Assessing Chronic Pain

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Our series on Pain Management continues this week with insight on how clinicians assess pain. We spoke with Bryan Jensen, PhD, a clinical health psychology postdoctoral fellow at the VA Salt Lake City Health Care System, where he treats inpatients and outpatients with chronic pain as well as facilitates primary care chronic pain recovery groups. Dr. Jensen recently graduated with his doctorate in clinical psychology from Virginia Commonwealth University, where he focused his clinical and research work serving patients with chronic disease in both inpatient and primary care populations, most notably underserved patient populations and those with high levels of co-morbidities.

We asked him about his recent Translational Behavioral Medicine article on chronic pain assessment within a translational framework and the challenges facing researchers and clinicians who are studying and treating chronic pain.

Real World Health Care: Can you provide a summary of your recent article in Translational Behavioral Medicine?

Bryan Jensen: As researchers and clinicians seek to treat pain, we first need to understand if we are assessing pain accurately. The article is a review of how pain is assessed across the translational continuum. It starts by exploring the basic science of animal models of pain and the types of methods used in that setting to assess pain. Clearly, these methods are not the same methods we use in clinical practice — a rat is not the same as a human — but they must translate. We are starting to understand that older models of pain assessment may no longer be adequate, so we are looking at newer models and seeking to determine a more accurate definition of pain across clinical and research settings. Other translational issues are outlined with a focus on how providers are using pain assessment tools and how they can implement newer evidence-based tools for more evidence based assessment.

The article points to three main areas that hold promise to bridge current gaps. One is using computer adapted technologies to obtain self-reported measures of pain. Because we can’t take a “thermometer reading” of pain, we rely on patients’ assessments. But pain is multi-dimensional, and asking patients to go through a 100-question survey is daunting and time-consuming, so scientists have developed computer programs that evaluate how patients respond to clinicians’ questions and adapt those responses so clinicians can more efficiently and effectively get the information they need. The NIH has been rolling out these tools over the past decade.

The second promising area is lab-based, for example, using a blood draw to look for proxy measures of pain. This is more of a downstream method to assess the patient. These tools still require further research to understand how to directly translate into clinical practice.

The third promising area is observational. In animal models, we poke a rat and watch its response. With very few exceptions — such as needle prick tests for diabetic neuropathy — we’re not going to go poking human patients. But there are observation-based methods that allow clinicians to accurately measure pain and pain behaviors. For example, the University of Alabama at Birmingham developed a pain behavior scale. Unfortunately, it isn’t widely used, even though it has demonstrated excellent validity in terms of helping providers easily and quickly measure pain and pain behaviors like grimacing, holding one’s back, and limping. It really does an excellent job giving a complete picture of a patient’s experience.

RWHC: What are some of the important implications for patients and for the field of pain management?

BJ: The whole point of accurate pain assessment is to allow for more effective treatment. If patients are more aware of various pain assessment methods, they can advocate for themselves and request clinicians to widen their scope of assessment. Informed patients always help the clinical process.

The goals are improved assessment and treatment, which would lead to better patient care, higher patient satisfaction, and a reduced burden on patients, their families, and our nation. Economically, the cost of chronic pain is over $600 billion a year. If we can chip away at that, we would be making a huge impact.

RWHC: What are the biggest challenges facing researchers when it comes to studying pain assessment, and how can those challenges be overcome?

BJ: From a research perspective, there’s less emphasis on assessing pain than there is on treating pain. The main challenge is a financial one, with fewer research dollars dedicated to studying pain measurement. Another challenge is a theoretical one. There’s been some exciting, cutting-edge research on neurological measures, focused on neurosignatures that act as a thermometer to measure pain, but there’s been some discord in the field as to whether this is a useful pursuit. We also need better uniformity across the literature in terms of methods and measurement. The Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) has been working for well over a decade to develop consensus and establish best practices for measuring pain in clinical trials, but these best practices aren’t always followed.

RWHC: What are the biggest challenges facing clinicians in assessing pain, and how can those challenges be overcome?

BJ: Making clinicians aware of the latest research is a big challenge. I hear lots of clinicians express that they don’t have the training to fully assess and treat pain — especially chronic pain. Many providers approach treating someone with chronic pain with some trepidation as we have seen political, societal, and clinical swings in the use of opiates and other pain medications. Many clinicians will opt to not treat chronic pain or to seek out clinics with non-opiate policies. This is problematic, because the fact is that some patients do benefit from opiates.

We need more focus on early medical training. Medical schools are just starting to employ an integrated approach to pain, by combining the fields of primary care, psychology, pharmacy and social work. Trainees and residents are now being exposed to a broad-based perspective on how to approach and treat chronic pain, but additional course work is needed.

Clinicians also have a practical challenge. Most cases of pain are managed in primary care practices, and these clinicians are time-strapped. They default to the model of assessing pain by asking patients what their pain is on a scale of one to ten without looking at how pain impacts a patient’s functionality and quality of life. Those quality of life measures, like being able to get back to work or play with your kids, are important goals for treatment.

RWHC: What initially attracted you to this field and what continues to inspire you?

BJ: I initially became interested in the field of pain assessment when my daughter was born. She had an early medical condition — which fortunately turned out to be benign— and I was struck by the integrated team at the Shriner’s hospital who cared for her and our family. Since then, I’ve had wonderful opportunities to do clinical work with chronic pain patients. I continue to be inspired by my patients and the impact pain has on their lives. It’s gratifying to help them go from being essentially disabled to the point where they can regain their lives and take part in meaningful activities.

Read this article on Real World Health Care.