Chronic Pain in Primary Care: Assessment Across the Lifespan Module 2

1. Chronic Pain in Primary Care: Assessment Across the LifespanModule 2 Stephanie Key, MSN, RN, CPNP-PC Mary Lou Adams, PhD, RN, FNP-BC, FAAN Frances Sonstein, MSN, RN, FNP, CNS Diane Tyler, PhD, RN, FNP-BC, FNP-C, FAAN Paula Worley, MSN, RN, FNP-BC The University of Texas at Austin School of Nursing Consultants: Yvonne D’Arcy, MSN, RN and JoEllen Wynne, MSN, RN, FNP-BC, FAANP

2. Objectives: • Discuss factors that affect the assessment of chronic pain. • Describe components of the comprehensive assessment of chronic pain. • Identify valid and reliable pain assessment tools appropriate for primary care. Goal: provide NPs with a concise overview of standardized pain assessment methods.

3. Factors that affect Pain Assessment • Personal meaning of pain • Quality of life • Financial burden • Social isolation • Cultural aspects • Race/ethnicity • Language • Cognition • Extraneous factors

4. Comprehensive Assessment • History • Present Illness (OLDCARTS) • Onset • Location • Duration • Characteristics • Aggravating and Alleviating factors • Radiate • Timing • Severity/Intensity • Past medical (co-morbidities) • Any past issues with pain management

5. Comprehensive Assessment • Physical Examination • Vital Signs • General survey • Neurological exam • Musculoskeletal exam • Pain evaluation & descriptors • Nociceptive • Sharp & stabbing; Dull, aching & throbbing • Neuropathic • Burning, electric & tingling

6. Comprehensive Assessment • Psychosocial factors • Impact on lifestyle • Family dynamics • Social isolation • Sleep • Work productivity • Fear of addiction • Mental health • Suicide risk • Depression

7. Comprehensive Assessment • Medication review • Current medicines • Past medicines for pain control and effect • Behavioral measures • Checklist of Nonverbal Pain Indicators(CNPI) • Vocal complaints: nonverbal (sighs, gasps, groans, moans, cries) • Facial grimaces (furrowed brow, clenched teeth, tightened lips, distorted expressions, narrowed eyes) • Bracing (clutching or holding onto something or affected area during movement) • Restlessness (constant or intermittent shifting, rocking, hand motions, inability to sit still) • Rubbing (massaging of affected area) • Vocal complaints (words expressing pain or discomfort, cursing during movement, exclamations of protest) Feldt, K.S. (2000). The checklist of nonverbal pain indicators (CNPI). Pain Management Nursing.3(1): 13-21.

8. Comprehensive Assessment • Diagnostic Studies • Individualized to the patient and history • Low back pain national guidelines • “Diagnostic imaging is indicated for patients with low back pain only if they have severe progressive neurologic impairments or signs or symptoms indicating a serious or specific underlying condition, or if they are candidates for invasive interventions. Routine imaging is not associated with clinically meaningful benefits in other patients and can lead to harms.” Roger Chou, Amir Qaseem, Douglas K. Owens, Paul Shekelle, ; Diagnostic Imaging for Low Back Pain: Advice for High-Value Health Care From the American College of Physicians. Annals of Internal Medicine. 2011 Feb;154(3):181-189.

9. Pain Assessment Tools • Types of Pain Scales • Uni-dimensional • Multi-dimensional • Tools for Adults • Tools for Children

10. Tools for Adults • Adult faces tool • Multiple-Language Pain Assessment Scale • Brief Pain Inventory (BPI)- Short form • McGill Pain Questionnaire (MPQ) • Short-form MPQ • Pain Quality Assessment Scale (PQAS) • Depression scale

12. Tools for Children and Infants • Wong/Baker Faces Rating Scale • Body Outline Tool • Neonatal Infant Pain Scale (NIPS) • Depression scale

14. Tool for Dementia Patients • Pain Assessment in Advanced Dementia Scale (PAINAD) • Breathing • Negative vocalizations • Facial expression • Body language • Consolability • Scores range 0-10

15. Screen for Addiction • Screening Instrument for Substance Abuse Potential (SISAP)® • a 5-item, clinician-administered test that asks pointed questions concerning alcohol, marijuana, and cigarette abuse • Screener and Opioid Assessment for Patients in Pain (SOAPP)® • a self-report questionnaire available in 5-, 14-, and 24-item versions, which has recently undergone revisions and which is considered less susceptible to patient deception • Opioid Risk Tool (ORT) ® • a 5-item, yes-or-no, self-report for measuring and predicting the probability that a patient taking opioids will display aberrant behaviors • Current Opioid Misuse Measure (COMM)® • a 40-item patient directed questionnaire that assesses how patient is currently using their medications

16. Implications • Assessment is the basis for appropriate management. • Assessment is a multifactorial process. • The patient is part of the team in managing chronic pain. • As a health care provider, it is pertinent to trust your patients and verify the information. • Finally document, document, document!

17. Website References • http://www.painedu.org/tools.asp • www.wongbakerfaces.org • www.emergingsolutionsinpain.com • http://www.inflexxion.com/COMM

18. References • Bouhassira, D. & Attal, N. (2011). Diagnosis and assessment of neuropathic pain: The saga of clinical tools. PAIN, 152, S74-S83. • Feldt, K.S. (2000). The checklist of nonverbal pain indicators (CNPI). PainManagement Nursing.3(1): 13-21. • Chou, R., Qaseem, A., Owens, D.K., & Shekelle, P. (2011). Diagnostic imaging for low back pain: Advice for high-value health care from the American College of Physicians. Annals of Internal Medicine 54(3):181-189. • Loretz, L. (2005). Primary care tools for clinicians. St. Louis, MO: Mosby. • Herr, K, Bursch, H., Miller, L.L. , & Seafford, K. (2010). Use of pain-behavioral assessment tools in the nursing home. Journal of Gerontological Nursing, 36, 18-29. • Narayan, M.C. (2010). Culture’s effects on pain assessment and management. American Journal of Nursing, 110(4), 38-47.

19. Post-Test Questions • Pain is highly complex and personal. • True • False • Which of the following are factors that affect pain assessment? • Race/ethnicity • Cognition • Language barriers • All of the above

20. Post-Test Questions 3. What does the “A” stand for in the acronym OLDCARTS in the history of present illness? • Adverse reactions • Alcohol use • Aggravating and Alleviating factors • All of the above

21. Post-Test Questions 4. Listening to a patient’s description of his pain can provide insight into the type of pain such as nociceptive or neuropathic. • True • False

22. Post-Test Questions • There is a lower suicide risk in patients with chronic pain than in the average population. • True • False

23. Post-Test Questions • During an examination of a 82-year old male who is non-verbal, you observe that the patient has tightened lips and clenched teeth when you palpate his shoulder. This is an example of which behavior on the Checklist of Nonverbal Pain Indicators(CNPI)? • Restlessness • Facial grimaces/Winces • Bracing • Rubbing

24. Post-Test Questions 7. Basic X-ray films should be ordered on all patients that complain of chronic pain. • True • False

25. Post-Test Questions • A screening tool that allows the provider to assess only the intensity of pain is called a: • Uni-dimensional scale • Multi-dimensional scale • Bi-modal scale • Multi-factorial scale

26. Post-Test Questions • All of the following chronic pain tools are reliable and valid to use with adults except: • Brief Pain Inventory(BPI)-Short form • McGIll Pain Questionnaire(MPQ) • Pain Quality Assessment Scale(PQAS) • Neonatal Infant Pain Scale(NIPS)

27. Post-Test Questions • Which of the following screening tools for opioid use measures and predicts the probability that a patient taking opioids will display aberrant behaviors? • Current Opioid Misuse Measure(COMM) • Opioid Risk Tool(ORT) • Screening Instrument for Substance Abuse Potential (SISAP) • Screener and Opioid Assessment for Patients in Pain (SOAPP)®