Activity 5: Practical Aspects of Chronic Pain Management: A Case-based Approach

Two algorithms are referred to in this series. They were created by the Institute for Clinical Systems Improvement (ICSI) to accompany their guideline ‘Assessment and management of chronic pain.’ The algorithms are available from the ICSI website:

On the ICSI website you can also find these tools:

  • Brief pain inventory (short form)
  • Patient health questionnaire (PHQ-9)
  • Functional ability questionnaire
  • Personal care plan for chronic pain

Recommendation #1: All patients have the right to an adequate pain assessment including documentation of pain location, intensity, quality onset/duration/variations/rhythms, manner of expressing pain, pain relief, what makes it worse, effects of pain, and a pain plan

Recommendation #2: Patient self report is the "most reliable indicator of the existence and intensity of pain" (National Institutes of Health) and is a key component of chronic pain assessment. Tools to assess chronic pain should:

  • Identifying significant areas of impairment or disability
  • Establishing specific functional outcome goals within a care plan
  • Measuring the effectiveness of the care plan or treatment interventions
  • Source: Institute for Clinical Systems Improvement (ICSI). Assessment and management of chronic pain. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2007.
    http://www.guidelines.gov/summary/summary.aspx?doc_id=12998
  • Strength of evidence: C,R

Recommendation #3: A plan of care for patients with chronic pain should address all of the following major elements:

  • Set personal goals
  • Improve sleep
  • Increase physical activity
  • Manage stress
  • Decrease pain
  • Source: Institute for Clinical Systems Improvement (ICSI). Assessment and management of chronic pain. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2007.
    http://www.guidelines.gov/summary/summary.aspx?doc_id=12998
  • Strength of evidence: A,M,R

Recommendation #4: Opioids are effective for the treatment of long-term pain due to nerve damage.

  • Source: Eisenberg E, McNicol E, Carr DB. Opioids for neuropathic pain. Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD006146. DOI: 10.1002/14651858.CD006146.
    http://www.cochrane.org/reviews/en/ab006146.html
  • Strength of evidence: Meta-analysis

Recommendation #5: Neuropathic pain can be treated with antidepressants and the effect is independent of any effect on depression.

  • Source: Saarto T, Wiffen PJ. Antidepressants for neuropathic pain. Cochrane Database of Systematic Reviews 2005, Issue 3. Art. No.: CD005454. DOI: 10.1002/14651858.CD005454.pub2.
    http://www.cochrane.org/reviews/en/ab005454.html
  • Strength of evidence: Meta-analysis

Recommendation #6: Anticonvulsant drugs are effective for relieving pain caused by damage to nerves, either from injury or disease. Approximately two-thirds of patients who take either carbamazepine or gabapentin can be expected to achieve good pain relief.

  • Source: Wiffen P, Collins S, McQuay H, Carroll D, Jadad A, Moore A. Anticonvulsant drugs for acute and chronic pain. Cochrane Database of Systematic Reviews 1998 Issue 2. Art. No.: CD001133. DOI: 10.1002/14651858.CD001133.pub2.
    http://www.cochrane.org/reviews/en/ab001133.html. Recommendation withdrawn Sept. 2009.
  • Strength of evidence: Meta-analysis

Recommendation #7: Cognitive-behavioral approaches to the rehabilitation of patients with persistent and unremitting chronic pain are considered to be among the most helpful available.

Recommendation #8: Chronic pain is frequently associated with psychological problems and even comorbid psychiatric diagnoses. If psychological difficulties or psychiatric co-morbidities are found, the patient's treatment plan should include specific steps to address them.

Recommendation #9: Initial evaluation should include a description of pain in relation to impairments in physical and social function (e.g., activities of daily living, sleep, appetite, energy, exercise, mood, cognitive function, interpersonal and intimacy issues, social and leisure activities, and overall quality of life). (IIA) The patient's attitudes and beliefs regarding pain and its management, as well as knowledge of pain management strategies, should be assessed. (IIB)

  • Source: American Geriatrics Society
  • The Management of Persistent Pain in Older Persons. Journal of the American Geriatrics Society 2002;50(6Suppl):S205-S224.
    http://www.ncbi.nlm.nih.gov/pubmed/12067390?dopt=Abstract
  • Strength of evidence:
  • IIA (II = Evidence from at least one well-designed clinical trial without randomization, from cohort or case-controlled analytic studies, from multiple time-series studies, or from dramatic results in uncontrolled experiments. A = Good evidence to support the use of a recommendation; clinicians "should do this all the time".)
  • IIB (II = Evidence from at least one well-designed clinical trial without randomization, from cohort or case-controlled analytic studies, from multiple time-series studies, or from dramatic results in uncontrolled experiments. B = Moderate evidence to support the use of a recommendation; clinicians "should do this most of the time".)

Recommendation #10: For the older adult who is cognitively intact or who has mild to moderate dementia, the physician should attempt to assess pain by directly querying the patient. For the older adult with moderate to severe dementia or who is nonverbal, the physician should attempt to assess pain via direct observation or history from caregivers.

  • Source: American Geriatrics Society
  • The Management of Persistent Pain in Older Persons. Journal of the American Geriatrics Society 2002;50(6Suppl):S205-S224.
    http://www.ncbi.nlm.nih.gov/pubmed/12067390?dopt=Abstract
  • Strength of evidence:
  • IIA (II = Evidence from at least one well-designed clinical trial without randomization, from cohort or case-controlled analytic studies, from multiple time-series studies, or from dramatic results in uncontrolled experiments. A = Good evidence to support the use of a recommendation; clinicians "should do this all the time".)

Download PDF with Recommendations

Approved and Off-label medications for Chronic Pain: Download PDF

The first file contains a PDA version of the lecture notes for the material covered in the first six Learning Link activities.
Download Lecture Notes: Chronic pain-AAFP learning link.zip

The second file (OpCalc) is an equianalgesic opioid calculator. This PDA tool allows easy and accurate conversion when switching from one opioid medication to another opioid and uses standard equianalgesic dosing.
Download Opiate Calculator for Palm OS, Pocket PC (Windows Mobile) and PC Windows: OpCalc.prc

Installation Instructions
RediReader for Palm OS
RediReader for Pocket PC

Presentation Slides for Practical Aspects of Chronic Pain Management: A Case-based Approach.

Functional MRI: Gatchel RJ et al. Pain and the Brain. Practical Pain Management. 2008; 8(5):28-40

Toombs JD, Kral LA.
Methadone treatment for pain states. American Family Physician. 2005;71(7):1353-8: http://www.aafp.org/afp/20050401/1353.html

 

Pomm HA, Pomm RM. Management of the Addicted Patient in Primary Care. NY: Springer Science, 2007.

Chronic Pain: A Primary Care Guide to Practical Management. Marcus DA. 1st Edition, HumanaPress, Totowa, NJ, 2005

Anxiety Screen: Download PDF
CAGE AID: Wisconsin Medical Journal 1995;94:135-140.
COMM tool: http://www.painedu.org/soap.asp
Documentation Charting Sheets for Treatment of Chronic Pain: Download PDF
Drug Abuse Screening Test (DAST): http://www.projectcork.org/clinical_tools/html/DAST.html
Methadone Fact Sheet: Download PDF
Opioid Risk Tool: http://www.painknowledge.org/physiciantools
Pain Agreement: Download PDF
Pain Severity Assessment Tool: Download PDF
Pain Scale Comparison: Download PDF
Patient Health Questionnaire (PHQ): www.phqscreeners.com Download PDF
Release of Information Form: Download PDF
SOAPP: http://www.inflexxion.com/offerings.aspx?id=260

Pain Scales

 

 

 

 

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