Providing Valuable Input
In the past decade, leading practitioners and researchers in the field of pain management have recognized the importance of a multidisciplinary approach to assessing and treating pain — and the valuable role that psychological assessment instruments play in evaluating pain patients.
While physicians may have a natural bias toward objective measures such as physical and functional examinations, studies show that these measures alone do not adequately assess pain. "Pain is a complex, multidimensional, subjective experience," according to The Handbook of Pain Assessment. "Many individuals report significant degrees of pain but have minimal or no objective physical findings, or the reported pain appears to be disproportionate to the extent of physical pathology that is identified... Although biomedical factors appear to instigate the initial report of pain, psychosocial, and behavioral factors may exacerbate and maintain high levels of pain and subsequent disability... Evaluation of the sufferer requires that attention be given to assessing the range of psychological factors — behavioral, cognitive, and affective — that contribute to the experience.” New industry standards recognize the importance of assessing psychological factors for pain patients. The Joint Commission on Accreditation of Healthcare Organization's (JCAHO) recently released guidelines require an evaluation of the psychosocial status of pain patients. In addition, practice guidelines soon to be issued by the American Society of Interventional Pain Practitioners (ASIPP) state that, "The three crucial components of evaluations and management services are history, physical examination and medical decision making," and that "psychological evaluation is an extension of the evaluation process."
How can psychosocial assessments be used in practice? Below is a brief description of how practitioners at three clinics have integrated psychosocial assessments into their protocols.
Part of an Integrated Approach
Eugene Mironer, MD, became attuned to the importance of a multi-disciplinary approach to pain management early on. "During my training in the specialty of pain management," he says, "one of the most important messages we received is that this is a multi-specialty field — and that, after the leading physician, the psychologist is the second most important person on the team. When you deal with pain, you simply cannot do without psychologists."
Dr. Mironer shares a practice with three other physicians in South Carolina that focuses 100 percent on chronic pain management. Several years ago, the practice formed cross-referral alliances with local psychologists. More recently, the group brought a psychologist on board full time as an in-house resource.
Psychological assessments are a significant component of the group's pain management protocol, starting at diagnosis. "We are trying to find out what lies beneath what we see in the office," says Dr. Mironer. "Behind the patient's behavior is suffering, behind the suffering is pain, and behind the pain is the medical condition. Psychological assessments helps us look closely at each of those layers to gauge how much of the patient's behavior is due to psychological versus physical factors."
Assessments also are important in helping the team determine whether a patient qualifies for receiving an implantable pain reduction device such as a spinal cord simulator or an intrathecal pump. "Before we take such a step," says Dr. Mironer, "we need to have a very good understanding of whether this procedure will in fact address the pain problem. Through the psychological evaluation, we may discover, for example, that the majority of the patient's pain issue is psychological, not physical, making psychological counseling the best first step. In other instances, the psychological finding may confirm that the patient's pain is primarily due to physical causes and that, therefore, the patient will be likely to realize the benefits of the medical procedure."
Another benefit of psychological assessments is to support the psychologist's recommendations regarding drug therapy. While the psychologist can't prescribe medication, he or she can provide valuable input — such as whether antidepressants or anxiety treatment drugs are the most appropriate for the patient. In addition, the group uses assessments to help measure outcomes of the patient's pain management strategy.
Dr. Mironer also points out that the use of a psychological assessment can help avoid unnecessary services and the attendant costs. With any patient whom they are considering referring to the psychologist, the group uses the P-3 instrument, a brief psychological instrument that helps screen for the presence of depression, anxiety, and somatization — the factors most frequently associated with chronic pain. "The screener quickly gives us a good idea of the patient's situation," says Dr. Mironer. "It helps us determine, in conjunction with the physician's initial clinical assessment, whether a psychological evaluation is warranted. After all, not every pain patient needs to see a psychologist. If the physician clearly doesn't see a psychological need and the screening instrument supports that assessment, we can avoid overwhelming the patient with an unneeded consultation."
Recognizing the Mind/Body Connection
Psychological assessments play an important role in the protocol at Kaiser Permanente's Pain Service in the Sacramento, California area. The service was designed to coordinate the evaluation and treatment of members with chronic pain.
Robert Fernbach, PhD, one of the program developers, emphasizes the importance of understanding the mind/ body connection with regard to pain symptomatology. He also notes that providing a thorough assessment of psychosocial as well as physical factors is a necessary beginning for empowering people in acquiring essential self-management skills. "For members whose daily functioning is impaired by chronic pain, self-management skills are often the missing component for successful adaptation," says Dr. Fernbach.
The service uses a variety of psychological assessments, including the BHI™ (Battery for Health Improvement), Survey of Pain Attitudes (SOPA), and the SF-36® tests, as well as informally assessing readiness of change to self-management coping strategies.
Assessment includes identifying the psychosocial factors that contribute to an individual's pain experience and that may inform motivational strategies for treatment. Reviewing assessment results with patients clarifies for them differences between acute and chronic pain as well as the impact of chronic pain on their life and the rationale for recommended treatment. This clarity then provides the basis for added motivation for patients to move through the stages of change.
Evaluation results are explored with members so as to mutually refine an understanding of their "pain dynamics," especially how mind and body are interacting to produce the person's pain experience. Care coordinators help members determine the most suitable treatment options based on degree of impairment, practical consideration, and current motivation of the patient. The clinic also shares the evaluation results, along with treatment recommendations, with the referring providers.