Acute pain: effective management requires comprehensive assessment.

Postgraduate Medicine

ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20

Acute Pain: Effective Management Requires Comprehensive Assessment Richard Radnovich DO, C. Richard Chapman PhD, Jeffrey A. Gudin MD, Sunil J. Panchal MD, Lynn R. Webster MD & Joseph V. Pergolizzi Jr MD To cite this article: Richard Radnovich DO, C. Richard Chapman PhD, Jeffrey A. Gudin MD, Sunil J. Panchal MD, Lynn R. Webster MD & Joseph V. Pergolizzi Jr MD (2014) Acute Pain: Effective Management Requires Comprehensive Assessment, Postgraduate Medicine, 126:4, 59-72 To link to this article: http://dx.doi.org/10.3810/pgm.2014.07.2784

Published online: 13 Mar 2015.

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C L I N I C A L F O C U S : P A I N M A N A G E M E N T, R A R E D I S E A S E S , A N D A L L E R G I E S

Acute Pain: Effective Management Requires Comprehensive Assessment

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DOI: 10.3810/pgm.2014.07.2784

Richard Radnovich, DO 1 C. Richard Chapman, PhD 2 Jeffrey A. Gudin, MD 3 Sunil J. Panchal, MD 4 Lynn R. Webster, MD 5 Joseph V. Pergolizzi Jr, MD 6 President and CEO, Injury Care Medical Center, Boise, ID; 2 Professor Emeritus, Department of Anesthesiology, The University of Utah, Salt Lake City, UT; 3Director, Pain Management and Palliative Care, Englewood Hospital and Medical Center, Englewood, NJ; 4President, National Institute of Pain, Lutz, FL; 5 Vice President of Scientific Affairs, PRA International, Salt Lake City, UT; 6Adjunct Assistant Professor, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 1

Abstract: Pain is among the most common reasons that patients seek medical care, and inadequate assessment may result in suboptimal management. Acute pain in response to trauma or surgery can be complex, variable, and dynamic, but its assessment is often simplistic and brief. One-dimensional rating scale measures of pain severity facilitate rapid evaluation and often form the basis of treatment algorithms. However, additional features of pain should inform the selection of a treatment regimen, and can include pain qualities, duration, impact on functional capabilities, and underlying cause. Patient age, sex, psychosocial features, and comorbid conditions are also important features to consider. Use of a multidimensional tool is recommended for assessing many of these features if time permits. Additionally, clinicians often fail to recognize or consider the potentially detrimental long-term effects of acute pain. As the United States continues to experience a prescription drug crisis, a “universal precautions” approach including abuse risk assessment and abuse deterrence strategies should be implemented for patients receiving opioids. Increased efforts and research are necessary to enhance the utility of available acute pain assessment tools. Developing more comprehensive tools for patient assessment is the first step in achieving the ultimate goal of effective acute pain management. The objectives of this review are to summarize issues regarding the complexity of acute pain and to provide suggestions for its evaluation. Keywords: pain measurement; acute pain; pain perception; opioid-related disorders

Introduction

Correspondence: Richard Radnovich, DO, Injury Care Emergency Medical Service, 4850 North Rosepoint Way, Suite 100, Boise, ID 83713. Tel: 1-208-939-2100 Fax: 1-208-939-4411 E-mail: dr.radnovich@injurycaremedical. com

Several organizations and initiatives have increased the awareness of inadequately treated pain and the importance of assessment in addressing acute and chronic pain.1–3 In 1996, the American Pain Society introduced the concept of pain as the fifth vital sign, underscoring the significant role of pain in a patient’s physiological state.4 A few years later, The Joint Commission on Accreditation of Healthcare Organizations recommended pain assessment in all patients.4 In 2001, the US House of Representatives further highlighted the issue by initiating the Decade of Pain Control and Research (2001–2010).5 A landmark report in 2011 by the Institute of Medicine also highlighted the need for change in pain assessment and treatment within federal healthcare and financial programs.6 In response to these initiatives, clinicians have begun to incorporate pain assessment into routine practice.7 Financial incentives for the management of pain have also been enacted. For example, the Deficit Reduction Act of 2005 encouraged improved pain management in acute care hospitals.8 As part of this act, hospitals for which the Inpatient Prospective Payment System annual payment update applies must collect and submit data from Hospital Consumer Assessment of Healthcare Providers and Systems surveys, which

© Postgraduate Medicine, Volume 126, Issue 4, July/August 2014, ISSN – 0032-5481, e-ISSN – 1941-9260 59 ResearchSHARE®: www.research-share.com • Permissions: [email protected] • Reprints: [email protected] Warning: No duplication rights exist for this journal. Only JTE Multimedia, LLC holds rights to this publication. Please contact the publisher directly with any queries.


Radnovich et al

include questions on pain management (questions 13 and 14), to avoid a reduction in payment.8,9 The results (ie, patient satisfaction) will also be tied to payment from the Centers for Medicare and Medicaid Services.10 However, several problems have emerged with the use of patient satisfaction as a measure of quality7; satisfaction measurements have a potential for bias.10 Recent data also suggest that high satisfaction ratings are associated with the overuse of healthcare resources and may ultimately result in higher costs and poor clinical outcomes.10 In a prospective cohort study involving . 50 000 respondents, patients in the highest satisfaction quartile had approximately 9% greater total healthcare and prescription drug expenditures and 26% greater mortality risk than those in the lowest patient satisfaction quartile after correction for several potentially confounding factors.10,11 Thus, improved methods for measuring success in pain management are needed. Despite efforts to increase awareness, inadequately managed pain is a persistent problem.1 Suboptimal management of acute pain may result from physicians’ concerns regarding the development of patient addiction.12 Additional contributing factors for suboptimal management may include a lack of proper pain assessment and clinicians’ assumptions about a patient’s pain level. A prospective cohort study of . 50 000 patients undergoing 179 types of surgical procedures indicated that appendectomy, cholecystectomy, hemorrhoidectomy, and tonsillectomy were among the 25 operations associated with the highest pain intensity the day after the procedure.13 Acute pain is often ineffectively treated after these procedures because staff views the operations as “minor,” they underestimate patients’ postoperative pain intensity, and they assume that the patient is experiencing little discomfort.13 Only a thorough pain assessment can address the complex and multifaceted nature of acute pain and ensure the application of appropriate treatment strategies. Although onedimensional rating scales for pain are expeditious, they do not adequately reflect the acute pain experience, which includes sensory, emotional, psychological, and cultural components (Figure 1).14 Moreover, simple intensity-based assessment tools do not evaluate relevant features of acute pain, such as quality and rate of resolution (duration; Figure 2). Some assessments include nonverbal pain indicators, and few multi dimensional tools evaluate aspects such as pain quality.15,16 Related features of patients with acute pain, such as risk of medication abuse (Figure 3), require additional evaluation. A comprehensive evaluation of patients with acute pain may enable optimal treatment and address the widespread problem of suboptimally treated pain. 60

Methods

Information for this review was obtained through PubMedand Scopus-based literature searches of English-language articles using terms such as “acute pain trajectories,” “pain assessment,” and “acute pain assessment.” Sources were also obtained from the reference lists of identified articles and through the authors’ knowledge of relevant literature. Although some older references were included, articles from 2004–2014 were preferentially cited to provide a comprehensive review of more recent literature. The recommendations made are expert opinions.

Complexities and Trajectories of Acute Pain

Many physicians believe acute pain is less complex and impactful than chronic pain.17,18 Acute pain occurs in response to tissue injury or an underlying disease (eg, renal calculus [kidney stone], sickle-cell crisis), is short-lived, and is adaptive, thereby restricting behaviors that incur risk and promoting recuperation after tissue trauma.18–22 Because acute pain is self-limiting, it requires only short-term care.23,24 Chronic pain, in contrast, serves no known useful function,25,26 is maladaptive, and has an indefinite duration, requiring longterm management. Clinicians consider chronic pain more complex, because the link between it and pathophysiology is often unclear. Conversely, the cause of acute pain is often identifiable. The perception of acute pain as simpler than chronic pain is consistent with the common belief that after surgery pain is a normal and essentially harmless process that resolves in a short time with minimal or no long-term consequences.18 However, this is not necessarily the case. The physiological processes that accompany acute pain can compromise cardiac27 and pulmonary28 functions and suppress the immune system.29 Poorly managed postoperative pain causes needless suffering and extends the time required for hospitalization, thereby increasing the cost of care.30 Results from a prospective cohort study (n = 411) showed that patients Figure 1. Aspects of the acute pain experience.

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Acute Pain: Comprehensive Assessment


Figure 2. Dynamic features of acute pain that may inform treatment decisions.

with higher pain intensity at rest had a significantly longer hospital stay (P = 0.03).30 Thus, acute pain is associated with many negative outcomes in the short term. Importantly, patients with inadequately managed acute pain incur a risk of developing chronic pain31; literature documents the high incidence of chronic pain after various surgeries, including mastectomy, thoracotomy, and herniorrhaphy.31 Therefore, a more detailed understanding of acute pain management may result in an effective strategy for preventing the development of chronic pain. The transition from acute to chronic pain is a poorly understood process, and may vary on the basis of physio logical, psychological, social, and occupational factors.32,33 The physiological changes appear to involve peripheral and central components of the nervous system.34 Distinguishing a temporal relationship between acute and chronic pain can be challenging because of normal variations in healing time.19 Generally, pain that persists for 2 to 3 months after surgery is considered chronic,35–37 whereas acute pain typically lasts 2 to 10 days after most surgical procedures.38 However, these definitions should not be relied upon too strictly because acute pain may last up to 6 months in some

cases.19,39 An improved understanding of the normal course of acute pain resolution for a given operation may help identify those progressing to chronic postoperative pain and allow for clinicians to intervene in hopes of preventing that transition. The rate of resolution and trajectory of acute pain are the focus of research in the international pain community. The pattern of acute pain intensity over time varies across types of tissue injuries, individuals, and clinical settings.26,40,41 For example, in a study of pain intensity in the 6 days after emergency department (ED) discharge, pain resolution occurred most quickly in patients presenting with hip pain; those with chest pain experienced the longest times to pain resolution.40 In contrast, findings from a study of postoperative pain during the 6 days after abdomen, back, chest, head/neck, hip, limb, or shoulder surgery showed that pain resolution occurred most quickly for patients undergoing chest procedures and most slowly for those undergoing hip operations.26 A patient’s psychological state (eg, anxiety, depression, aggressiveness) is also associated with prolonged postsurgical pain.42,43 The many variations in the rate of resolution/duration of acute pain underscores its complexity.

Figure 3. Patient features that merit consideration when treating acute pain.

Abbreviation: PTSD, posttraumatic stress disorder. © Postgraduate Medicine, Volume 126, Issue 4, July/August 2014, ISSN – 0032-5481, e-ISSN – 1941-9260 61 ResearchSHARE®: www.research-share.com • Permissions: [email protected] • Reprints: [email protected] Warning: No duplication rights exist for this journal. Only JTE Multimedia, LLC holds rights to this publication. Please contact the publisher directly with any queries.

Radnovich et al


Concepts for Acute Pain Evaluation Frequency of Pain Assessment

Because acute pain is dynamic, frequent assessment of its intensity and quality over time is necessary to make adjustments in analgesic doses and multimodal pharmacotherapy treatment strategies. Some clinicians recommend acute pain evaluation as frequently as every 2 hours,2 though this is not standard or practical in all settings. Pain assessments after surgery should be more frequent initially, and as the pain becomes less severe, the time between measures can lengthen. 44 Clinicians should also assess pain after every analgesic intervention to determine treatment efficacy.2 Unlike initial assessments performed in the hospital immediately after surgery, frequent assessment of outpatients is challenging and often infeasible. A better understanding of the expected duration or trajectory of acute pain may suggest that, in some cases, scheduled dosing is more effective than an as-needed administration of analgesics.45 In a small (n = 113) randomized clinical trial of children who underwent outpatient tonsillectomy, those who received as-needed acetaminophen and hydrocodone had significantly higher pain intensities at rest and with swallowing (P = 0.017 for both) than those who received the same medication on an every-4-hour schedule.45 These data support the importance of dosing frequency for analgesic efficacy. Dosing frequency should be guided by either frequent pain assessment or, when assessment is difficult, by predictions of pain intensity patterns that are as accurate as possible.

Assessment of Key Characteristics of Pain

Although severity is the most salient feature of acute pain, other aspects of this type of pain also require assessment (Figure 4). Probable duration of acute pain after a particular surgical procedure would be useful information for physicians, however, this estimation is challenging because of a lack of data.43 In all acute pain settings, including the ED and postoperative unit, physicians usually have a probable cause for the patients’ pain, which assists in identifying appropriate treatment. Physicians should also determine which actions improve or worsen the patient’s pain46 and should evaluate the effect of pain on the patient’s ability to function over time, particularly regarding activities of daily living.47 Pain assessments should include an analysis of function relevant to the injury or surgical procedure. Information on the patient’s function may facilitate treatment decisions; nonrandomized studies on postoperative pain management suggest that patients receiving multimodal therapy achieve mobility more rapidly than those receiving conventional analgesia.48,49 Thus, 62

the impact of pain on function should be evaluated along with other characteristics and effects. Qualities of acute pain are also important to assess.50 Descriptors such as “dull,” “aching,” “sharp,” and “stabbing” communicate important features of pain,46,50,51 but may not mean the same thing to all patients.52 The ability to describe pain may be limited by healthcare literacy,53 vocabulary,54 and education, in addition to differences in cultural background between patients and healthcare professionals.55 Despite these limitations, such descriptors are useful for the diagnosis and classification, or taxonomy, of pain, especially when distinguishing nociceptive from neuropathic types.50,51,56,57 Patients may respond to treatment differently on the basis of the qualities of their pain, and multiple classes of analgesics may be necessary for adequate relief,58–60 making treatment of pain with multiple qualities challenging.61

Impact of Patient Characteristics on Pain Assessment

Beyond the assessment of pain itself, a comprehensive understanding of patient characteristics can assist in estimating pain trajectories and inform optimal treatment decisions. Evidence suggests that the postsurgical pain of women and younger patients is initially more intense but resolves more quickly than that of men and older patients, respectively.26 Women also showed a significantly higher initial pain intensity than men in the ED setting.40 Additionally, the presence of comorbid conditions (eg, severe asthma, sleep apnea, obesity) may influence treatment decisions.62–65 If opioid therapy is under consideration, physicians should ask about previous opioid exposure to guide treatment decision making (eg, dosing) and appropriate risk monitoring (Figure 4). Patients who receive opioids for chronic pain are likely opioid tolerant and often require larger-than-anticipated doses to maintain effective pain control in a surgical or other acute pain setting.66–68 Those who receive long-term opioid therapy may benefit from the use of multimodal analgesia, including acetaminophen, nonsteroidal anti-inflammatory drugs, or additional agents with analgesic properties (eg, ketamine).69 In addition, patient risk factors for abuse can guide important decisions on the possible use of abusedeterrent opioid formulations on discharge. Opioid equianalgesic tables have historically guided dosing when medication is rotated from one drug to another, but use of these tables requires caution.66 Because these morphine equivalent conversion tables are based on studies of patients with little opioid exposure,66 patients who develop tolerance to one opioid and are switched to another may require adjusting




Figure 4. This broad model algorithm assists in the assessment of various types of acute pain.a

Mild pain is defined as an NRS score , 4, moderate pain corresponds to an NRS score of 4–6, and severe pain is defined as an NRS score $ 7. Abbreviations: BPI, Brief Pain Inventory; DVPRS, Defense and Veterans Pain Rating Scale; IPO, International Pain Outcomes; NRS, numerical rating scale; ORT, Opioid Risk Tool. a

to a dose below the predicted equivalent; the dose may need to be decreased by as much as 50% in some patients.70 Alternatively, patients may require slow downward titration of a drug dose and upward titration of another because of incomplete cross-tolerance.71 Equianalgesic tables provide average values, which mask the marked variation in analgesic potency across individuals.66 Because of genetic variations among patients, the efficiency of the metabolic pathways of various opioids, and therefore their analgesic efficacy, varies across patients.72 Creating further confusion, conversion ratios do not always agree across equianalgesic tables.73 Webster and Fine73 reminded the pain community that although equianalgesic dose tables are informative, their use in patients undergoing opioid rotation requires caution to avoid fatal outcomes. Treatment decisions should be informed by individualized evaluation and assessment rather than based on average values provided in an equianalgesic dose table. The varying effects of patient characteristics on pain and analgesic efficacy emphasize the importance of patient assessment for tailoring treatment regimens.

Psychological Characteristics of Patients

Psychological factors, such as patient perceptions and expectations regarding pain and its treatment (Figure 3),

may influence the acute pain experience.18 Setting reasonable expectations about pain control with patients contributes to their satisfaction with the treatment approach.16,74 Patients’ expectations of pain after elective surgery tend to be unrealistic,75 and an evaluation of expectations may prompt educational interventions (eg, preoperative instructional programs75) in order to adjust their perspectives. Physicians should recognize that patients with high levels of anxiety or depression are also likely to experience heightened levels of acute pain.76,77 A causal relationship has not yet been demonstrated, and it is unclear whether these mood disorders exacerbate pain or whether pain causes anxiety and depression.76 Additional confounding factors may be involved; for example, loss of functional ability after surgery or injury may contribute to depression and anxiety.78,79 Regardless of the underlying relationship, it is often useful for physicians to evaluate patients with acute pain for possible anxiety and depression. Catastrophizing is another important psychological factor in the acute pain setting,80 and refers to a cognitive distortion linked to anxiety and depression in which a situation is viewed as more extreme than the reality.80 After surgery or injury, some patients may catastrophize and magnify



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the intensity of the pain they are experiencing or distort its meaning.80–82 A common intervention for catastrophizing is cognitive behavioral therapy (CBT), which involves changing behaviors and active modification of dysfunctional thoughts and emotions.80 This therapy has effectively modified levels of catastrophizing and reduced pain intensity in chronic pain settings,80 but some evidence also supports the application of CBT for acute pain.83 Use of CBT is amenable in this setting because its effects are typically immediate.83 Multiple linear regression analyses in a randomized trial showed a significantly lower pain intensity (P , 0.05) in patients receiving CBT (n = 143) than in those receiving no intervention (n = 141) at 1, 2, 3, 7, and 14 days after an orthodontic treatment.83 These data suggest that patients should be evaluated for catastrophizing because an effective intervention is available to facilitate accurate perceptions of and relief from pain.

Risk of Chronification

In addition to their importance in short-term pain management, many pain features (eg, high initial pain intensity, burning or electrical sensations, wound numbness indicative of nerve injury) and patient characteristics (eg, female, younger age, preoperative psychological features) increase the transition risk from acute to chronic pain.20,61,84,85 Conditions such as obesity and posttraumatic stress disorder are often comorbid with chronic postsurgical pain86,87 and may also be risk factors. Patients at high risk for developing chronic pain require more monitoring than those at low risk.84 Strategies to prevent the transition to chronic pain are still evolving. Because high-intensity, early postoperative pain predicts long-term pain,88 aggressive treatment of acute pain may be helpful.34 Prescribing analgesics as-needed may contribute to suboptimally treated postoperative pain and associated behaviors89 such as clock watching, repetitive requests for opioids, and anxiety. Additional studies are needed to confirm these observations and to identify specific patient types for whom continuous dosing is appropriate and for whom it may prevent development of chronic pain. High doses of potent opioids are not optimal for the prevention of chronic pain because they may lead to persistent abnormalities in pain sensitivity or to opioid tolerance in some patients.1,90 Some clinicians have proposed that an effective multimodal pharmacotherapy treatment for acute pain (ie, one involving drugs with different mechanisms of action) can help deter chronic pain by preventing initial high-intensity pain while avoiding the risks of high-dose opioids84; however, this concept requires further study. A more detailed discussion 64

of treatment options including pharmacologic multimodal therapy is outside the scope of this review, which focuses on acute pain assessment.

Risk of Opioid Abuse, Misuse, and Diversion

Historically, concerns about opioid abuse have addressed the management of chronic pain rather than the treatment of acute pain.3,91 However, the hydrocodone/acetaminophen combination product, typically used for the treatment of acute pain, is the most frequently prescribed drug of any class in the United States,92 and it has substantially contributed to the pool of diverted drugs. Additionally, opioid overprescribing in the acute pain setting is common. After ambulatory surgery, surgeons often prescribe more immediate-release opioid formulation tablets on an as-needed basis than necessary. This excess medication then becomes a source for opioid diversion, with the remainder possibly shared with, or discovered by, friends and family.93,94 A potential first step in the prevention of opioid abuse, misuse, and diversion is identification of patients at high risk for these activities. No hard evidence exists to estimate the prevalence of addiction in patients with acute pain, and observational studies and review articles related to opioiduse problems in patients with chronic pain are limited by the variable definitions used to describe misuse, abuse, and addiction, thus yielding inconsistent findings. A systematic review examined incidence or prevalence of opioid dependence syndrome (as defined by DSM-IV or ICD-10) in patients receiving opioids for treatment of acute or chronic pain and reported that incidence ranged from 0% to 24% (median, 0.5%) and prevalence ranged from 0% to 31% (median, 4.5%).95 The authors recommended screening for potential risk factors, including anxiety, depression, psychiatric disorders, current or past substance abuse, and family history of addiction.95,96 The desire to increase the efficiency of patient care, in conjunction with a false sense of security regarding abuse in the acute pain clinical setting, has led to the underassessment of opioid abuse risk in patients with acute pain. Although no validated, rapid, and reliable tools exist for assessing the risk of abuse or addiction in patients with acute pain, the Opioid Risk Tool is one of several assessments validated for chronic pain.97,98 The 5 straightforward questions from this tool could apply to all candidates for an opioid prescription, regardless of whether the tool is formally used. The questions posed establish patient and family history of drug abuse, age, history of sexual abuse, and psychological history.97 Physicians




can quickly pose these questions in the office or ED during the patient interview (Figure 4). Additional tools and databases are available to assist in the identification of individuals who may be currently abusing drugs. The 10-item Drug Abuse Screening Test and a single screening question (“How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?”) have been used to identify drug use and associated disorders in a primary care setting.99 Reviewing prescription drug monitoring program (PDMP) databases can also identify patients receiving opioids from multiple prescribers and are likely seeking drugs for nonmedical reasons.100 A potential barrier to risk assessment using this method is the currently burdensome process of accessing the PDMP databases in several states.101,102 In some places, physicians cannot obtain PDMP information because access is restricted to law enforcement personnel.102,103 To increase their use, these databases should be readily accessible to physicians in all states. The end goal of acute pain assessment is to better understand how to effectively treat the pain with the least amount of risk to the patient. For patients classified as being high risk for opioid abuse, physicians should implement extra precautions, such as use of abuse-deterrent opioid formulations, referral to a pain specialist, and/or consultation with an addiction specialist.3 Patients who abuse opioids and have become dependent may benefit from multimodal analgesic treatment.104 Because no risk assessment tool predicts aberrant drugrelated behavior with a high level of accuracy105 and some assessments lack validation in the acute pain clinical setting, clinicians should implement universal strategies to mitigate risk of abuse, misuse, and diversion for all patients. For example, limiting the prescription of excess opioid tablets could help prevent drug diversion.93 Additionally, a better understanding of the pain trajectory for various conditions would help clinicians match treatment duration with the expected duration of pain (eg, determine the appropriate number of tablets to prescribe). However, surprisingly little research on acute pain trajectories has been documented in the literature.43 Patients should also receive counseling on safe home storage and disposal of medications.106 Opioid formulations with abuse-deterrent properties are important tools for decreasing risk of abuse.107 Primary care physicians, emergency medicine physicians, and surgeons could prescribe these formulations to all patients who require opioid medications for acute pain. These general risk management strategies and those targeted at patients with a high

risk for opioid abuse may reduce opioid abuse and misuse. Although opioid formulations with abuse-deterrent properties are becoming more prevalent, treatment of patients at risk for abuse is complicated; physicians who may have a lack of comfort in treating high-risk patients should refer these individuals to a pain specialist.

Assessment Tools Current Scales for Pain Assessment

Physicians often make treatment decisions based on pain intensity alone. In common clinical practice, no standardized tools can accurately and objectively measure a patient’s pain intensity; there is no equivalent of a blood pressure monitor for measuring pain. Therefore, virtually all assessments of pain are a variation of the question “What is your pain level?” Intensity scales commonly used for measuring acute pain include the numerical rating scale (NRS), visual analog scale (VAS), and Wong-Baker FACES Pain Rating Scale and its revised form. The NRS measures pain intensity on a numerical scale ranging from 0 to 10, with corresponding verbal anchors (eg, “no pain” and “worst possible pain”) on both ends.108 The NRS is the most frequently used scale for measuring pain,108 but results show poor reproducibility in repeated tests of the same subjects.109,110 Another option for assessing pain severity is the VAS, where patients rate their pain by putting a mark on a line anchored by verbal descriptors “no pain” and “worst imaginable pain”; pain severity is determined by the distance of the mark to the “no pain” end.110 In addition to vague anchor descriptions, another limitation of the VAS is that it is exclusively administered on paper or electronically.110 Both the Wong-Baker FACES Pain Rating Scale and its revised form feature a series of faces representing increasing pain intensity levels.111,112 These graphic tools are appropriate for use in children,112 but may not translate well across cultures.113 As previously discussed, the major drawback to these assessment tools is that they measure only 1 pain dimension: severity. Patients may find it challenging to simplify a complex pain experience into a one-dimensional score.52 Furthermore, rating pain numerically may not accurately reflect how meaningful pain or its reduction is from the patient perspective.114 In contrast to one-dimensional assessments, multidimensional tools assess several aspects of a patient’s pain and pain experience, including the quality of the pain, the patient’s emotional characteristics, and how the pain interferes with activities of daily living.16 Currently used multidimensional



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tools typically assess chronic pain 16 but can also be appropriate for acute pain.115 Examples of multidimensional tools include the McGill Pain Questionnaire52,116–121 and its short forms,52,122–129 the Brief Pain Inventory130–134 and its short form,131,135–137 the original59,138–141 and revised138,142–144 Pain Quality Assessment Scale, the International Pain Outcomes questionnaire,145 and the Defense and Veterans Pain Rating Scale.146 To choose the most appropriate multidimensional pain assessment tool, physicians should consider the information they would like to obtain, the patient population, and the cost and time to administer each tool. To assist in these decisions, relevant features for multidimensional tools are presented in Table 1. For example, the Defense and Veterans Pain Rating Scale and the short forms of the McGill Pain Questionnaire and Brief Pain Inventory were specifically designed to rapidly obtain patient information.50,131,146 Other multidimensional assessments, such as the full McGill Pain Questionnaire and Brief Pain Inventory, may require more time to administer50,117,131 but are more thorough.116,131 A precise pain evaluation can improve the rational basis for a particular course of treatment. Additional tools may be necessary to obtain information on patient features not assessed by the previously mentioned tools or in special populations. For patients with difficulty communicating verbally (eg, preverbal children, patients with dementia, intubated/unconscious adults), nonverbal scales, such as the Pain Behavior Assessment Tool, Critical-Care Pain Observation Tool, and Multidimensional Objective Pain Assessment Tool, take behavioral observations such as body movements and facial expressions into account.16,147–149 Tools for measuring depression and anxiety, such as the Beck Depression Inventory and Beck Anxiety Inventory, may also be considered, although their value in acute pain populations needs to be further validated.150,151 Patient satisfaction is important for quality assurance in many institutions. Although most providers assess this outcome with a simple NRS, the Pain Treatment Satisfaction Scale can provide higher quality measurement because it assesses multiple dimensions of the pain experience (ie, information about pain and its treatment, medical care, impact of current pain medication, side effects).152 Many tools are available for the assessment of patients with acute pain, and physicians should compare their properties (eg, in Table 1) to determine which tool is the most appropriate and feasible in their clinical setting.

Suggestions for Patient Assessment

Currently available multidimensional tools do not evaluate all aspects of the acute pain experience that may be of interest; 66

clinicians can gather additional information through dialogue with their patients involving open-ended questions. Table 2 provides a list of questions regarding patients’ acute pain that the authors currently use in their practices. The questions presented examine patterns of pain intensity, psychological characteristics, effects of pain on functional abilities, and concerns about analgesics. Table 2 can be used as a resource for characterizing a patient’s pain experience and developing subsequent treatment goals. Refer to Figure 4 for an algorithm of acute pain assessment that derives from expert consensus. Not all steps apply to all causes of acute pain; this algorithm should be used as a guideline rather than a strict protocol. Pain intensity, function, and multidimensional assessments should be repeated as needed (eg, after interventions to assess efficacy).

Future of Acute Pain Assessment

Currently available tools for assessing patients with acute pain tend to be either too simplistic or too cumbersome to administer, and research is needed to develop more reliable and comprehensive tools. These tools should be easy and swift to administer, reproducible, easily communicable, and useful for guiding treatment decisions. Future tools will likely include mathematical algorithms based on clinical research in pain trajectories (for which more studies are needed) to better estimate pain duration and intensity, and response to intervention. Newer tools will also incorporate functional assessments, because the ability to return to normal activity after surgery or trauma may be as important as pain relief. Additionally, satisfaction ratings after treatment may be included because of the connection between high patient satisfaction levels and Inpatient Prospective Payment System payments.8 Several tools for incorporating multifaceted pain data are currently in development. Moving forward, technology will increasingly support pain assessment. Electronic medical records may increase the efficiency of pain assessment.153 Computer applications show promise for facilitating pain evaluation in real time, thus enabling the measurement of dynamic variations in pain.154 Emerging literature on mobile phone applications for cancer pain and chronic noncancer pain shows great promise for guiding patients in the self-management of painful conditions, but to date this work has not extended to postoperative or other acute pain self-management.155–157 Future mobile phone applications studies should address post–hospital discharge acute pain self-management, and cancer pain and chronic noncancer pain self-management.


116

117,118

Free for clinical use

Freeb for clinical use129 Freeb for clinical use131

Pain qualities128 General patient information; history of disease; location, intensity, and qualities of pain; what improves/worsens pain; effects of and attitudes regarding current therapies; interference of pain with function, mood, sleep, relationships, and enjoyment of life132 Location and intensity of pain; relief with current therapies; interference of pain with function, mood, sleep, relationships, and enjoyment of life135 Intensity, qualities, temporal pattern of pain141

N/A

Pain intensity, physical and emotional functional interference, side effects, perceptions of care, nonpharmacologic therapies, presence of persistent pain145 Intensity, interference with activity and sleep, contributions to mood and level of stress146 N/A

Freeb for clinical use138

Intensity, qualities, temporal pattern of pain143

Freeb for clinical use138,141



Pain qualities, intensity50

b

Pain location, qualities, pattern over time, intensity 116

Cost

Areas Addressed

b

a

119,120

Military patients with acute and chronic pain146

Patients with chronic low back pain,139 carpal tunnel syndrome,141 spinal cord injury,140 and multiple sclerosis140 Patients with chronic low back pain, fibromyalgia, and headache144 Patients with postoperative pain145

Patients with chronic arthritis, low back pain,136 and postoperative pain137, c

Patients with chronic pain and dental surgery pain121 Patients with chronic back pain,125 osteoarthritis,126 spinal injuries,127 and rheumatic pain127 Patients with chronic pain128 and acute low back pain122 and veterans with chronic pain123 Patients with HIV/AIDS and cancer pain133 and pain after cardiac surgery134

Populations Validateda

The list of validated populations may not be exhaustive. Fees may apply for funded research. c For a modified version of the tool. Abbreviations: AIDS, acquired immune deficiency syndrome; HIV, human immunodeficiency virus; min, minutes; N/A, information not readily available.

Defense and Veterans Pain Rating Scale146

Revised Pain Quality Assessment Scale142 International Pain Outcomes Questionnaire145

Pain Quality Assessment Scale59

Brief Pain Inventory, Short Form131

Short-form McGill Pain Questionnaire50 Revised short-form McGill Pain Questionnaire128 Brief Pain Inventory131

McGill Pain Questionnaire

Assessment Tool

Table 1. Comparison of Multidimensional Pain Assessment Tools


N/A

N/A

N/A

N/A

5 min131

10 min131

N/A

2–5 min50

5–30 min50,117

Time to Administer



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Table 2. Assessment Questions for Treatment of Acute Paina 1 2 3 4 5

How are you feeling emotionally? Depressed? Anxious? Manic (nervous/hyperactive)? Are you worried about limiting the amount of pain medication you use because of concerns about “getting hooked”? Have you had any side effects from previous pain medications? Are you having any side effects from your current pain medications? Are you satisfied with your current pain management?

6 7 8 9 10 11 12

Overall, is your pain getting better or worse? During what time of the day is your pain the worst? How would you describe the pain sensations you are experiencing (eg, stabbing, throbbing, burning, electrical)? What are you unable to do because of pain? How does your pain affect your sleep? What is your overall daily pain score on a scale of 1 to 10? What makes your pain better?

Assessment questions for clarification of patients’ acute pain and analgesic medication experience. Not all questions apply to patients with newly emergent acute pain.


a

These tools will include an assessment of pain intensity and quality (eg, burning and tingling versus aching and stabbing). Technology is expected to greatly facilitate pain assessment, enabling new types of tools to be administered easily.

Conclusions

Although many practitioners consider acute pain to be simple, it can be quite complex and variable. The acute pain experience has sensory, emotional, psychological, and cultural components (Figure 1). Additionally, pain intensity, duration, and rate of resolution vary across different surgical procedures and traumas and among individuals. Increased study of the mechanisms underlying adaptive pain may facilitate targeted therapies and help individualize treatment. Future studies should particularly address gaps in knowledge on the trajectory and duration of acute pain and the appropriateness of matching analgesic therapies to the duration of effect (eg, long-acting opioids for continuous acute pain). The treatment of acute pain is often a continual daily process,158,159 but currently available analgesics indicated for the treatment of acute pain tend to be short acting. Although long-acting products are in development for the treatment of acute pain, extended-release/long-acting opioids are not typically used in this clinical setting because of safety concerns, including risk of overdose.160 Improvements in the characterization of acute pain trajectories may assist in decisions regarding the type and number of analgesic tablets to prescribe at discharge. Simple measures of pain intensity do not capture critical aspects of the patients’ pain experience that could influence treatment decisions. For example, catastrophizing is reduced when CBT is added to standard medical treatment for pain.161 A multimodal treatment strategy may be particularly beneficial for a variety of patients, including those predisposed to chronification (ie, with characteristics such as female sex, young age, preoperative anxiety/depression/catastrophizing); 68

those experiencing acute pain with neuropathic qualities, such as electrical and burning sensations; and patients who are using opioids for preexisting chronic pain.61,84,85,104,162 A comprehensive evaluation of patients with acute pain should include assessments of pain intensity and function. Risk of opioid medication abuse should also be evaluated when opioids are being considered. A multidimensional assessment tool is appropriate if time allows and the patient does not require immediate intervention (Figure 4). The interview questions provided in Table 2 are another resource for assessing pain intensity in addition to other important facets of the patient’s pain experience. A pressing need exists for improvement in assessment tools. Current evaluation methods are challenging to use in the outpatient setting, and many tools for evaluating the risk for abuse have not yet been validated for use in patients experiencing acute pain. New multidimensional acute pain assessment tools are being developed, and technology will likely play a greater role in patient evaluations in the future.

Acknowledgments

The authors would like to thank Mallinckrodt Pharmaceuticals, Inc., for commercial support and Carolyn Cain, PhD, of MedLogix Communications, LLC (Schaumburg, Illinois), for technical and editorial support of this manuscript.

Conflict of Interest Statement

This text was sponsored by Mallinckrodt Pharmaceuticals, Inc., and included professional writing and editorial support from MedLogix Communications, LLC. The authors are guarantors of this text, which expresses their opinions and conclusions. The authors actively participated in the preparation of this text in line with the principles of the Uniform Requirements of the International Committee of Medical Journal Editors (ICMJE).




Richard Radnovich, DO, and Sunil J. Panchal, MD, declare no conflicts of interest. C. Richard Chapman, PhD, reports a conflict of interest with Mallinckrodt Pharmaceuticals, Inc. Jeffrey A. Gudin, MD, discloses conflicts of interest with Alere, Depomed, Inc., INSYS Therapeutics, Inc., Mallinckrodt Pharmaceuticals, Inc., Nektar Therapeutics, Pacira Pharmaceuticals, Inc., Purdue Pharma L.P., Salix Pharmaceuticals, Inc., Teva Pharmaceutical Industries Ltd., and XenoPort, Inc. Lynn R. Webster, MD, reports conflicts of interest with AcelRx Pharmaceuticals, Inc., Acura Pharmaceuticals, Inc., AstraZeneca, BioDelivery Services International, Inc., Collegium Pharmaceutical, CVS Caremark, Inspirion Pharmaceuticals, INSYS Therapeutics, Inc., Jazz Pharmaceuticals plc, Mallinckrodt Pharmaceuticals, Inc., Medtronic, Inc., Nektar Therapeutics, Neura Therapeutik, Nevro Corp., Orexo AB, QRxPharma Limited, Shionogi Inc., Teva Pharmaceutical Industries Ltd. Joseph V. Pergolizzi, MD, discloses conflicts of interest with Mallinckrodt Pharmaceuticals, Inc., Inspirion Pharmaceuticals, Inc., Janssen Pharmaceuticals Inc., and Purdue Pharma LP.

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