Opioid Prescribing and Monitoring - (Second Edition)
Primary Care Models for Pain Management

Assessment and Monitoring of Pain: Current Tools

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The IPCPS uses a modified FIM scale, which allows it to work well for a wide range of conditions while remaining consistent with the IPCPS’s pain intensity scale. Instead of the original 0 to 7 scale, the modified FIM uses an 11-point scale, with 0 meaning “perfect function” and 10 indicating “complete disability.” Patients are also allowed to self-report their ratings rather than have a health care professional evaluate their performance. As with the pain intensity scale, each number is described in words so that the patients can contextualize their functional limitations.

Indiana Polyclinic Combined Pain Scale

Indiana Polyclinic Combined Function Scale

Indiana Polyclinic Combined Depression Scale

Indiana Polyclinic Combined Anxiety Scale

How IPCPS Incorporates Depression and Anxiety

Shame, guilt, humiliation, embarrassment, and mental defeat are categorized as “self-conscious emotions,” and are significantly more common among chronic pain patients than among control patients.32 Such self-conscious emotions can exacerbate pain intensity levels, and mental defeat is significantly related to disability.32 Catastrophizing also can worsen chronic pain conditions.33

Meanwhile, chronic pain patients asked to quantify their internal experiences can overestimate their depressive symptoms.34 In addition to items related to depression and anxiety in pain rating scales, validated assessment tools can be used to specifically measure such symptoms. However, these rating systems are sometimes complex or require a specially trained clinician to conduct them.35

Reporting depression and anxiety scores in a VAS format allows patients to be evaluated frequently over a period of time and can provide a series of scores that offer insights into symptomatology, pain progression, and treatment results.36 Because VAS scores are numerical, they can overcome literacy, linguistic, or cultural barriers that may arise when clinicians ask patients to describe their state of mind.37 Overall, VAS tests are simple to take, easy to administer, quick, inexpensive, and practical for busy real-world clinics with diverse patient populations.38

The Indiana Polyclinic team aimed to set the metric for the rating scale’s emotional component so that it could accurately classify depression and anxiety in a way that would allow patients to correctly and objectively self-report their emotional status. Although anxiety and depression are both mental health conditions that can impact pain, they require separate scales because they are fundamentally different states.

It is important to recognize that a diagnosis of major depressive disorder (MDD) does not require that patients feel depressed. Anhedonia along with other symptoms such as fatigue and decreased concentration suffice for an MDD diagnosis. For that reason, “joy of life” was added to the questionnaire to help better identify patients experiencing some degree of anhedonia.

Using the IPCPS in Practice

The IPCPS consists of 4 test instruments of similar design, each offering patients both verbal descriptions and numeric ratings. The experience of the Indiana Polyclinic over the past 15 years suggests that it’s most useful to administer all 4 tests to complex and chronic pain patients, even those who do not seem particularly depressed or who show no noticeable signs of functional impairment. While these test instruments may appear verbose at first glance, they become familiar after the first few uses. Patients can then rate these 4 aspects (pain intensity, function, depression, and anxiety) in a matter of minutes. The textual descriptions of the various ratings also may serve as springboards for more in-depth discussions about each patient’s experiences.

Further study is needed to validate the IPCPS and compare it with more established pain scales (all scales can be downloaded at http://indianapolyclinic.com/images/PainScales.pdf).

Addiction Monitoring for Chronic Pain

With the documented rise in adverse events, deaths, and disorders linked to long-term opioid treatment for chronic pain, it’s important that providers carefully select appropriate patients and subsequently monitor those who are at risk for opioid misuse.39-42

The risks and benefits of long-term opioid therapy for chronic pain management can evolve over time. Personal or family history of addiction is a common risk factor associated with potential abuse and addiction, while psychosocial issues as well as comorbid medical and mental health conditions may be dynamic factors.39 Therefore, continuous assessment is necessary.43,44

Combining several addictive medication classes increases the likelihood of abuse and addiction. The CDC guidelines specifically caution against concurrent prescribing of benzodiazepines and opioids due to an increased risk of morbidity and mortality associated with the combination therapy. When mixed with opioids, benzodiazepine exposure can increase mortality by 70%.45

Opioid-induced respiratory depression (OIRD) is the most serious possible complication of opioid use. The common risk factors of OIRD were identified in a cohort of Veterans Health Administration patients. To determine the probability of serious OIRD, the authors developed a 17-question survey called the Risk Index for Overdose or Serious Opioid-Induced Respiratory Depression (RIOSORD).46 Opioid dependence, psychiatric disorder, pulmonary disease, liver disease, use of an extended-release opioid, use of an antidepressant, use of a benzodiazepine, daily morphine milligram equivalents (MME), and recent hospitalizations or emergency department visits were all identified as relevant risk factors for OIRD. Each of these variables correlates with an average predicted probability of OIRD by incremental risk of 3% to 94%.

Beyond the risk of respiratory depression, benzodiazepine exposure has been associated with higher cardiovascular and suicide mortality.47 Accordingly, pain practitioners should collect relevant information and pay close attention to which medications are prescribed to which patients by other health care providers.

Researchers identified significant differences between chronic pain patients with and without a substance use disorder long ago, but clinicians paid little attention to such differences for many years.48 Many of the available risk monitoring assessments are intended for use before commencing long-term opioid therapy and predict the probability of future misuse. However, these assessments ignore the need to continuously monitor risks and benefits.40-42 Even those instruments intended for continuous monitoring are often specific to opioid misuse and fail to assess other potential risk factors, such as psychosocial changes, abuse of other substances, and presence of psychiatric conditions.42 Current Opioid Misuse Measure (COMM) is one of the very few tools intended for ongoing reassessment of a pain patient on opioids, but it still does not include assessment of tobacco, alcohol, or other substances of abuse.49

Last updated on: September 13, 2017
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