Elements of Assessment

Researchers and clinicians agree that, because chronic noncancer pain (CNCP) is a multifaceted condition, assessment must include more than measures of pain intensity (Brunton, 2004; Haefeli & Elfering, 2006; Karoly, Ruehlman, Aiken, Todd, & Newton, 2006; Sullivan & Ferrell, 2005). Some elements are essential to assess; others, ideal. In many cases, even after a thorough assessment, the clinician may not detect the nociceptive source of a patient’s chronic pain.

Collateral information is an important part of the assessment. Clinicians need to communicate with families, pharmacists, and other clinicians after the patient has given full consent for these discussions. If the patient declines to give consent, prolonged treatment with controlled substances may be contraindicated. Furthermore, a clinician who prescribes controlled substances to a patient who refuses to permit access to outside information could be considered to be ignoring evidence of addiction or substance misuse and, therefore, to be trafficking. Collateral information also helps protect the patient from misusing medications. Exhibit 2-1 presents elements of a comprehensive assessment.

Exhibit 2-1

Elements of a Comprehensive Patient Assessment.

Assessment Tools

Standardized instruments provide ways to assess and track patient pain levels, function, substance use, and other factors important to managing CNCP. Standardized tools provide supplemental information for treatment planning and assessment of risk and outcomes. If used well, tools can reduce clinician bias during patient assessment.

The sensitivity and specificity of screening instruments vary, and all can yield false-positive or false-negative results. In addition, no single instrument has been shown to be appropriate for use with all patient populations (Bird, 2003; Brunton, 2004). Because of their limitations, standardized tools should not be the absolute determinants of treatments offered or withheld.

When using standardized tools, clinicians should (Bird, 2003):

• Understand the strengths and weaknesses of each tool.
• Select a tool appropriate for the patient, considering memory problems, cognitive impairments, eyesight, literacy level, cultural background, gender, ethnicity, and other factors.
• Teach patients how to use self-administered tools, even “self-explanatory” tools; otherwise, the information they provide may be invalid.

Instruments are available to assist with assessment of pain and functioning, SUDs, psychiatric comorbidities, coping skills, and potential problems with opioid use.

Assessing Pain and Function

The assessment of CNCP should include documentation of the following:

• Pain onset, quality, and severity; mitigating and exacerbating factors; and the results of investigations into etiology
• Pain-related functional impairment
• Emotional changes (e.g., anxiety, depression, anger) and sleep disturbances
• Cognitive changes (e.g., attentional capacity, memory)
• Family response to pain (i.e., supportive, enabling, rejecting)
• Environmental consequences (e.g., disability income, loss of desired activities, absence from desirable or feared work)
• Physical examination
• Partial mental status examination (e.g., affect [how pain is experienced], somatic preoccupation, cognition, moans, gasps, lying down during the interview)

Several factors may complicate an assessment of pain levels in any pain patient:

• Some patients may report not only their level of pain intensity, but their suffering, which may be greater than their pain intensity.
• Clinicians tend to believe that a patient’s pain level is actually lower than the patient reports, except when the patient reports low pain (Sloman, Rosen, Rom, & Shir, 2005; Stalnikowicz, Mahamid, Kaspi, & Brezis, 2005).
• Clinicians are especially likely to underestimate—and, therefore, to undertreat—pain and disability in women, the elderly, minorities, people of low economic status, and people with SUDs (Green, Baker, Smith, & Sato, 2003; Rupp & Delaney, 2004).

An assessment of pain and function in patients with SUD histories may be further complicated by the following factors:

• Some patients with histories of SUDs may overreport their pain experience if they are afraid that they will be under-medicated or that their symptoms will not be taken seriously.
• Others may underreport their pain experience if they are afraid they will be prescribed medications that will cause them to relapse.
• Some patients may exaggerate pain and disability levels to get opioids for reasons other than pain control.

The level of functional impairment in patients with CNCP is markedly modified by environmental contingencies (e.g., the incentives and disincentives for healthful versus so-called “sick role” behaviors). For instance, evidence shows that pain-related behaviors increase in the presence of a solicitous spouse, meaning one who is attentive to and reinforcing of such behaviors (Pence, Thorn, Jensen, & Romano, 2008). It is also demonstrated that work-related functional impairment varies with the strengths of reinforcement contingencies for function versus absenteeism. The workers’ compensation system may provide a special example of this. Studies typically find that patients receiving income from this source respond less well to rehabilitation efforts than do those not receiving disability income from this or other sources. The explanation is thought to reside in such factors as the need to “prove” one is ill to obtain tests and specialty consultation and the fear of loss of income if one is witnessed engaging in normal activities. The relative magnitude of rewards and punishments for function may thus play a determining role in disability. A thorough assessment of a patient with CNCP, therefore, requires a review of the overall consequences of resuming healthy function.

When assessing pain and function in patients with histories of SUDs, clinicians should keep in mind the following:

• Individuals with similar complaints (e.g., low back pain) usually describe and rate their pain differently.
• Functional impairments affect patients differently.
• Pain scores do not reflect tissue pathology, disability, or treatment response.
• Pain reduction is insufficient to judge treatment success, which also requires optimization of function and normalization of mood.

Exhibits 2-2 and 2-3 list the strengths and weaknesses of common one-dimensional and multidimensional pain tools, respectively. Exhibit 2-4 presents tools for assessing the extent to which pain interferes with usual functions and activities. Information on how to obtain the tools is located in Appendix B. Studies show that patients who have chronic pain may develop cognitive impairments (e.g., changes in attentional capacity, memory, processing speed) that appear to be independent of other variables (e.g., age, educational level, pain intensity, pain relief ) (Dick & Rashtiq, 2007; Hart, Martelli, & Zasler, 2000; Hart, Wade, & Martelli, 2003). Therefore, clinicians need to be alert to the possibility of these changes and include an evaluation of mental status as part of the patient’s ongoing assessment (e.g., the Mini-Mental State Examination, [Folstein & Folstein, 2010]) or refer the patient to a neurologist as necessary.

Exhibit 2-2

Tools To Assess Pain Level.

Exhibit 2-3

Tools To Assess Several Dimensions of Pain.

Exhibit 2-4

Tools To Assess Pain Interference With Life Activities and Functional Capacities.

Assessing Substance Use and Addiction

As with assessing pain and function, assessing patient self-reports of substance use, whether via interviews or structured self-report questionnaires, should be corroborated by other sources of information (e.g., medical records, interviews with family, urine toxicology, information from State prescription monitoring programs) (Katz & Fanciullo, 2002).

When initiating a conversation about alcohol and drug use, clinicians should:

• Approach the topic matter-of-factly, handling it as part of the overall medical history.
• Incorporate questions about drug and alcohol use into a general behavioral health inventory including discussion of other lifestyle behaviors (e.g., diet, exercise).
• Ask about nicotine and caffeine use; questions about use of these substances provide opportunities to move to assessment of other substances, beginning with alcohol, the most commonly abused substance.
• Assure patients that honest answers to questions of substance use are necessary to developing a treatment plan and that their responses will remain confidential.

A good prescreening question is, “When did you last have a drink of beer, wine, or liquor?” If the patient reports drinking within the past year, the clinician should ask questions to determine:

• Frequency (“How many days per week do you typically drink alcohol?”)
• Quantity (“How much alcohol do you drink on a typical drinking occasion?”)
• Evidence of binge drinking (for men: “On any day in the past year, have you ever had five or more drinks?”; for women: “On any day in the past year, have you ever had four or more drinks?”)

The clinician should ask the patient to define what the patient means by “a drink” (e.g., an 8-ounce glass, half a glass). The National Institute on Alcohol Abuse and Alcoholism (NIAAA) defines one drink as one 12-ounce bottle of beer or wine cooler, one 5-ounce glass of wine, or 1.5 ounces of 80-proof distilled spirits. According to NIAAA (2005), if the male patient drinks more than 4 standard drinks in a day (or more than 14 drinks per week), or more than 3 drinks in a day (or more than 7 drinks per week) for the female patient, the person is at increased risk for developing alcohol-related problems.

Whether or not the patient reports drinking, the clinician should probe for the use of licit and illicit drugs, starting with the most commonly used illicit drug in the United States: marijuana. Questions can continue to address other major classes of drugs with abuse potential (e.g., depressants, stimulants, opioids), with particular attention to use related to controlling pain or the patient’s anxiety and fear of pain (Passik & Kirsch, 2004). Exhibit 2-5 summarizes the substances that patients should be asked about using.

Exhibit 2-5

Items To Include in Substance Use Assessment.

NIDA provides a Web-based tool that helps clinicians screen for tobacco, alcohol, and illicit and nonmedical prescription drug use, and suggests levels of intervention. The tool is at http://ww1.drugabuse.gov/nmassist.

Screening for Substance Use Disorders

Although the amount of substance used is significant, it is more important to evaluate the consequences of the drug and alcohol use on life domains, such as family, work or school, and involvement with the criminal justice system (e.g., arrests for driving under the influence). When drug or alcohol use interferes with normal function, addiction is likely. Furthermore, addiction is characterized by impaired ability to control use of the substance. Asking whether the patient has ever attempted to decrease the amount consumed is an approach to determining his or her ability to modulate use. In the case of prescription medication, a patient’s loss of control may manifest as the inability to ration pills until the next prescription, so the patient’s partner may oversee the dispensing of the medications.

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR; American Psychiatric Association [APA], 2000) provides criteria for determining substance dependence that enable the clinician to distinguish between patients with at-risk substance use and those whose use is consistent with an SUD (Exhibit 2-6). It is important to remember that, essentially, all patients taking prescribed opioids or sedatives on a long-term basis will have a degree of tolerance and withdrawal and that these criteria are not indicative of addiction absent the “maladaptive pattern of substance use.”

Exhibit 2-6

DSM-IV-TR Criteria for Substance Abuse and Substance Dependence.

Although a patient’s former drug of choice is the one that is most likely to lead to cravings and relapse (Daley, Marlatt, & Spotts, 2003; Gardner, 2000), clinical experience suggests that a person with a history of an SUD involving any drug is susceptible to developing a cross-addiction with opioids (Covington, 2008; Savage, 2002).

Clinicians should try to determine patients’ recovery status, which is crucial in developing a treatment plan (Exhibit 2-7). Many patients will be forthcoming about past or recent substance abuse during a comprehensive assessment. Some patients who have an SUD lack a full appreciation of the effects of substances, prescribed or otherwise, on their function; however, family members can usually provide this information.

Exhibit 2-7

Steps Following Substance Abuse Assessment.

Several standardized tools for SUD screening are listed in Exhibit 2-8. Information on how to obtain the tools is in Appendix B. Most tools are short, can be self-administered, and can be integrated into the health-screening forms the patient completes prior to seeing the clinician. Although no tool is a substitute for a good clinical interview, screening is essential to case finding and a useful complement to the patient interview, the physical exam, and ongoing observation (Fishman, 2007).

Exhibit 2-8

Tools To Screen for Substance Use Disorders.

The Substance Abuse and Mental Health Services Administration’s Screening, Brief Intervention, and Referral to Treatment (SBIRT) initiative may be helpful in the primary care context (Exhibit 2-9). More information can be obtained from the Center for Substance Abuse Treatment (CSAT, 1999a). Research findings on SBIRT are available from National Association of State Alcohol and Drug Abuse Directors (2006).

Exhibit 2-9

Elements of Screening, Brief Intervention, and Referral to Treatment.

Referring for Further Assessment

If the clinical interview, collateral interview, medical records, and screening suggest an unacknowledged SUD in a patient seeking treatment for CNCP, the clinician should refer the patient to an SUD specialist, if possible. Ideally, clinicians should develop a strong referral network of substance abuse treatment clinicians who can collaborate in the care of these high-risk patients, but specialists may not always be available or accessible. Referral for an SUD does not obviate the need for pain treatment because addiction treatment facilities rarely have the resources or expertise to treat pain.

Patients may react negatively to a referral to an SUD specialist. To avoid surprising the patient and putting the specialist in an awkward situation, the clinician should clearly explain the purpose of the referral. When referring the patient, clinicians should:

• Present the referral to the SUD specialist as they would a referral to any specialist, using a matter-of-fact and unapologetic tone.
• Explain to the patient the importance of assessing factors that may be contributing to chronic pain, including substance use, and the problems SUDs or substance use may present for optimal treatment of chronic pain.
• Avoid getting distracted by the patient’s explanation of his or her substance use.
• Assure the patient that the referral does not mean transfer of care. The patient needs to know that care will be coordinated among all professionals involved, if indicated, and that discussions of short- and long-term treatment will involve everyone, including the patient.
• Help the patient make the appointment or make the appointment for the patient.

The clinician–patient relationship is especially critical for patients who have comorbid pain and an SUD. They may anticipate that clinicians will criticize their substance use and discount their pain, and they may misinterpret a concern about an SUD as a lack of concern for their pain. They may blame themselves for having developed an SUD and expect the clinician to do the same. Therefore, the clinician must maintain an attitude of respect and concern. The clinician should assure the patient that both pain and the SUD are uninvited chronic illnesses and that both need to be treated concurrently.

Federal regulations hold clinicians to a high standard of confidentiality regarding patient drug and alcohol treatment information (Exhibit 2-10). Appendix C provides elements of a written consent and a sample consent form from 42 Code of Federal Regulations (CFR).

Exhibit 2-10

Federal Protection of Patient Health Information.

Psychiatric Comorbidities

Both CNCP and SUDs are associated with high rates of psychiatric comorbidities, such as anxiety, depression, PTSD, and somatoform disorders (Chelminski et al., 2005; Dersh, Polatin, & Gatchel, 2002; Lebovits, 2000; Manchikanti et al., 2007; Saffier, Colombo, Brown, Mundt, & Fleming, 2007). Psychiatric comorbidity can be preexisting, or it can develop or worsen with chronic pain or SUDs. Therefore, the presence of comorbid psychiatric conditions should be assessed regularly in every patient with CNCP (see CSAT [2005b], for information on treating SUDs in people with co-occurring disorders).

Adults with chronic pain often exhibit fear about the loss of control over routine aspects of daily life; apprehension that clinicians will view their pain reports as exaggerated, imaginary, or contrived; and catastrophic thinking (hopelessness based on a conviction that things are worse than they really are). However, the distress that frequently accompanies CNCP may or may not signal a psychiatric disorder, so the clinician should try to make the distinction. Nevertheless, the decision to treat is based on the patient’s level of suffering and not on whether the symptoms reach the threshold for a DSM-IV-TR diagnosis. It is often difficult to differentiate a substance-induced condition from a primary psychiatric disorder, and evaluation of symptoms over time may be necessary. Where indicated, refer patients to a mental health provider. Exhibit 2-11 identifies instruments to assess distress, anxiety, fear, and depression. Information on obtaining these instruments is in Appendix B.

Exhibit 2-11

Tools To Assess Emotional Distress, Anxiety, Pain-Related Fear, and Depression.

Assessing Ability To Cope With Chronic Pain

Coping and anxiety are closely related, from a clinical viewpoint. The patient who has CNCP may have anxiety because of maladaptive coping skills, for example. The concept of acceptance has been studied in CNCP. This concept refers to the patient’s belief that there is more to life than pain, that being completely free of pain is unrealistic, and that activities should be pursued, even at the price of some increase in pain (Risdon, Eccleston, Crombez, & McCracken, 2003). Patients who have high levels of acceptance report lower pain intensity, less pain-related anxiety and avoidance, less depression, less physical and psychosocial disability, more daily uptime, and better work status than do patients who have not accepted pain.

Patients who have chronic pain who score high on measures of self-efficacy or have an internal locus of control report lower levels of pain, higher pain thresholds, increased exercise performance, and more positive coping efforts (Asghari, Julaeiha, & Godarsi, 2008; Barry, Guo, Kerns, Duong, & Reid, 2003). Exhibit 2-12 lists tools to assess coping skills. Information on obtaining these instruments is provided in Appendix B.

Exhibit 2-12

Tools To Assess Coping.

Evaluating Risk of Developing Problematic Opioid Use

When any patient with a behavioral health disorder is considered for opioid therapy for CNCP, the clinician must carefully weigh the risks and benefits of opioid use. Risk assessment is made over time and may change over the course of treatment (Gourlay & Heit, 2009). A patient’s risk level is a matter of clinical judgment. Exhibit 2-13 presents one risk assessment schema. All patients who have SUD histories have some risk, which in many cases can be safely managed. However, in some patients, the risks of opioid use are so great and the likely benefit so small that they should not be treated with chronic opioid therapies.

Exhibit 2-13

Risk of Patient’s Developing Problematic Opioid Use.

Screening tools may be one element of a risk assessment. Two commonly used screening tools are the Screener and Opioid Assessment for Patients with Pain–Revised (SOAPP–R) and the Opioid Risk Tool (ORT). Both can be helpful for identifying patients at risk, but neither has been fully validated. Chapter 4 describes tools for assessing patients who have already begun opioid therapy.

Screener and Opioid Assessment for Patients with Pain–Revised

SOAPP–R can predict which patients who have CNCP are at high risk for problems with chronic opioid therapy (Exhibit 2-14) (Butler, Fernandez, Benoit, Budman, & Jamison, 2008). It is a self-administered questionnaire answered on a 5-point scale ranging from 0 (never) to 4 (very often). The numeric ratings are added; a score of 18 or higher suggests the patient is at high risk for problems with chronic opioid therapy.

Exhibit 2-14

SOAPP–R Questions. How often do you have mood swings? How often have you felt a need for higher doses of medication to treat your pain?

Opioid Risk Tool

Opioid Risk Tool (ORT; Webster & Webster, 2005) identifies patients at risk for aberrant drug-related behaviors (ADRBs) if prescribed opioids for CNCP (Exhibit 2-15). Like SOAPP-R, ORT may help clinicians decide which patients may require close monitoring if opioids are prescribed for them. Most patients who have CNCP and histories of behavioral health disorders are likely to have elevated scores, indicating a high level of risk on opioid therapy.

Exhibit 2-15

ORT.

Ongoing Assessment

Clinicians must assess all patients who have CNCP at regular intervals because a variety of factors can emerge that can alter treatment needs. For example, a patient may develop tolerance to a particular opioid, the underlying disease condition may change another physical or mental health problem, which might develop or worsen, or there may be changes in the patient’s cognitive functioning.

Comparative data can be obtained by using the same assessment tools over time. For patients who have SUD histories or other behavioral health disorders, regular assessments should include checking for evidence of medication misuse. Chapter 4 provides a discussion on assessing and documenting the behavior of patients on opioid therapy.

The clinician should regularly:

• Assess adherence to all the recommended treatment modalities.
• Assess patient reactions to the treatment regimen.
• Determine the extent of adherence to the prescribed regimen (otherwise, the reported response may inaccurately reflect on the therapies prescribed).
• Obtain the perspectives of significant others on the patient’s relief from pain, the effects of analgesia on function, and adherence to and safety with prescribed medications. (Permission to obtain collateral information is a prerequisite for prolonged opioid treatment.)

Nicholson and Passik (2007) recommend that the elements in Exhibit 2-16 be documented and kept current in a patient’s record. The frequency with which these areas need to be assessed in individual patients is a matter of clinical judgment.

Exhibit 2-16

Elements To Document During Patient Visits.

Treatment Setting

A clinician may conclude that optimal treatment includes more specialized care, such as that provided at a pain clinic. Where distance, costs, or other factors prohibit such a referral, the clinician must be resourceful, perhaps combining various local resources and support groups or suggesting specific electronic resources. Chapter 5 provides more details.

The vast majority of chronic pain syndromes (e.g., lumbago, osteoarthritis) in patients who do not have major psychopathology or histories of SUDs (excluding tobacco) are managed by primary care physicians. When the pain syndrome is atypical, or when there is comorbid psychiatric illness or SUD history, specialty consultation may be indicated. In the presence of current or past SUD, addictionology consultation may be necessary before instituting chronic therapy with scheduled medications.

Key Points

• Patients should receive a comprehensive initial assessment.
• It is important to discover the cause of a patient’s chronic pain; however, clinicians should not assume a patient is disingenuous if the cause is not discovered.
• The patient’s personal and family substance use histories and current substance use patterns should be assessed.
• It is crucial to obtain collateral information on the patient’s pain level and functioning, as well as SUD status.
• Comorbid psychological disorders should be assessed and treated.
• Assessment of the patient with co-occurring chronic pain and SUD or other behavioral health disorders should be ongoing.