Assessment of the Patient with Pain

Assessment of the Patient with Pain

by Kenneth L. Kirsh, PhD

& Steven D. Passik, PhD

Expert authors received compensation from Janssen Pharmaceuticals, Inc. for their contributions to PrescribeResponsibly.com

Case Study Profile

  • Assessment of complicated issues in a patient with cancer pain
  • Male
  • Age 54
Situation Overview

As part of responsible opioid prescribing, it is imperative that some risk stratification and ongoing assessment be used when prescribing opioid therapy. Simply adopting one of the measures available to healthcare professionals and applying it without clinical judgment, however, is problematic. Rather, assessment tools should be combined with clinical judgment as well as other objective measures, such as urine screens, to arrive at a plan of care and overall risk management.

Certain behaviors observed in people who abuse pain medicines are obviously aberrant. Aberrant behavior is when the patient steps outside the boundaries of the agreed upon treatment plan, which is established as early as possible in the healthcare professional-patient relationship. Examples of the more obvious aberrant behaviors include intravenous injection of oral formulations and concurrent use of related illegal drugs. Other behaviors, however, are less blatant. It is important to recognize that these, more subtle behaviors — for example, aggressively requesting medication or unsanctioned dosage escalations — are not necessarily an indicator of an opioid addiction and may be the result of a patient experiencing unrelieved pain. 1

The case below highlights the issues that can arise when using risk assessment tools. While this case discusses a patient with cancer pain, many of the issues translate to patients with non-cancer-related pain and can be applied to that population as well.

Scenario

Mr. JT, a 54-year-old patient, is introduced to an ambulatory palliative care service after a diagnosis of end-stage pancreatic cancer. The initial intake reveals that he has a significant history of drug use and criminal activity. His Opioid Risk Tool (ORT) score places him firmly in a high-risk category, indicating that caution will likely be needed when prescribing opioid analgesics. Given his poor prognosis, the patient is placed into hospice care. Hospice staff become increasingly worried when they observe that the patient often appears overly sedated, complains of increasing pain, and runs out of medications early. Assessment using the Pain Assessment and Documentation Tool (PADT™) on an ongoing basis shows the appearance of aberrant behaviors coupled with a failure to improve any functioning. The patient is considered for discharge from hospice after his aberrant behaviors continue and his lack of response to the prescribed medication regimen does not improve.

The hospice staff is able to gain his confidence and learn that the patient's son, who also has a criminal history, has been stealing his pain medications and sedating him with promethazine. When the hospice staff asks him why he did not tell them sooner, the patient says that he didn’t want to get his son into trouble. The patient's home situation is adjusted, and the patient is able to stay in hospice and achieve adequate pain care.

Key Learning

This case demonstrates that proper assessment is a necessary but not comprehensive part of pain management. Based upon the ORT scores and PADT findings alone, Mr. JT would be identified as having aberrant behaviors, and the likelihood of him abusing or diverting his medications would be considered. His ORT correctly classified him as high risk, which would place him in a category requiring close supervision (but this does not mean he should be denied treatment). The ongoing PADT results showed failure to improve functioning (which should occur even in patients with cancer, but with an obvious sliding scale with regard to what designates improved function), as well as what appeared to be aberrant behaviors (eg, overly sedated, running out of medications early, among others). A third variable, however, namely his son with a criminal background, was actually the causative factor behind the problems.

How would this case differ if Mr. JT had been a patient with severe low-back pain? If he had exhibited a similar constellation of behaviors, would you have responded differently?

Application

When considering opioid analgesic therapy as a form of treatment for pain, healthcare professionals must recognize the need to do a thorough workup and physical exam, including some level of risk stratification and ongoing assessment. There is no "cookie cutter" approach, however, to pain management, and we must therefore remember that the tools available to us should not be used on their own to determine eligibility. Clinical judgment will still be needed to assess all of the findings and to develop an appropriate and cohesive treatment plan for each patient with pain.

References Used in the Section:

  • 1 Passik SD, Portenoy RK, Ricketts PL. Substance Abuse Issues in Cancer Patients, Part 1: Prevalence and Diagnosis. Oncology. 1998; 12(4):517-521.