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summary of TIp The management of CNCP in patients with a comorbid SUD is challenging for both patients and clinicians; however, it can be done successfully. This TIP advises clinicians to conduct a careful assessment; develop a treatment plan that addresses pain, functional impairment, and psychological symptoms; and closely monitor patients for relapse. Even the best treatment is unlikely to completely eliminate chronic pain, and efforts to achieve total pain relief can be self-defeating. Patients may benefit when clinicians team with other professionals ( e.g., psychologists, addiction counselors, pharmacists, holistic care providers). Patients must also assume a significant amount of responsibility for optimal management of their pain. Educating patients, family members, and caregivers in this process, and helping patients improve their quality of life, can be gratifying for everyone involved. Key points • CNCP and the disease of addiction involve neurophysiological processes. • Both genetic and environmental factors contribute to and influence the development and course of CNCP and addiction. • Clinicians must understand CNCP, addiction, and other behavioral health issues to best serve the chronic pain patient with or in recovery from an SUD. • Despite the complexities of CNCP and SUDs, patients with these co-occurring, chronic conditions can be treated effectively. 11 2 patient Assessment  In ThIs chApTer • Elements of Assessment • Assessment Tools • Assessing Pain and Function • Screening for Substance Use Disorders • Referring for Further Assessment • Assessing Ability To Cope With Chronic Pain • Evaluating Risk of Developing Problematic Opioid Use • Ongoing Assessment • Treatment Setting • Key Points elements of Assessment Researchers and clinicians agree that, because chronic noncancer pain (CNCP) is a multifaceted condition, assessment must include more than measures of pain intensity (Brunton, 2004; Haefeli & Elfering, 2006; Karoly, Ruehlman, Aiken, Todd, & Newton, 2006; Sullivan & Ferrell, 2005). Some elements are essential to assess; others, ideal. In many cases, even after a thorough assessment, the clinician may not detect the nociceptive source of a patient’s chronic pain. Collateral information is an important part of the assessment. Clinicians need to communicate with families, pharmacists, and other clinicians after the patient has given full consent for these discussions. If the patient declines to give consent, prolonged treat ment with controlled substances may be contraindicated. Furthermore, a clinician who prescribes controlled substances to a patient who refuses to permit access to outside information could be considered to be ignoring evidence of addiction or substance misuse and, there fore, to be trafficking. Collateral information also helps protect the patient from misusing medications. Exhibit 2-1 presents elements of a comprehensive assessment. Assessment Tools Standardized instruments provide ways to assess and track patient pain levels, function, substance use, and other factors important to managing CNCP. Standardized tools provide supplemental informa tion for treatment planning and assessment of risk and outcomes. If used well, tools can reduce clinician bias during patient assessment. The sensitivity and specificity of screening instruments vary, and all can yield false-positive or false-negative results. In addition, no single instrument has been shown to be appropriate for use with all patient populations (Bird, 2003; Brunton, 2004). Because of their limitations, standardized tools should not be the absolute determinants of treatments offered or withheld. 13  exhibit 2-1 elements of a comprehensive patient Assessment
14 2—Patient Assessment  exhibit 2-1 elements of a comprehensive patient Assessment (continued)
When using standardized tools, clinicians should (Bird, 2003): • Understand the strengths and weaknesses of each tool. • Select a tool appropriate for the patient, considering memory problems, cognitive impairments, eyesight, literacy level, cul tural background, gender, ethnicity, and other factors. • Teach patients how to use self-adminis tered tools, even “self-explanatory” tools; otherwise, the information they provide may be invalid. Instruments are available to assist with assess ment of pain and functioning, SUDs, psychi atric comorbidities, coping skills, and potential problems with opioid use. Assessing pain and Function The assessment of CNCP should include documentation of the following: • Pain onset, quality, and severity; mitigating and exacerbating factors; and the results of investigations into etiology • Pain-related functional impairment 15 • Emotional changes (e.g., anxiety, depres sion, anger) and sleep disturbances • Cognitive changes (e.g., attentional capacity, memory) • Family response to pain (i.e., supportive, enabling, rejecting) • Environmental consequences (e.g., dis ability income, loss of desired activities, absence from desirable or feared work) • Physical examination • Partial mental status examination (e.g., affect [how pain is experienced], somatic preoccupation, cognition, moans, gasps, lying down during the interview) Several factors may complicate an assessment of pain levels in any pain patient: • Some patients may report not only their level of pain intensity, but their suffering, which may be greater than their pain intensity. • Clinicians tend to believe that a patient’s pain level is actually lower than the patient reports, except when the patient reports low pain (Sloman, Rosen, Rom, & Shir, 2005; Stalnikowicz, Mahamid, Kaspi, & Brezis, 2005). • Clinicians are especially likely to under estimate—and, therefore, to undertreat— pain and disability in women, the elderly, minorities, people of low economic status, and people with SUDs (Green, Baker, Smith, & Sato, 2003; Rupp & Delaney, 2004). An assessment of pain and function in patients with SUD histories may be further complicated by the following factors: • Some patients with histories of SUDs may overreport their pain experience if they are afraid that they will be under- medicated or that their symptoms will not be taken seriously. 16 • Others may underreport their pain experience if they are afraid they will be prescribed medications that will cause them to relapse. • Some patients may exaggerate pain and disability levels to get opioids for reasons other than pain control. The level of functional impairment in patients with CNCP is markedly modified by envi ronmental contingencies (e.g., the incentives and disincentives for healthful versus so-called “sick role” behaviors). For instance, evidence shows that pain-related behaviors increase in the presence of a solicitous spouse, mean ing one who is attentive to and reinforcing of such behaviors (Pence, Thorn, Jensen, & Romano, 2008). It is also demonstrated that work-related functional impairment varies with the strengths of reinforcement contin gencies for function versus absenteeism. The workers’ compensation system may provide a special example of this. Studies typically find that patients receiving income from this source respond less well to rehabilitation efforts than do those not receiving disability income from this or other sources. The explanation is thought to reside in such factors as the need to “prove” one is ill to obtain tests and specialty consultation and the fear of loss of income if one is witnessed engaging in normal activities. The relative magnitude of rewards and punishments for function may thus play a determining role in disability. A thorough assessment of a patient with CNCP, therefore, requires a review of the overall consequences of resuming healthy function. When assessing pain and function in patients with histories of SUDs, clinicians should keep in mind the following: • Individuals with similar complaints (e.g., low back pain) usually describe and rate their pain differently. • Functional impairments affect patients differently. 2—Patient Assessment • Pain scores do not reflect tissue pathology, disability, or treatment response. • Pain reduction is insufficient to judge treatment success, which also requires optimization of function and normaliza tion of mood. Exhibits 2-2 and 2-3 list the strengths and weaknesses of common one-dimensional and multidimensional pain tools, respectively. Exhibit 2-4 presents tools for assessing the extent to which pain interferes with usual functions and activities. Information on how to obtain the tools is located in Appendix B. Studies show that patients who have chronic pain may develop cognitive impairments (e.g., changes in attentional capacity, memory, pro cessing speed) that appear to be independent of other variables (e.g., age, educational level, pain intensity, pain relief ) (Dick & Rashtiq, 2007; Hart, Martelli, & Zasler, 2000; Hart, Wade, & Martelli, 2003). Therefore, clinicians need to be alert to the possibility of these changes and include an evaluation of mental status as part of the patient’s ongoing assessment (e.g., the Mini-Mental State Examination, [Folstein & Folstein, 2010]) or refer the patient to a neurologist as necessary.  exhibit 2-2 Tools To Assess pain level
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