LAS VEGAS—A comprehensive assessment is needed to achieve an optimal outcome when treating patients with chronic pain, according to a presentation at PainWeek 2016.1
As many as 100 million adults in the United States are afflicted with chronic pain, more than the total affected by heart disease, cancer, and diabetes combined.2 Yet many medical schools provide inadequate preparation and training, including few training hours in pain and end of life; few hours in substance abuse, misuse, diversion, and overdose deaths; few hours in opioids; and almost no hours in pain assessment, according to Michael Robert Clark, MD, MPH, MBA, an associate professor and director of the Chronic Pain Treatment Program in the Department of Psychiatry and Behavioral Sciences at the Johns Hopkins Hospital in Baltimore, Maryland.
“Good outcomes begin with a foundation of thorough evaluation and assessment,” Dr Clark told Clinical Pain Advisor. “Current medical school and residency training schedules are packed with a wide range of topics. Finding the time is difficult for any new subject matter. As the recognition of pain and its consequences and comorbidities has grown, more schools and programs are attempting to take on this education.”
Ongoing education and access to mentorships through case review are needed to help physicians treat patients with chronic pain. Standardized programming needs to be made mandatory for maintenance of board certification,” Dr Clark said.
According to Dr Clark, clinicians need to evaluate/adopt a personalized “step approach” to pain assessment and management, such as HAMSTER (history, assessment, mechanism of pain, social and psychological factors, treatment, education, and reassessment).
The general assessment should include a detailed history, physical examination including both musculoskeletal and neurologic assessments, and diagnostic studies. Physicians also need to perform a functional assessment to determine if pain interferes with activities of daily living; a psychological assessment to determine if the patient has depression, anxiety, or mental status change; and an assessment of medication history.
The next steps are identifying pain tools that work for a physician’s practice and setting realistic goals for pain reduction. Management of pain should include both nonpharmacologic and pharmacologic therapy and referrals to specialists only when necessary, including if there is uncertainty about diagnosis, if specialized treatment is needed, if pain and functional goals cannot be achieved, and if evidence suggests opioid misuse or abuse, according to Dr Clark.
Consistent reassessment is key to treatment efficacy, Dr Clark said. Reassessment should include re-review of medications, discussions about appropriate medication usage, and readdressing psychological health and functionality.
1. Clark MR. Chronic pain assessment. Presented at: PainWeek 2016. Las Vegas, NV; September 6-10, 2016.
2. Institute of Medicine Report from the Committee on Advancing Pain Research, Care, and Education. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research (2011). The National Academies Press. Available at: http://www.nap.edu/read/13172/chapter/2. Accessed August 31, 2016.