Evaluating the Patient with Chronic Pain

Strategies for Evaluating the Patient with Chronic Pain – Academy of Integrative Pain Management Blog – Written by W. Clay Jackson, MD, DipTh, Vice President of the Board

It seems the Academy of Integrative Pain Management (AIPM, previously AAPM) is not on our side.

Most articles they post are like the one I’ve annotated and commented on here; they express suspicion about patients’ pain, consider all possible reasons for pain except the biological, and tout all possible treatments except opioid therapy.

A comprehensive evaluation of the patient with chronic pain is rarely straightforward, and it begins with the recognition that a complete cure is unlikely.  

The patient’s pain experience may be complicated by numerous factors, including

  • lack of an obvious pathological cause,
  • concomitant anxiety and depression, and
  • a downward spiral of inactivity and lowered self-esteem.

The author never considers that this spiral of negative factors could be the result of pain, rather than a “complicating” cause (medical-speak for “patient’s bad behavior”.).

Any scientific writing about pain these days follows the same “politically correct” script:

Almost every behavior, feeling, and thought of a patient with chronic pain is almost always assumed to be involved in causing the pain.

Never mentioned is that constant pain itself is just as likely the cause of such behaviors, feelings, and thoughts.

Often, medications used to treat the pain may themselves cause side effects that contribute to the patient’s reduced function.

The skillful clinician will work with the patient, incorporating time-efficient tools to determine a treatment plan that combines a variety of modalities and may or may not include the use of opioids.

It sounds like it’s critical that only time-efficient tools should be used, a strange criterion for patient evaluations.

With chronic pain patients, the evaluation is key: Failure to identify all the factors that contribute to the pain can lead to ineffective treatment, further deterioration, and mutual frustration, not to mention legal and regulatory consequences

The above sentence implies that “Failure to identify all the factors that contribute to the pain can lead to” “legal and regulatory consequences”.  This makes no sense in plain English, so it must be medical-speak for “Failure to find a reason not to prescribe opioids”.

A seasoned clinician listens carefully to validate the patient’s pain without allowing elaborate descriptions to derail the timing and purpose of the visit.

This sounds like the effort to “validate the patient’s pain” is the only reason to listen carefully.

The author’s need to prohibit “elaborate descriptions to derail the timing and purpose of the visit” is a judgement about how a patient is explaining their pain.

At what point does a description of any medical symptom become “elaborate” and not just “thorough”?  I have never seen such cautions urged for descriptions of any other medical symptom.

This is another sign of how our culture minimizes or denies pain.

For most patients with persistent pain, the goal of treatment is not the complete relief of pain, but rather improvements in the patient’s physical and mental functioning that result in an improved quality of life as he or she takes increasing responsibility in his or her own therapy.

In the midst of such a biased article, I’m surprised to find something I can absolutely agree with: the goal is to be able to function better. I know most pain cannot be completely eradicated, but I also know my functionality increases with decreasing pain.

I don’t believe much improvement in function is possible without significantly less pain, since pain is what is restraining functionality.

The Assessment Process

The clinician should evaluate and document the patient’s pain history including

  • the nature, location, intensity, and duration of the pain;
  • current and prior pharmacological and nonpharmacological treatments;
  • factors that worsen or improve the pain;
  • underlying or coexisting conditions; and (importantly)
  • the effect of the pain on the patient’s life.

An assessment of function should includethe impact of the pain on the patient’s family and social life, employment, and sleep, and provide a baseline for follow-up evaluations. The clinician should also be alert to signs that the patient is minimizing or maximizing the subjective reports of the pain or, in cases of cognitive impairment, lacks the proper resources to describe it

As the noted clinician Sir William Osler stated, it is more important to consider what kind of patient has the disease, rather than what kind of disease the patient has

Really? This immediately asks a doctor to make a judgement about the patient’s character, whether they are believable or not, and can quickly prejudice the rest of the assessment.

A true assessment can only come from non-judgemental listening, as free as possible of personal prejudice and beliefs.

Thus, I include questions about depression, anxiety, posttraumatic stress disorder, and other factors that might impact pain, including stress levels at home or at work.

In this article as in most others, there is more emphasis on psychological causes than physical.

I consider the patient’s capacity for chemical coping, or the likelihood of using pain medication to cope with life’s stresses.

Of course, I use pain medication to cope with life’s stress! That’s exactly what constant pain is: a chronic stress in life.

And, of course, any evaluation that may lead to a trial of opioids should include an assessment of the patient’s risk for opioid misuse, but it also should include a qualitative assessment of the patient’s goals.

  • What are the patient’s functional goals?
  • How does the patient define functionality?
  • What are simple, concrete things the patient wants to do in the next 30 days?
  • How can treatment help the patient reach her goals?

I ask which medications has the patient tried:

  1. nonsteroidal anti-inflammatory drugs (NSAIDs),
  2. serotonin norepinephrine reuptake inhibitors (SNRIs),
  3. nerve cell membrane stabilizers (anticonvulsants), and/or
  4. opioids.

I like to think of these as the four pharmacologic pillars of pain relief, which often yield salutary results when used in combination. Is the patient equally balanced on all four pillars, or is he leaning on just one?

No medical article ever explains that opioids are the LEAST damaging of all these classes of drugs used for pain.

Constipation is the only certain side-effect and a few may become addicted (1%-5%), but opioids are vastly more effective than the others.

When dealing with a pain patient who may be considered difficult because he has lost the ability to cope with life [?], it is tempting to try to rush the evaluation.

I don’t understand the meaning of “lost the ability to cope with life”. In this context, I assume it’s medical-speak for something like “no longer polite and compliant due to uncontrolled pain”.

But most such patients have complex issues and histories that require a commitment on the clinician’s part to take the time to unravel them.

This sounds like he’s saying that most patients’ pain is due to their “complex issues and histories”, and I doubt he’s referring to medical or biological issues and histories.

The clinician should perform a focused physical examination based on the patient’s history and carry out appropriate diagnostic testing.

Of course. This is the standard medical process.

Quantitative measurements of the patient’s capacity for successful opioid treatment can be obtained from urine drug screens, electronic databases, and standard tools for risk stratification, such as the Opioid Risk Tool (6) and the revised version of the Screener and Opioid Assessment for Patients with Pain (SOAPP-R)

The strange wording about “patient’s capacity for successful opioid treatment” is probably medical-speak for “patient’s liklihood of getting addicted”.

The author casually assumes patients are or will be guilty of drug abuse – and thus be ineligible for opioid pain treatment – unless they can quantitatively prove their innocence.

Only hard numerical data will be accepted as proof, no other information is considered.

Treatment Considerations

The patient-clinician relationship is best viewed as a collaborative partnership; whereas patient demand should not determine the choice of a therapy, it should inform the choice.

I completely agree with the first part of the sentence, but then it goes on to qualify the statement with a lecture about patient demands, as though such demands were a common occurrence in patient-clinician relationships.

My reading has found the contrary: pain patients feel like they are at a doctor’s mercy. The only demands they make are that their pain be treated – and treated effectively.

Perhaps patients are seen as demanding if they insist on a therapy that has been effective in the past, rather than going along with the doctor’s preferred, but ineffective, treatment.

Most complex pain patients will be taking multiple medications, so I try to maximize their effectiveness during treatment. For example, switching a patient who is already taking a selective serotonin reuptake inhibitor (SSRI) to an SNRI will often provide additional analgesia.

I try to prescribe treatments that will ‘multitask’ – give multiple therapeutic effects from one molecule. Another example: if lack of sleep is an issue, I usually give gabapentinoids at night. Of course, opioids may also be required, if the risk/benefit ratio is appropriate, and non-opioid therapies alone have failed.

I trust my clinical judgment–especially when I am confident that my evaluation has been comprehensive and has involved collaborating with the patient.

I am comfortable treating my patients with chronic pain, even when they become angry and disagree with the treatment decision. Because I have laid the proper groundwork, I view this not as a treatment failure, but as an opportunity to strengthen the therapeutic relationship.  

About this, I’m skeptical.

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One thought on “Evaluating the Patient with Chronic Pain

  1. Peggy Marshall Prigge

    I love this! I have eds vulnerability syndrome and after years of suffering, I finally found a doctor who prescribed narcotic pain medicine which have helped tremendously! I wish I could do without them as they contribute to drowsiness, but enable me to live much less painfully. I fear, however, that the opiate police will win and many of us will be screwed.

    Liked by 1 person

    Reply

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