Understanding, Assessing, and Treating Pain

Orlando—Patients experiencing chronic pain are a burden on the healthcare system from an economic perspective and in terms of high utilization of medicine.

Each year, lost work productivity related to chronic pain costs an estimated $61.2 billion. Another study found that total annual costs of poorly controlled persistent pain are >$100 billion, according to Mark Rosenberg, MD, PhD, president of BHM Healthcare Solutions, a management consulting and advisory firm. Identifying and treating pain can be a challenge because there are psychological, physiological, and structural causes of pain but no objective indicator. At the NAMCP meeting, Dr. Rosenberg spoke about how providers and others can assess and manage the complex pain-associated issues in a session titled Undertreated Pain Epidemic: Multi-Modality Approach to Pain Management. Dr. Rosenberg used the International Association for the Study of Pain definition of pain: “An unpleasant sensory and emotional experience which we primarily associate with tissue damage, or describe in terms of such damage, or both.” However, when considering pain and its significance, Dr. Rosenberg said there are several components, such as the location, intensity, and quality of pain; whether pain is intensified by depression or anxiety; and whether there is a cognitive component in which one’s thoughts magnify the cause or significance of the pain.

Dr. Rosenberg cited a report from the National Center for Health Statistics, indicating 1 of 10 people in the United States and 60% of those ≥65 years of age experienced pain lasting >1 year. In the majority of cases, there are several concurrent factors responsible for a person’s chronic pain rather than a single source, which Dr. Rosenberg said makes it imperative that managing pain depends on a comprehensive assessment. When evaluating pain, Dr. Rosenberg said healthcare professionals should implement psychosocial and psychiatric assessments, which are particularly helpful in determining persistent pain. He described persistent pain as usually not well defined and of an unknown duration, but typically associated with irritability or depression. An effective pain assessment begins with gathering a detailed history of the pain, followed by conducting a physical examination, reviewing medical records and diagnostic studies, and developing diagnoses for the pain as well as a treatment plan. Dr. Rosenberg said it is sometimes beneficial for patients to keep a written daily diary during the treatment period, which providers can utilize to determine if the treatment is working.

According to Dr. Rosenberg, it is also important to quantify pain using an assessment tool that considers the time frame of the pain, the clinical context, and the average pain intensity. There are one-dimensional pain scales, such as the Numeric Rating Scale, in which the patient keeps track of his or her pain from 0 (no pain) to 10 (unbearable pain), as well as the visual analog scale, in which there are no numbers but the patient writes the magnitude of his or her pain on a scale ranging from “no pain” to “worst possible pain.” Multidimensional pain scales are even more effective, according to Dr. Rosenberg. The McGill Pain Questionnaire assesses pain on 3 dimensions (sensory, affective, and evaluative); the Brief Pain Inventory includes 7 intensity scales; and the Treatment Outcomes of Pain Survey is useful for tracking a large number of patients but not for determining individual patient changes. After a pain assessment is determined, physicians must treat the pain, with the method varying depending on the type. If a person has acute pain, the goal is to reduce the pain intensity as quickly as possible.

For cancer-related persistent pain, the focus is on comfort, relieving other symptoms, and managing comorbidities. Patients with noncancer-related pain must have their pain intensity reduced, symptoms relieved, comorbidities managed, and functional capabilities restored. There are numerous treatment options, too. Pharmacologic strategies include prescribing nonopioid drugs such as aspirin or other salicylates, nonsteroidal anti-inflammatory drugs, or cyclooxygenase-2 inhibitors; opioid analgesics such as morphine, hydromorphone, fentanyl, oxycodone, oxymorphone, and meperidine; or adjuvant analgesics depending on the pain indication. Some patients may benefit from physical or occupational therapy, psychotherapy, injection or implant therapies, surgery, or complementary and alternative medicine. According to Dr. Rosenberg, physicians should consider using multiple approaches when treating patients with persistent pain, recurrent pain, a high level of disability, or a history of poor response to analgesics.