Summary 2021_Michigan_Medical_Licensure_Program.pdf ( PROFFESIONAL) (1)

Differentiating between nociceptive and neuropathic pain is critical because the two respond differently to pain treatments. Neuropathic pain, for example, may respond poorly to both opioid analgesics and non-steroidal anti-inflammatory (NSAID) agents.18 Other classes of medications, such as anti-epileptics, antidepressants, or local anesthetics, may provide more effective relief for neuropathic pain.19 Another important dimension of pain is its effects beyond strictly physiological functioning. Pain is currently viewed as a multi-dimensional, multi-level process similar in many ways to other disease processes which may start with a specific injury but which can lead to a cascade of events that can include physical deconditioning, psychological and emotional burdens, and dysfunctional behavior patterns that affect not just the sufferer,but their entire social milieu (illustrated in Figure 3).1 The pain community is currently discussing an expansion of the current definition of pain to include a biopsychosocial perspective: “pain is a distressing experience associated with actual or potential tissue damage with sensory, emotional, cognitive, and social components.”20 Acute pain is defined as having an abrupt onset and is typically due to an obvious distress (e.g., depression or anxiety), heightened illness concern, or ineffective coping strategies regarding the ability to control pain and function despite it.23 It may also be shaped by personality, culture, attitudes, and beliefs. For example, injured soldiers who had positive expectations of pain (e.g., evacuation and safe recuperation) requested less analgesic medication than civilians with comparable injuries who had more negative associations with pain (e.g., loss of wages and social hardship).15 Assessing pain Goals and Elements of the Initial Assessment Important goals of the initial assessment of pain include establishing rapport with the patient and providing an overview of the assessment process.24 These processes help to engage the patient, foster appropriate treatment expectations, and promotea coordinated approach to management. The clinician’s primary objective is to obtain information that will help identify the cause of the pain and guide management. A patient history, physical examination, and appropriate diagnostic studies are typically conducted for this purpose. Patient history The patient’s self-report is the most reliable indicator of pain.25 Physiological and behavioral management, fewer treatment side effects, improved function and quality of life, and better use of health care resources. The manner in which information is elicited from the patient is important. Ideally, the clinician should afford ample time, let patients tell their stories in their own words, and ask open-ended questions. Information to be elicited during the initial assessment of pain includes: • Characteristics of the pain (e.g., duration, location, intensity, quality, exacerbating/ alleviating factors) • Present and past pain management strategies and their outcomes • Past and present medical problems that may influence the pain and/or its management • Relevant family history • Current and past psychosocial issues or factors that may influence the pain and its management • Pregnancy/contraceptive status • Functional status • The impact of the pain on the patient’s daily life and functioning • The patient’s and family’s knowledge of, expectations about, and goals for pain management. Assessing the impact of pain on functional status and sleep and screening for mental health conditions potentially related to pain or treatment adherence (e.g., depression, anxiety, and memory issues) may provide useful information for pain management.26 Depression in older patients, for example, sometimes presents with somatic complaints of pain. Pain complaints may resolve when the underlying depression is treated. Patients can also be screened for known risk factors for OUD (see below). Assessment tools Many tools have been developed to document and assess pain. Initial approaches to assessing pain severity use a visual analog scale (VAS) rating pain from 0 (no pain) to 10 (worst pain you can imagine) (some scales use a 0 to 100 scale). Such scales are often used in clinical trials of pain therapies, and the minimal clinically important difference using these scales is generally considered a 20%-30% change from baseline (i.e., 2-3 points on a 0-10 scale or 20-30 points on a 0-100 scale).27 Multidimensional tools, such as those described below, include questions relating to quality of life and participation in daily activities. Such tools can provide a more comprehensive approach to assessing pain and response to treatment. The selection of a pain assessment tool must balance the comprehensiveness of the assessment obtained with the time and energy required to use the tool in a real- world practice setting. Brief pain inventory The Brief Pain Inventory (BPI) is used frequently in clinical trials to assess pain. Specifically developed for patients with chronic pain, the BPI more fully captures the impact of pain on patient function and quality of life than simple VAS scales.28 By includinga pain map, the BPI allows tracking of the location of pain through the course of management. The BPI is self-administered but somewhat time-consuming, which may limit its role in a busy clinical practice. PEG scale The PEG scale (Pain average, interference with Enjoyment of life, and interference with General activity) is a three-item tool based on the BPI and is practical for clinical practice (Figure 4). Zero-to-10 scales are used to assess pain, enjoyment of life, and general activity. PEG can be self-administered or done by the clinician and is relatively brief. 29 Assessing acute pain Acute pain intensity can be assessed with unidimensional tools such as the VAS and the Wong-Baker FACES Pain Rating Scale (faces depicting increasing levels of pain). While usefulfor a quick assessment, these scales alone maynot appropriately identify patients with pain-related suffering driven by functional limitations, worry, or other factors, and may not detect some patients with clinically significant pain.30 Although developed for patients with chronic pain, the BPI is also applicable to patients with acute pain. Completed by the patient, the BPI captures ways that pain impacts function and quality of life, although, like most multidimensional questionnaires, it requires more time (about 10 minutes) and concentration to complete, which may limit its utility in some elderly patients.28 Assessing pain in the cognitively impaired Although patients with mild-to-moderate dementia can report their pain and its location, those with severe dementia are often unable to communicate their pain experience or request medication. In these patients, physicians need to observe pain behaviors, including facial expressions, verbal cues, body movements, changes in interpersonal interactions, activity patterns, and mental status. Caregiver observations and reports are critical to appropriate assessment and management of chronic pain conditions.31 BEFORE MOVING ONTO THE NEXT SECTION, PLEASE COMPLETE CASE STUDY 1 ON THE NEXT PAGE. Screening for risk of chronic pain after acute pain A number of factors have been associated with an increased risk for chronic pain following acute pain or surgery including older age, psychological problems, higher levels of pre-procedural pain or pain sensitivity, type and duration of surgery, severity and number of comorbidities, and use of post-procedural radiation or chemotherapy.32 Some tools have been developed to help clinicians predict the likelihood that a patient will experience chronic pain following acute injury or procedures. The 5-item PICKUP model, for example, showed moderate prognostic performance in a derivation study using data from 2,758 patients with acute low back pain.33 Sipila and colleagues developed a 6-item screening instrument for risk factors of persistent pain after breast cancer surgery based on a cohort of 489 women.34 Screening for opioid abuse risk factors Screening and monitoring in pain management seeks to identify patients at risk of substance misuse and overdose as well as improve overall patient care. Evaluations of patient physical and psychological history can screen for risk factors and help characterize pain to inform treatment decisions. Screening approaches include efforts to assess for concurrent substance use and mental health disorders that may place patients at higher risk for OUD and overdose. This includes screening for drug and alcohol use and the use of urine drug testing, when clinically indicated