Module 7: Pain Management – Topic E Identify the elements of a comprehensive and contextual person-centred pain assessment.

Learning Objectives

By the end of this topic, the student should be able to:

• Describe components of a comprehensive assessment of acute, chronic, and cancer pain that includes the person’s goals and expectations for treatment.
• Identify validated pain scales and their appropriate use in practice.
• Apply validated pain scales in conducting comprehensive pain assessments in practice.
• Discuss the value of repeated, routine pain and functional assessments for persons using opioids and other analgesics for pain management, during opioid and analgesic tapering, and following the discontinuation of opioids.

Key Concepts

• A person-centred pain assessment is individualized based on the person’s needs.
• The initial assessment of pain is the first opportunity to build rapport and a therapeutic relationship between the person experiencing pain and the health and social service provider or team.
• A goal of the initial assessment of pain is to create an environment of trust that encourages information sharing.
• An initial pain assessment may be conducted over more than one visit to ensure comprehension and comfort for the client.
• A comprehensive assessment that includes the person’s experience of pain, their expectations related to care, and their goals for treatment improves the likelihood of effective pain management.
• The use of a validated pain scale reduces the risk of undertreatment and helps the person experiencing pain to feel that their experience of pain is believed.
• The pain scale used in the initial assessment should be used in all subsequent pain assessments.
• A comprehensive pain assessment focuses on the functional, physical, psychological, social, and cultural dimensions of a person, as well as their experience of pain and goals for management.

Baseline Pain Assessment

The purpose of a baseline pain assessment is to develop a treatment plan for the person experiencing chronic pain. A multidimensional and comprehensive assessment is needed to address pain, which includes the:

• affective,
• cognitive, and
• behavioral aspects of the person’s experience.

A baseline assessment identifies the person’s goals and expectations for services and care. These goals and expectations may be any of the following:

• decreased pain intensity or frequency or freedom from pain,
• confirmed diagnosis of the cause of the pain,
• improved functional status such as reduced physical disability, ability to return to work, improved social/family relationships
• improved sleep, mood, sense of well-being, and
• decreased side effects of medication.

The person’s concerns about stigmatization related to chronic pain is assessed; feelings of being devalued, blamed, or alienated are also explored.

The baseline assessment helps to identify risks or challenges for positive treatment outcomes. A closer follow-up and a multimodal approach to treatment is needed if the assessment indicates the following:

• severe pain or disability that includes activity limitation (i.e., walking, dressing, cooking) or participation limitations (i.e., working, social, recreational), or if pain is in more than one location or system
• belief that pain causes bodily harm
• preference for passive treatments versus active rehabilitation treatments
• catastrophic thinking about the pain experienced in which the person focuses on irrational worst-case scenarios
• poor problem solving and coping strategies
• health beliefs that differ from generally accepted societal norms about disease, treatment, and outcomes of care
• high levels of distress related to pain intensity (severity) or the affective impact of pain intensity; may present as agitation, anger, depression, or other affective expressions
• concerns about returning to work, such as lack of confidence in performance, heavy workload, little control over workload, poor work relationships
• social isolation
• membership in more than one marginalized or high-risk group in society as this has been linked with increased risk for chronic pain

The Symptom Assessment Acronym (Fraser Health, 2017), an additional tool that is helpful to assess pain. The following has been adapted from that tool:

Adapted from Fraser Health. (2017). Symptom assessment acronym. https://www.fraserhealth.ca/-/media/Project/FraserHealth/FraserHealth/Health-Professionals/Professionals-Resources/Hospice-palliative-care/SymptomAssessmentRevised_Sept09.pdf

Functional Assessment

A functional assessment examines the limitations, impairments, and impact of pain on:

• the person’s capacity to function physically,
• their quality of life, and
• their social interactions.

Components of a functional assessment include the following:

Peacefully7/iStock (daily living and household work icons); palau83/iStock (mood/mental health icons); SirVectorr/iStock (activity icon); Yuriy Altukhov/iStock (relationships icon); da-vooda/iStock (sleep icon); PeterSnow/iStock (enjoyment of life icon)

Mental Health History

An assessment of current mental health status includes an assessment of the family mental health history, and using validated tools such as the following:

• Patient Health Questionnaire (PHQ9) (PDF) – measures the severity of depression.
• Generalized Anxiety Disorder 7-item scale (GAD-7) (PDF) – used to screen for common anxiety disorders.

Comprehensive Physical Assessment

The physical exam includes the following:

• general physical assessment of all systems
• specific assessment of ambulation, range of motion, dexterity, degree of described disability, region(s) or structures impacted by pain, any areas of weakness, wounds or injuries, affect and mood

Substance Use and Opioid Risk Assessment

A substance use and opioid risk assessment is an important component of a comprehensive initial pain assessment. It allows the level of risk for problematic opioid use to be considered when developing a collaborative plan of care. The assessment includes the following:

• history of substance use, abuse and addiction—family and personal
• alcohol, cannabis, prescription medications, and illicit drug use
• addiction treatment programs, medications

Urine drug testing would be considered before starting opioid treatment, if current opioid use is suspected.

Ongoing Regular Assessment

Regular ongoing assessments are recommended to determine whether the agreed upon intervention/treatment plan is attainable and whether the plan requires modifications, additions, or deletions. Regular ongoing assessments also allow for positive change to be acknowledged with strengths emphasized.

Frequency will vary but should be consistent with the person’s goals and expected responses to the individualized plan of care. Generally, reassessment should occur every three to four weeks initially and more frequently when medication is being tapered or titrated.

Assessments can be conducted in person, by phone, or by electronic means (text, medication logs, check lists, etc.). Convenience and safety for the person using opioids and service provider should be taken into consideration.

Ongoing assessments should address the following:

• Any new onset of pain
• Adherence to treatment
• This can be based on self-report (medication logs).
• Urine drug screens can be used to measure adherence to the medication plan. This practice is usually undertaken as part of practice policy or a contract with the client.
• Adverse events secondary to treatment
• Generally, clients are advised to report any adverse events immediately.
• Review of potential side effects and possible adverse events should occur at each visit.
• There is a federal program for reporting adverse events related to pharmacological products.
• Treatment effect
• Pain experienced will be assessed with the same scale used for the initial assessment. This ensures consistent and comparable measurements of treatment effect.
• For pain assessment, consistency is important in assessing and measuring the effect of the treatment plan on functional status, as well as quality of life, mood and social function.
• Achievement of individual’s goals
• Evidence of opioid use disorder
• As persons using opioids for chronic pain management are at risk for opioid use disorder, evidence of the following may be assessed:
• altering the route of delivery of the opioid (for example, injecting or crushing oral products)
• accessing opioids from other sources such as from friends or other health and social practitioners, or purchasing on the street
• using opioids in unsanctioned ways, such as dose escalations or binging rather than scheduled use
• drug seeking (trying to get higher doses, pressuring for last-minute appointments, requesting faxed scripts, declaring that nothing is working)
• having repeated withdrawal symptoms (dysphoria, myalgia, GI symptoms such as nausea and diarrhea, cravings)
• having concomitant addictions or substance use disorders (alcohol, stimulants, marijuana)
• deteriorating social functioning or family concerns
• acknowledging mood elevating effects, being addicted, or having withdrawal symptoms, resisting tapering or switching
• avoiding urine drug screening as per contract or practice routine
• changing otherwise stable behaviours, such as missing appointments, demonstrating signs of depression, anxiety, isolation, anger, agitation, frustration, or disruptive behaviours in the office, the home, or the workplace

Pain Scales

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Pain scales are commonly used to assess the experience of acute or chronic non-cancer pain and cancer pain and the client’s response to treatment. Many of these tools have been adapted for use with persons of different ages and different cultures, and to assess specific types of pain (neuropathic, nociceptive, etc.).

• Some focus on pain intensity only and are most commonly used to assess acute pain and its response to treatment.
• Other scales are multidimensional and reflect an understanding of pain as a complex experience that includes the impact of pain, especially chronic pain, on a person’s ability to function physically, psychologically, and socially.

The tools that are commonly used in clinical practice have been studied extensively and have been shown to be reliable and valid measures of a person’s experience of pain.

Unidimensional Scales

Numerical Rating Scale (NRS)

• self-report
• a measure of only the intensity of pain on a numeric scale from 0 to 10
• 0 = no pain, 10 = worst pain ever
• reliable and validated for children and adults
• easy to use, easy to understand

Visual Analog Scale (VAS)

• similar to NRS
• validated for use in adults
• self-report of pain intensity
• a 100 mm line: 0 = no pain, 100 = worst pain
• easy to use, to understand, and to administer

FACES

• Wong-Baker Scale for measurement of pain intensity in children ages 3 to 7 years
• a visual representation of pain through facial expression
• can be self-report or observational
• validated for use in children and for adults where language is a barrier
• translated into several languages, adapted for different cultures, and validated

Northern Pain Scale (NPS)

• Wong-Baker Scale translated, adapted, and validated for Inuit language and culture (Bertram, n.d.)
• Dr. Jacqueline Ellis (Ellis et al., 2011) revised the Wong-Baker FACES scale to reflect an Inuk person’s facial expressions and style of dress (Bertram, n.d.).

Multidimensional Scales

Brief Pain Inventory (BPI)

• self-report
• commonly used in assessing chronic pain
• a measure of the intensity of pain and its impact on daily life
• validated and translated in several languages
• validated for measuring pain in chronic non-cancer pain and osteoarthritis
• recommended by the Centre for Effective Practice for assessment of pain and function for persons experiencing chronic non-cancer pain.

Verbal Rating Scale (VRS)

• self-report
• categorical descriptors of pain intensity
• subjective assessment of pain experience
• validated for use with children and adults

McGill Pain Questionnaire

• validated for use with adults with various types of pain
• self-report
• 20 items that address intensity and subjective quantification
• longer to complete and administered by health and social service professional

Neuropathic Pain

Cancer Pain

The Brief Pain Inventory was originally developed as a tool for assessing the multidimensional experience of cancer pain. It continues to be used and comes in a long form for a more detailed assessment.

Palliative Care (End-Of-Life Care)

Both the Brief Pain Inventory and the McGill Pain Questionnaire are validated for use in end-of-life care.

Questions

Which of the following is a risk for poor outcomes for people experiencing chronic non-cancer pain? (Select all that apply.)

a. Catastrophic thinking

b. Negative beliefs about pain

c. Poor problem-solving capacity

d. Severe pain or disability

Check

Please select an answer.

Correct! All these options are among the yellow flags (Centre for Effective Practice, 2018) for poorer outcomes in chronic pain management.

Incorrect. The correct answers were a, b, c, and d. All these options are among the yellow flags (Centre for Effective Practice, 2018) for poorer outcomes in chronic pain management.

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True or false: The Northern Pain Scale has been validated for use among Inuit.

a. True

b. False

Correct! The tool was adapted by Dr. J. Ellis from the Wong-Baker scale for use among Inuit.

Incorrect. The correct answer is a. The tool was adapted by Dr. J. Ellis from the Wong-Baker scale for use among Inuit.

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Which of the following reduces the risk for undermanaged pain?

a. Use of opioids

b. Use of a validated pain scale

c. Cognitive behavioural therapy

d. Massage

Correct! The use of a validated pain scale has been shown to reduce the risk of undermanaged pain.

Incorrect. The correct answer is b. The use of a validated pain scale has been shown to reduce the risk of undermanaged pain.

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Which of the following is the first opportunity to build a therapeutic relationship between the health and social service provider and the person experiencing pain?

a. Use of a pain scale.

b. Referral to a pain specialist

c. A plan of care that includes non-pharmacological interventions

d. An initial comprehensive assessment of pain

Correct! The first opportunity to build rapport and a therapeutic relationship is a comprehensive initial pain assessment.

Incorrect. The correct answer is d. The first opportunity to build rapport and a therapeutic relationship is a comprehensive initial pain assessment.

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References