scales, and measures affective and sensory pain and pain intensity.17 The patient selects words from a group of 20 that describe their pain. It can also be used to evaluate pain interventions. The MPQ has demonstrated high reliability and validity, and there are several short-form variations that exist.10

Using a body map can help the patient demonstrate the location(s) where the pain is occurring, and how widespread it is. It can be useful in nociplastic pain, and is an effective tool to determine if the pain will respond to peripherally or centrally directed therapies.18

A patient’s previous pain and history of pain can give the physician clues to the origins of the current pain. Some chronic pain conditions, such as migraines are genetic, and evaluating a family history can be useful in these cases.19

Finally, a patient’s pain preferences: are important to understand, both in terms of their pain story and preferences: for treatment. A patient’s experience of pain must be respected, since it is always a personal one.20

Recognizing and identifying risk factors for substance use disorders (SUDs)

Opioids are a major reason for the drug overdose epidemic in the US. Opioids are generally safe when prescribed for moderate-to-severe pain but can also become highly addictive.22 It may be challenging to distinguish actual addiction from physical dependence, which is a normal reaction caused by tolerance and withdrawal.23 Addiction involves a behavioral component in addition to physical dependence. According to the DSM-5, addiction is defined by compulsive use and craving, and impaired control over substance use.23 Physicians can be considered the “gatekeepers” of opioids, therefore, it’s essential that they review certain risk factors that will influence what type of treatment is prescribed.24 For example, a patient’s age, sex, concomitant medications, and co-morbidities should be reviewed as potential risk categories.24 Lifestyle differences, such as a labor-intensive or stressful job can also lead to a greater risk of recurrent pain.25 A personal and family history of mental health disorders as well as SUDs should be assessed.23 SUD is a condition where there is uncontrolled use of a substance, such as alcohol, tobacco, or psychoactive substances.26 It often presents with multiple physiological, behavioral, and cognitive symptoms.27 People with SUD can continue use of substance(s) despite knowing the harmful consequences.

Recent research has demonstrated that SUDs can be inherited, and there are shared genetics between SUDs and mental disorders.28 There is also evidence that genes and epigenetics make up between 40%-60% of a person’s risk of an addiction.29

It can be challenging to identify SUD since substance use may be hidden, and there can be varying levels of functionality. Certain signs and symptoms to look for include behavioral, such as drop in work performance, mood swings, and irritability.30 Other behaviors can include history of selling drugs and losing medications multiple times.31 Physical signs include sudden weight loss/gain, slurred speech, or tremors.

Asking the patient about a suspected SUD can be an emotionally charged situation, but there are ways to minimize negativity.21 Physicians can include drug/alcohol use in general health or lifestyle conversations, using basic prescreening questions, such as asking about their last drink, and moving on to defining the quantity and frequency.21 Similarly, asking about drug use can start with questions about marijuana and move on to other classes of drugs, ending with drugs associated with controlling pain.21

In addition to conversations, physicians can also utilize tools for screening patients to assess risk. These include traditional measures for alcohol and general drug use, as well as ones specific to opioids. Although these are self-reported and rely on a patient’s honest responses, they should still be used rather than solely relying on a physician’s impressions of the patient or suspicions of a SUD.31 A quick and widely used one is the Opioid Risk Tool (ORT),which measures risk for opioid abuse among adults with chronic pain.32 Another commonly used tool is the Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R).33

If the risk is still uncertain, urine drug testing can be an option, however a positive or negative result does not predict risk of future aberrant opioid use or addiction.33 Interviews with family members (provided the patient has given consent), reviewing previous medical records, and data from state prescription monitoring programs can be additional methods to assess risk.21 Using a combination of some or all these tools can lead to better accuracy in identifying patients with a current or prior SUD.34

Managing SUD

If there is diagnosis of an actual SUD, clinicians should determine the patient’s recovery status and if the SUD is still current.21 If the SUD is active, the patient should be referred to a substance abuse or addiction specialist.21 This does not replace pain management or treatment, since addiction facilities are not always equipped to treat pain.21 Clinical judgement is an important part of assessing risk for developing problematic opioid use in the setting of a SUD.21 Some risk exists for all patients with a history of SUD; however, while many can be safely managed with chronic opioids, there are those who should not be treated due to the significant risk far outweighing any benefit.21 If opioid therapy is needed, clinicians can work with addiction specialists to determine if safeguards can be put in place, and find out if there is an adequate social support system for the patient.21 Ongoing assessment is another essential element for interval determination of adherence, reactions and misuse of any prescribed regimen.21 For patients with an active opioid use disorder (OUD), clinicians can now prescribe buprenorphine, a medication used to treat OUD, without requiring the patient to engage in counseling prior to the prescription.35

References

  1. Dydyk AM, Grandhe S. Pain assessment. StatPearls. Last updated January 29, 2023. https://www.ncbi.nlm.nih.gov/books/NBK556098/
  2. National Institute of Arthritis and Musculoskeletal and Skin Diseases. Back Pain: Diagnosis, Treatment, and Steps to Take. Last reviewed February 2023. https://www.niams.nih.gov/health-topics/back-pain/diagnosis-treatment-and-steps-to-take
  3. Bird M, et al. AAFP Chronic Pain Toolkit: Sec 2: Functional Pain Assessment. AAFP. https://www.aafp.org/dam/AAFP/documents/patient_care/pain_management/cpm-toolkit.pdf
  4. Williams DA. The importance of psychological assessment in chronic pain. Curr Opin Urol. 2013;23:554‑559.
  5. Herr K, et al. Pain assessment in the patient unable to self-report: Clinical practice recommendations in support of the ASPMN 2019 position statement. Pain Manag Nurs. 2019;20:404-417.
  6. McGuire DB, et al. Pain Assessment in noncommunicative adult palliative care patients. Nurs Clin North Am. 2016;51:397-431.
  7. Herr KA, Garand L. Assessment and measurement of pain in older adults. Clin Geriatr Med. 2001;17:457‑478.
  8. Wells N, et al. Improving the quality of care through pain assessment and management. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Chapter 17. April 2008. https://www.ncbi.nlm.nih.gov/books/NBK2658/
  9. Haefeli M, Elfering A. Pain assessment. Eur Spine J. 2006;15 (suppl 1):S17-S24.
  10. Fillingim RB, et al. Assessment of chronic pain: Domains, methods, and mechanisms. J Pain. 2016;17(9 suppl):T10-T20.
  11. Vertsberger D, et al. Intensity of chronic low back pain and activity interference: A daily diary study of the moderating role of cognitive pain coping strategies. Pain Med. 2023;24:442-450.
  12. National Institute of Child Health and Human Development. How can I describe my pain to my health care provider? Last reviewed January 31, 2017. https://www.nichd.nih.gov/health/topics/pelvicpain/conditioninfo/describe
  13. Chen JS, Kandle PF, Murray IV, et al. Physiology, pain. StatPearls. Last updated July 24, 2023. https://www.ncbi.nlm.nih.gov/books/NBK539789/
  14. Mayo Clinic. Peripheral neuropathy – Symptoms and causes. September 2, 2023. https://www.mayoclinic.org/diseases-conditions/peripheral-neuropathy/symptoms-causes/syc-20352061
  15. International Association for the Study of Pain (IASP). Faces Pain Scale. https://www.iasp-pain.org/resources/faces-pain-scale-revised/
  16. Kamki H, et al. Evaluation of effectiveness of graphics interchange format and Wong-Baker faces pain rating scale as pain assessment tool in children. J Contemp Dent Pract. 2022;23:634-638.
  17. Hawker GA, et al. Measures of adult pain: Visual Analog Scale for Pain (VAS Pain), Numeric Rating Scale for Pain (NRS Pain), McGill Pain Questionnaire (MPQ), Short-Form McGill Pain Questionnaire (SF-MPQ), Chronic Pain Grade Scale (CPGS), Short Form-36 Bodily Pain Scale (SF-36 BPS), and Measure of Intermittent and Constant Osteoarthritis Pain (ICOAP). Arthritis Care Res (Hoboken). 2011;63(suppl 11):S240-S252.
  18. Clauw DJ. Why don’t we use a body map in every chronic pain patient yet? Pain. 2024;1651660-1661. https://journals.lww.com/pain/fulltext/2024/08000/why_don_t_we_use_a_body_map_in_every_chronic_pain.2.aspx
  19. James S. Human pain and genetics: Some basics. Br J Pain. 2013;7:171-178.
  20. International Association for the Study of Pain (IASP). Terminology. https://www.iasp-pain.org/resources/terminology/
  21. Center for Substance Abuse Treatment. Patient Assessment. Managing Chronic Pain in Adults With or in Recovery From Substance Use Disorders. Treatment Improvement Protocol (TIP) Series, No. 54. 2012. https://www.ncbi.nlm.nih.gov/books/NBK92053/
  22. National Institutes of Health (NIH), National Institute on Drug Abuse (NIDA). Prescription Opioids DrugFacts. https://nida.nih.gov/publications/drugfacts/prescription-opioids
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  27. American psychological association (APA). Substance use, abuse, and addiction. 2024. https://www.apa.org/topics/substance-use-abuse-addiction
  28. National Institute on Drug Abuse. New NIH study reveals shared genetic markers underlying substance use disorders. March 22, 2023. https://nida.nih.gov/news-events/news-releases/2023/03/new-nih-study-reveals-shared-genetic-markers-underlying-substance-use-disorders
  29. Bevilacqua L, Goldman D. Genes and addictions. Clin Pharmacol Ther. 2009;85:359-361.
  30. Cleveland Clinic. Substance Use Disorder (SUD). Last updated October 20, 2022. https://my.clevelandclinic.org/health/diseases/16652-drug-addiction-substance-use-disorder-sud#symptoms-and-causes
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  32. National Institute on Drug Abuse. Opioid Risk tool – OUD (ORT-OUD). May 6, 2021. https://nida.nih.gov/nidamed-medical-health-professionals/screening-tools-resources/opioid-risk-tool-oud-ort-oud
  33. Black RA, et al. Development and validation of an eight-item brief form of the SOAPP-R (SOAPP-8). Pain Med. 2018;19:1982-1987.
  34. Jamison RN, et al. Assessment and treatment of abuse risk in opioid prescribing for chronic pain. Pain Res Treat. 2011;2011:941808.
  35. US Food and Drug Administration (FDA). Counseling and medications used to treat opioid use disorder. FDA. May 9, 2023. https://www.fda.gov/media/168027/download?attachment
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All URLs accessed August 15, 2024.

Defining Pain

Pain Assessment

Analgesia Modalities

Guidelines

Individualizing Pain Plans

Safe Opioid Use

Addiction Medicine

Reading and Resources

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