Assessing Patients With Pain and Using Evaluation Tools
Prescribing opioid analgesics safely hinges on risk stratification and the accommodation of that risk into a treatment plan. Healthcare professionals writing prescriptions for opioid analgesics need to become proficient in performing and documenting a risk assessment. The use of a screening or ongoing assessment tool fulfills the growing requirement for due diligence in screening for the patient's vulnerabilities and risk and incorporating the results into treatment planning. Additionally, the use of validated tools not only helps guide the assessment, but also upgrades the healthcare professional's chart documentation.28
Patient Risk Stratification
An assessment of chronic pain should include a detailed assessment of the pain itself, including:
- Intensity, quality, location, and radiation of pain;
- Identification of factors that increase and decrease the pain; and
- Review of the effectiveness of various interventions that have been tried to relieve the pain.
The impact of pain on quality of life (eg, function in work, relationships, and recreational activities; effects on sleep, mood, level of stress) should also be assessed because improvement in these domains may be a goal of pain treatment and a measure of the efficacy of interventions.
Numerous general screening instruments are available to assist in these assessments. Among those used in clinical settings are the Brief Pain Inventory,3 the Roland Morris Disability Scale,29 and the 9-item Patient Health Questionnaire (PHQ-9), a brief measure to identify depression,30 the most common psychiatric problem seen among patients with pain.31
While these tools offer good generalized assessment, there has been a need for more focused risk assessment tools to help identify patients who are likely to misuse opioid analgesics. While caution is always warranted regarding interpretation of scores, several tools have emerged as clinically useful.32 One recommended example is the Opioid Risk Tool (ORT), which consists of 5 self-report items that cover issues such as family and personal history of substance abuse, age, history of preadolescent sexual abuse, and psychological disease. Each positive response is given a score based on patient gender, and then the scores are summed into categories of low, moderate, or high risk.32 The ORT is a very useful tool for healthcare professionals because of its brevity and ease of scoring, but it may be prone to underreporting and deception.32 Another, slightly more time-intensive example is the Screener and Opioid Assessment for Patients with Pain (SOAPP), which is an accurate tool for assessing abuse potential in patients being considered for opioid analgesic therapy and has good psychometric properties.32 It consists of 14 items utilizing a 5-point scale (0 = never, to 4 = very often), with a cutoff score of 8 to determine risk. The relatively low cutoff score of 8 was chosen, in part, because individuals who believe that their responses may determine their opioid analgesic treatment may underreport their behavior, and because some patients fear their answers may be misconstrued.32
Ongoing Pain Assessment
Performing an initial risk assessment is valuable but also should be followed with some form of ongoing assessment. To perform a comprehensive yet time efficient follow-up, it is important to consider four domains for patients on opioid analgesics. These domains have been labeled the "4 As" (analgesia, activities of daily living, adverse effects, and aberrant drug-related behaviors) for teaching purposes.33
To help healthcare professionals use the 4 As clinically, Passik and colleagues created a simple charting device called the Pain Assessment and Documentation Tool (PADT™).34 The PADT is a two-sided chart note that can be easily included in the patient's medical record and is designed to be intuitive, pragmatic, and adaptable to clinical situations.34 The value of assessing pain relief, side effects, and aspects of functioning has been emphasized repeatedly in the literature and the PADT acknowledges these standards. Documentation of drug-related behaviors, however, is a relatively new concept that has been incorporated into the PADT.34
Successful outcomes in pain management depend on how well healthcare professionals motivate patients to take responsibility for active participation in their care, and how they use their medications is one aspect of this responsibility. The 4 As described above double as both an ongoing assessment tool as well as an opportunity for interaction. A further opportunity for clear communication involves the use and implementation of opioid agreements.
The Psychology of Opioid Agreements
While opioid agreements and consents are discussed in What A Prescriber Should Know Before Writing the First Prescription, it is important to explore this issue with regard to the psychology and meaning behind them, as well as how they can impact the therapeutic milieu. An opioid agreement (OA) can be nothing more than a piece of paper if it is signed, sealed, and placed in the patient's medical record and never discussed or examined again. Opioid agreements, which often have been incorrectly called "contracts," traditionally have been used only after a patient had a lapse in behavior or judgment that compromised the medicine’s clinical value or the trust between the healthcare professional and the patient. At its best, however,an OA can be educational, informative, and even motivational if it helps the patient understand opioid therapy and how it differs from other drug therapies where adherence to the rules of drug-taking are not nearly as emphasized. In addition, they can be helpful in reducing multiple prescribers, preventing abuse, and clarifying goals of treatment.35
If a medical practice is to avoid bias and the accusation that they are singling out only the problematic patients, the use of an OA should be practice-wide at the outset of opioid therapy. The agreement should be handed out and introduced as an exercise in mutual trust and goal-setting by the medical staff. The OA should be introduced and discussed by the healthcare professional, not the clerical staff. In addition, the language in the OA should be flexible; otherwise, the staff is likely to be in violation of its agreement as often as the patient. Healthcare professionals must always remember that violations of the agreement might be due to a range of issues from misunderstanding, pseudoaddiction, chemical coping or more illicit behaviors such as frank abuse or diversion. As such, flexible language in the OA allows the healthcare professional an opportunity to test these hypotheses and determine the true nature and cause of the infraction.Conclusion
The following are a few best practices for assessment and use of evaluation tools:
- View pain management activities as always involving some level of risk management.
- All good pain management efforts should begin with a proper history and physical exam (ie, documenting source of pain, length of time with condition, aggravating and alleviating factors, and impact on psychosocial functioning).
- Use a known and available general pain tool such as the Brief Pain Inventory to get a global sense of the patient's pain concerns.
- Before an opioid medication is written, use an available predictive risk tool such as the ORT to get a general level of risk burden with a particular patient. (Note: Never use these tools to deny therapy, but do use them to determine level of oversight, which will be required.)
- If opioid therapy is started, be sure to document ongoing therapy goals and the 4 As.
- Use opioid agreements to initiate therapies, and refer back to them at least annually as a point of discussion with the patient.
- Always know your limits and do not be hesitant to make referrals or ask for specialty help (ie, addiction management or behavioral medicine specialists) when treating patients with complex medical and psychosocial issues.
References Used in the Section:
- 3 National Pharmaceutical Council in collaboration with Joint Commission on Accreditation of Healthcare Organizations. Pain: Current Understanding of Assessment, Management, and Treatments. 2001; 1-29
- 28 Chou R, Fanciullo GJ, Fine PG, et al. Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain. The Journal of Pain. 2009; 10(2):113-130.
- 29 Jordan K, Dunn KM, Lewis M, et al. A minimal clinically important difference was derived for the Roland-Morris Disability Questionnaire for low back pain. Journal of Clinical Epidemiology. 2006; 59:45–52.
- 30 Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. Journal of General of Internal Medicine. 2001 Sep; 16(9):606-613.
- 31 Dersh J, Polatin PB, Gatchel RJ. Chronic pain and psychopathology: research findings and theoretical considerations. Psychosomatic Medicine. 2002; 64(5):773-786.
- 32 Passik SD, Kirsh KL, Casper D. Addiction-related assessment tools and pain management: Instruments for screening, treatment planning, and monitoring compliance. Pain Medicine. 2008; 9(S2):S145-S166.
- 33 Passik SD, Kirsh KL, Whitcomb LA, et al. Monitoring outcomes during long-term opioid therapy for non-cancer pain: results with the pain assessment and documentation tool. Journal of Opioid Management. 2005; 1(5):257-266.
- 34 Passik SD, Kirsh KL, Whitcomb LA, et al. A new tool to assess and document pain outcomes in chronic pain patients receiving opioid therapy. Clinical Therapeutics. 2004; 26(4):552-561.
- 35 Fagan MJ, Chen JT, Diaz JA, et al. Do internal medicine residents find pain medication agreements useful? The Clinical Journal of Pain. 2008; 24(1):35-38.