PAIN EDUCATION Module 1: Assessing pain & physician patient communication

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1 The full version of this slide deck in MS PowerPoint format (containing presentation view and expanded notes) can be downloaded on please register! PAIN EDUCATION Module 1: Assessing pain & physician patient communication

2 2013 Excerpta Medica BV The material presented in this teaching slide deck is for educational purposes only. If you wish to reproduce, transmit in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, any part of the material presented, you will need to obtain all the necessary permissions by writing to the publisher, the original author, or any other current copyright owner. Please cite as: PAIN EDUCATION Teaching Slides, chapter: Assessing pain & physician-patient communication, Available from No responsibility is assumed for any injury and/or damage to persons or property as a matter of products liability, through negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. Because of rapid advances in the medical sciences, it is recommended that independent verification of diagnoses and drug dosages should be made. Produced by Excerpta Medica Radarweg NX Amsterdam Netherlands Supported by an unrestricted educational grant from Grünenthal. Produced in the Netherlands

3 Learning objectives Upon completion of this training module you should: Appreciate the complex multifaceted nature of chronic pain and how it differs from acute pain Understand the basis of how chronic pain is assessed Be able to identify the barriers to effective chronic pain management from both the physician and the patient perspectives Realize the importance of the physician patient relationship Understand the value of effective communication and active patient involvement and empowerment Recognize that chronic pain management requires a multimodal approach with realistic goals, driven by an understanding of chronic pain, its effects on the patient, and the underlying mechanisms For additional information and further educational content related to the assessment pain and physician patient communication please see Module 1 of the CME-accredited e-learning PAIN EDUCATION modules, available at

4 Definition of pain An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage Pain is a complex phenomenon an individual and subjective experience Pain is a multidimensional experience CNS activity involves emotions, thoughts, and beliefs simultaneously International Association for the Study of Pain (IASP), CNS = central nervous system. Fine PG, Ashburn MA. In: The Management of Pain. New York: Churchill Livingstone; 1998: International Association for the Study of Pain. IASP Taxonomy Available from: Accessed February World Health Organization. WHO Normative Guidelines on Pain Management Available from: Accessed February

5 Acute and chronic pain Acute pain Is a signal to the brain about a noxious stimulus or ongoing tissue damage Intensity correlates with the triggering stimulus Has a distinct warning and protective function Can be clearly located Chronic pain Is uncoupled from the causative event Intensity no longer correlates with causal stimulus Has lost its warning and protective function Not felt in one place Radiates in different areas Is a serious comorbidity which has an impact on clinical outcomes and quality of life Is a special therapeutic challenge Is associated with a complex set of physical and psychological changes Ashburn MA, et al. Lancet. 1999;353: Galer BS, et al. A Clinical Guide to Neuropathic Pain Gerbershagen K, et al. Clin J Pain. 2009;25: Portenoy RK, et al. Pain Management: Theory and Practice Turk DC, et al. In: Ashburn MA, et al., editors. The Management of Pain p Woolf CJ, et al. Lancet. 1999;353: World Health Organization (WHO). WHO Normative Guidelines on Pain Management Available from: Accessed February

6 Chronic pain a frequent phenomenon A survey of 46,394 adults from 15 European countries has shown that 19% suffer from chronic pain 61%: Work affected 21%: Depressed 34%: Severe chronic pain sufferers 40%: Pain inadequately managed 46%: Suffer from constant pain Chronic pain conditions can be a substantial socio-economic burden Becker N, et al. Pain. 1997;73: Breivik H, et al. Eur J Pain. 2006;10: Carmona L, et al. Ann Rheum Dis. 2001;60: Depont F, et al. Fundam Clin Pharmacol. 2010;24: McDermott AM, et al. Eur J Pain. 2006;10:

7 Multifaceted nature of chronic pain Biopsychosocial pain model Psychological factors Biological / physical factors Social factors Chronic pain Reference Becker N, et al. Pain. 1997;73: Breivik H, et al. Eur J Pain. 2006;10: Carmona L, et al. Ann Rheum Dis. 2001;60: Edwards D, et al. Pain Pract. 2006;6: Gatchel RJ, et al. Psychol Bull. 2007;133: Gore M, et al. J Pain. 2006;7:

8 Patient- / caregiver-related barriers to chronic pain management Communication, psychological, attitudinal issues include: Medical and psychological comorbidities Language barriers Cultural traditions Fatalism or belief in the inevitability of pain Anxiety, fear, anger, cognitive impairment Other potential barriers are: Reluctance to report pain to healthcare provider Low expectations of obtaining an effective analgesic Fear that pain implies worsening disease Fear of drug-related adverse effects Breivik H, et al. Eur J Pain. 2006;10: Glajchen M. J Am Board Fam Pract. 2001;14: McCracken LM, et al. Eur J Pain. 2002;6: National Pharmaceutical Council and Joint Commission on Accreditation of Healthcare Organizations, Pain: Current Understanding of Assessment, Management, and Treatments, December Available from: 5

9 Physician related barriers to chronic pain management Insufficient assessment Assessment bias Inadequate pain diagnosis Lack of training in pain management Lack of knowledge of current treatment options Regulatory scrutiny / concerns over prescribing controlled substances Disparity between physician and patient ratings of pain intensity Poor physician patient communication Healthcare provider time constraints Reference 6 Glajchen M. J Am Board Fam Pract. 2001;14:211-8.

10 Key features of a chronic pain patient Long pain history Psychosocial impact Ineffective attempts at pain management Davies HT, et al. Eur J Pain. 1998;2: Paris PM, Yealy DM. In: Rosen's Emergency Medicine: Concepts and Clinical Practice. 6th ed. Philadelphia PA: Mosby; Chapter 187. Stewart CE, MacMurdo D. In: Pain Management in Emergency Medicine. Norwalk, CT: Appleton-Lange, Turk DC, Okifuji A. In: The Management of Pain. New York: Churchill Livingstone; 1998:

11 Optimizing chronic pain management In-depth and complete assessment of pain and pain-related impairments Understanding of the underlying pathomechanisms and drivers of chronic pain Good communication between patient and physician Recognition and establishment of individual-patient treatment goals Alignment of patient and physician expectations from treatment Develop individualized therapy planning, evidence-based, multimodal or multi-mechanistic pain management approach Breivik H, et al. Eur J Pain. 2006;10: Glajchen M. J Am Board Fam Pract. 2001;14: McCracken LM, et al. Eur J Pain. 2002;6:

12 Establishing a trusting relationship Somatic factors Psychosocial factors Plausible biopsychological model Unlock patient potential Allay fears Trust and respect Combat psychosocial factors Avoid alibi solutions Mutual respect Active patient cooperation Agree therapeutic goals Set realistic targets Ensure patient and physician cooperation Reference Tunks ER, et al. Can J Psychiatry. 2008;53:

13 Effective communication: building a patient physician cooperation and partnership Be Repeat Consider highly and most non-verbal patient-focused take appropriate time communication to achieve language good two-way communication Empathize with patient concerns Patients Requires The Observe patient may any good must signs need verbal be time of able non-verbal and and to non-verbal understand repetition fear communication or to the inhibition understand physician in the key skills patient facts Help patients overcome their reservations and fears, by empathizing, Check Important Language Project to non-verbal ensure to should conduct that be signs appropriately conversations both through physician your structured. in and posture, patient atmosphere Remember eye convey contact, that and that allows and comprehend the facial true patient patient is relevant a focus making and keeping eye contact information Avoid partner expression(s) the who distraction needs that will to caused be reassure, well by informed notes, engender computer trust, and files, build and a interruptions relationship of Allay the patient s fears to gain their trust Use Messages cooperation open questions and and language partnership (rather should than be yes / no questions) to encourage the patient to open carefully up and chosen talk to freely match patient understanding Lowes R. Fam Pract Manag. 1998;5: Platt FW. West J Med. 1994;161:

14 Comprehensive clinical pain assessment Case history Pain history General medical history Treatment history Psychosocial history Physical examination Further diagnostic evaluations (as required) Lab tests Electrophysiology Imaging Nerve blocks Second opinion Psychological history or psychosocial case history / diagnosis (as required, possible referral) Diagnosis Explanation to the patient Therapeutic aims consensus Individual treatment plan Reference American Pain Society. Pain Control in the Primary Care Setting. Illinois: American Pain Society;

15 Different types of pain Pain is not a homogenous sensory entity Nociceptive pain Neuropathic pain Pain that arises from actual or threatened damage to non-neural tissue and is due to the activation of nociceptors Pain caused by a lesion or disease of the somatosensory nervous system Somatic Visceral Peripheral Central Superficial Deep Freynhagen R, et al. Curr Med Res Opin. 2006;22: IASP website. Available from: Accessed February Jensen TS. Eur J Pain. 2002;6:3-11. Lipman AG. In: The Management of Pain. New York: Churchill Livingstone; 1998: Miller KE, et al. Am Fam Physician. 2001;64: Weinstein SM. In: The Management of Pain. New York: Churchill Livingstone; 1998: Woolf CJ, et al. Ann Intern Med. 2004;140: Woolf CJ. Life Sci. 2004;74:

16 Medications for different types of pain Nociceptive pain Non-steroidal anti-inflammatory drugs (NSAIDs) Opioids A combination of treatment Neuropathic pain First-line medication: Antidepressants Anticonvulsants Topical agents Second-line medication: Opioids Accurate diagnosis is vital in order to choose the appropriate therapy Freynhagen R, et al. Curr Med Res Opin. 2006;22: Jensen TS. Eur J Pain. 2002;6:3-11. Lipman AG. In: The Management of Pain. New York: Churchill Livingstone; 1998: Miller KE, et al. Am Fam Physician. 2001;64: Weinstein SM. In: The Management of Pain. New York: Churchill Livingstone; 1998: Woolf CJ, et al. Ann Intern Med. 2004;140: Woolf CJ. Life Sci. 2004;74: NSAIDs = non-steroidal anti-inflammatory drugs. 13

17 How is pain measured? Unidimensional tools Numerical pain rating scales Visual rating scales Verbal rating scales Multidimensional tools BPI SF-36/SF-12 WOMAC EuroQoL/EQ-5D Pain DETECT LANSS Bennett M. Pain. 2001;92: Farrar JT, et al. Pain. 2001;94: Freynhagen R, et al. Curr Med Res Opin. 2006;22: Haanpää ML, et al. Am J Med. 2009;122(10 Suppl):S Kappesser J, Williams AC. Pain. 2010;148:

18 Pain case history and assessment Key factors considered for chronic pain assessment Location Focal Multifocal Generalized Referred Superficial Deep Intensity Apply rating scales Temporal features Onset Duration Course Pattern Patient concept Purely somatic? Impact on activity / quality of life Secondary signs / symptoms Neurological deficit Hyperalgesia, allodyna Character / quality Aching Throbbing Stabbing Burning etc. Impact of pain Use numerical and multi-dimensional tools Impact on physical and mental function Impact on quality of life Influential factors Aggravating factors Relieving factors Associated factors Mood Emotional distress Poor sleep Depression Treatment response Type of treatment Dosages Duration Side effects Reasons for stopping Reference Miller KE, et al. Am Fam Physician. 2001;64:

19 A complete case history Pain history General medical history Comorbidities and surgeries Medication history Contraindications, side effects History of drug abuse Treatment history Efficacy and tolerability of previous pain medications Reasons for stopping treatments Psychosocial history Social situation Any restrictions potentially affecting management strategies past current psychological symptoms and any history of adversities Subjective disease concept Expectations placed on therapy American Pain Society. Pain Control in the Primary Care Setting. Illinois: American Pain Society; Doleys DM, et al. In: The Management of Pain. New York: Churchill Livingstone; 1998: Lipman AG. In: The Management of Pain. New York: Churchill Livingstone; 1998:

20 Multimodal pain management plan Pharmacological management Non-pharmacological management Pharmacological management The following should be integrated into the should be driven mainly by the overall pain management plan: underlying pathomechanisms Individualized and pain treatment plan should be: not only by pain intensity Evidence-based Acupuncture Multimodal TENS Maximum analgesia with minimum Physiotherapy adverse effects Multi-mechanistic Relaxation Learning of pain Enhance functioning Stress coping strategies Allow patients to feel more comfortable Enable engagement in daily activities TENS = transcutaneous electrical nerve stimulation. American Pain Society. Pain Control in the Primary Care Setting. Illinois: American Pain Society; Backonja MM, Galer BS. Neurol Clin. 1998;16: Haanpää ML, et al. Am J Med Oct;122(10 Suppl):S Kehlet H, Dahl JB. Anesth Analg. 1993;77: Turk DC, Okifuji A. In: The Management of Pain. New York: Churchill Livingstone; 1998: Woolf CJ, Mannion RJ. Lancet. 1999;353:

21 A motivated patient physician team Patient and physician Pain diary Ongoing evaluation Realistic goals Therapeutic plan Modify plan Communication Patient empowered Improve chronic pain Guzmán J, et al. Cochrane Database Syst Rev. 2002;1:CD Hahn SR. Ophthalmology. 2009;116(11 Suppl):S Kerns RD, et al. Pain. 1997;72: Leung FH, et al. Med Teach. 2009;31:e Prochaska JO, Velicer WF. Am J Health Promot. 1997;12:

22 Summary Chronic pain is multidimensional, involving physical and psychological elements Assessment of chronic pain requires comprehensive clinical assessment, including evaluation of psychological elements There are many barriers to the provision of effective pain management, involving both the physician and the patient, which can be identified and overcome Effective communication and the development of a trusting physician patient relationship is of key importance Management of chronic pain requires a multimodal approach with realistic goals and patient involvement, driven by an understanding of the nature of pain and the underlying pathological processes 19