Assessment of long term pain

The experience of pain is complex and influenced by the degree of tissue injury (even when no longer present or identifiable), mood, previous experiences of pain and understanding of the cause and significance of pain. Previous thoughts, emotions and experiences can also contribute to the current perception of pain, and, if unresolved, can act as a barrier to treatment.

A pain assessment, like all medical evaluations, serves two main purposes:

[1]  To understand the nature of the pain problem and its confounding factors.

[2] To provide a baseline against which the effect of treatments can be measured.

This second aspect is often more difficult than for many medical problems where outcomes are often simpler to recognise.

For pain problems, improvement in ‘pain’ may, paradoxically, not be the main endpoint, but improving how the pain is understood and managed may be the essential outcomes.

Primary Assessment

Assessment should include patient education, understanding and expectations about chronic pain. Unrealistic expectations need to be recognised and addressed sympathetically and informatively.

Coloured Flags

The most common concepts are of RED and YELLOW flags. The former indicating possible pathology needing investigation, and the latter psychosocial aspects of beliefs around pain, coping and function. Various other colours have been suggested but are not widely used.

Core Details of a Pain Assessment

• Where is the pain?
• Description of pain
• Does it radiate elsewhere?
• How does it vary in intensity?
  • What makes it worse?
  • What is the effect on sleep?
  • What makes it better?
• Current medications and response.
• Response to previous medications and any other interventions.
• General Medical History including operations and illnesses – consider co-morbidities that may impact on drug considerations e.g., renal, hepatic, sleep apnoea.
• What is the effect on mood?
  • Try to differentiate between pre-existing and pain-related issues – difficult and not always possible or clear.
• What is the effect on physical function?
  • Employment / Daily / Social

• Mental health including emotional trauma, previous and current mood, contact with mental health circumstances. Mental health comorbidities and a history of significant emotional trauma are not a contraindication to opioid therapy but:
  • are a risk factor for opioid therapy becoming prolonged and for high doses to be used.
  • patients may use opioids to blunt unpleasant thoughts and experiences: this may make opioids difficult to stop.
  • are a risk factor for addiction to prescribed opioids.
  • will be contributory to the current pain experience so need to be identified and managed separately.
• Be aware that Mental Health issues may become apparent that need management beyond or in parallel with the pain problem. Consideration should be made of suitable contacts for urgent or routine advice.
  • Be wary of assuming either that pain is a symptom of - or a direct cause of - mental health issues.
• Current or previous history of substance misuse to drugs or alcohol. Patients with a current or past history will need careful management and support in collaboration with specialists with expertise in addiction (for more information click here).
• Patient circumstances and context (employment, family responsibilities, sources of support). Patients with a family/household member with problems will need additional support and counselling about risks of diversion of controlled drugs.
• Relevant physical examination including observation of patient mobility, distress.
• Imaging and other diagnostics (x-rays, scans, blood tests and electrophysiology).
• Patient’s understanding of pain and expectations of outcome.
  • This often needs addressing to create a viable contract of expectations between the clinician and the patient.
  • Unrealistic expectations need to be recognised and addressed sympathetically and informatively.

Pain Assessment Tools

Pain cannot be measured with any objective tool. No blood test, Xray, or other test will give a figure against which treatment can be measured.

Pain is a personal experience and is expressed as such. Pain Assessment Tools can however give an indication of the experience and can be helpful in assessing various aspects of suffering. Improvements are a useful indicator of treatment efficacy. Tools are based around various aspects of the pain experience:

• Pain Intensity
• Pain Interference
• Physical Functioning
• Emotional Functioning
• Quality of Life
• Patient reported global rating

Simple tools used for acute pain are not useful without context. The FPM guide on Outcome Measures ² provides detailed guidance on the use of various tools.

Review Appointments

With the issues outlined above, the multifocal nature of the review of treatment needs to be considered. A clear history, with a focus on the aims of treatment will make ongoing reviews easier to understand in terms of the chronicity of disease, what has – or has not – been achieved and how future therapeutics fit into the possible options, avoiding, both, blind optimism and pessimism.

References:

1. Dansie EJ, Turk DC. Assessment of patients with chronic pain. Br J Anaesth. 2013 Jul;111(1):19-25. doi: 10.1093/bja/aet124. PMID: 23794641; PMCID: PMC3841375.

2. Faculty of Pain Medicine. Outcome Measures.