Is A Holistic Approach To Pain Management Practical And Workable? No, It's Not!

Today's post from clinicalpainadvisor.com (see link below) is a bit of a blue-print for how doctors should examine, assess, diagnose and treat chronic pain patients (and especially nerve pain patients) in the future.It fits perfectly with the growing notion that patients need to be treated holistically (with a multi-discipline approach) and sets out some ideas as to how this should happen. However, (and it's a big 'however'!) what it doesn't take into account, is the time and money pressure that modern doctors are facing. Everything has to be accounted for to the last minute and the last cent in modern medicine - money talks and is actually the only one with a voice. So however ideal an holistic approach to chronic pain treatment is, it's neck is wrung by the practical considerations of the length of time a patient is allowed to spend with the doctor. Long gone are the days when your doctor was practically a member of the family and could talk to you at length before coming up with a considered diagnosis and course of treatment. Creating an individual treatment program for pain patients is all well and good but can you do it within the time and budget constraints that modern doctors have to face. No of course you can't, so basically something will have to give in the future, otherwise writing out a quick painkiller prescription will remain the only practical option.

Chronic Pain Assessment: A Comprehensive Approach
 Florence Chaverneff, Ph.D.     September 06, 2017 
  Current guidelines recommend a multi- and interdisciplinary approach to the management of chronic pain, in which patients are carefully selected for rehabilitation.
The following article features coverage from PAINWeek 2017 in Las Vegas, Nevada. Click here to read more of Clinical Pain Advisor's conference coverage.

LAS VEGAS – During a presentation he gave at PAINWeek, held September 5-9, Michael R. Clark, MD, MPH, vice chair and clinical affairs director of the pain treatment program at Johns Hopkins Medical School in Baltimore, Maryland, sought to outline a comprehensive approach to the assessment and follow-up of patients with chronic pain.1

Current guidelines recommend a multi- and interdisciplinary approach to the management of chronic pain, in which patients are carefully selected for rehabilitation.2 Dr Clark cited a 2012 article by some of the authors of the 2011 Institute of Medicine report titled “Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research,” stating that “Chronic pain has a distinct pathologic basis, causing changes throughout the nervous system that often worsen over time. It has significant psychological and cognitive correlates and can constitute a serious, separate disease entity.”3,4 Therefore, according to Dr Clark, “A complete assessment and formulation is essential for the successful treatment and rehabilitation of this complex patient.”

Chronic pain is accompanied by an array of factors to take into consideration when treating patients. These include concomitant symptoms and comorbidities, medication-associated side effects and risks of abuse/diversion, educational level, employment status, and social support.5

Treatments should include an initial assessment followed by regular individualized and comprehensive reassessments, insisted Dr Clark. A general assessment should start with a detailed patient history to evaluate pain characteristics and review medical records, followed by a physical examination of musculoskeletal and neurologic health and diagnostic testing. Pain etiologies and characteristics, as well as the biopsychological impact of pain, should be taken into consideration. Dr Clark noted the lack of objective tools to measure pain intensity and the reliance on the patient's account of their pain or pain relief.

More specific patient assessment should include 3 dimensions: (1) functional to evaluate pain interference with daily activities, (2) psychological to identify any changes in mental status, and (3) a history of medication usage. Dr Clark provided a helpful mnemonic for patient assessment with HAMSTER, an acronym for: History, Assessment, Mechanisms (of pain), Social (and psychological factors), Treatment, Education, and Reassessment.

Unidimensional pain assessment tools include the visual analog scale, which, although suitable to evaluate pain intensity and changes in the pain experience (eg, in response to treatment), is not adequate for neuropathic pain assessment. Additional options include the Wong-Baker Faces Scale, the Verbal Pain Intensity Scale, and the 0 to 10 Numeric Pain Intensity Scale.

A general psychological assessment seeks to evaluate pain comorbidities that include anxiety, depression, and suicide ideation. Although available screening methods (eg, Patient Health Questionnaire, Beck Depression Inventory) enable the identification of at-risk patients, they do not serve as diagnostic tools. Pain-related psychological factors such as pain catastrophizing, kinesiophobia, chemical coping (ie, a “middle ground between compliant medication use and addiction”),7 substance use disorder (for which screening may prompt further evaluation), and a broader general assessment (eg, with the Brief Pain Inventory, the McGill Pain Questionnaire) are also warranted.

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Dr Clark emphasized the need to develop a care plan, with a working diagnosis (pain etiology, pain syndrome, and inferred pathophysiology), and an individualized and multidisciplinary initial treatment of a stepwise nature. Reassessment is key to treatment success, he insisted, and should be consistent and include, in addition to physical examination, an assessment of treatment efficacy, goals, quality of life, and medication side effects. He cites another helpful mnemonic for follow-up, with 4 As: Analgesia, Adverse side effects, Activities of daily living, and Aberrant behavior.

It is essential to “adopt a personalized ‘step approach' to pain assessment and management,” concluded Dr Clark, to identify “pain tools that work for your practice, set realistic, achievable goals in pain reduction, combine (non-) pharmacologic therapies, and seek to minimize specialist referrals.”

Read more of Clinical Pain Advisor's coverage of PAINWeek 2017 by visiting the conference page.

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References 
 
Michael R. Clark. Chronic pain assessment. Presented at Pain Week 2017; September 5-9, 2017; Las Vegas, Nevada.
Stanos S, Houle TT. Multidisciplinary and interdisciplinary management of chronic pain. Phys Med Rehabil Clin N Am. 2006;17(2):435-450, vii.
Pizzo PA, Clark NM. Alleviating suffering 101—pain relief in the United States. N Engl J Med. 2012;366(3):19719-19729.
[No authors listed] Relieving pain in America: A blueprint for transforming prevention, care, education, and research. Mil Med. 2016;181(5):397-399.
Peppin JF, Cheatle MD, Kirsh KL, Mccarberg BH. The complexity model: a novel approach to improve chronic pain care. Pain Med. 2015;16(4):653-666.
Galer BS, Jensen MP. Development and preliminary validation of a pain measure specific to neuropathic pain: the Neuropathic Pain Scale. Neurology. 1997;48(2):332-338.
Kirsh KL, Jass C, Bennett DS, Hagen JE, Passik SD. Initial development of a survey tool to detect issues of chemical coping in chronic pain patients. Palliat Support Care. 2007;5:219-226.

http://www.clinicalpainadvisor.com/painweek-2017/chronic-pain-assessment-should-be-step-wise-individualized-and-multidisciplinary/article/685536/