In the final installation of our series on chronic pain, I would like to touch upon the tools that physicians have at their disposal for managing chronic pain.
The problem with the Likert scale
In the hospital, we love to use the Likert scale with the smiley and frowning faces to quantify the degree of pain. If a patient identifies himself or herself as having more pain with extension into the moderate to severe pain category, we (as physicians) respond accordingly with new or additional pain medication.
What happens in the outpatient setting when a patient who is already on pain medications, including opiate pain medicines, previously reported a 4 or 5 now presents as a 7? The physician, wanting to help and treat the pain, either writes a prescription for more drugs (opiates or opiate combo drugs) and/or adds another pain medication.
This type of scale encourages the patient to give a uni-dimensional “score” for all their suffering and misery, and blame it on the pain. As Dr. Moskowitz discussed in detail in the previous posts, pain is a biopsychosocial problem. This scale promotes the merging of the psychosocial with the biological. While it is useful when the single dimension needs to be considered in an acute setting of the hospital, it is less helpful when following patients in an ongoing outpatient basis.
What tools may be more helpful?
When physicians manage chronic pain patients, they must recognize that chronic pain management is more than “more pain, more drugs, less pain, less drug.” Chronic pain is characterized by a multitude of factors that must be assessed, recognized and managed. Validated instruments such as the Brief Pain Inventory (BPI) and the Oswestry Low back Pain Scale review the accurate diagnosis of pain, the complicating factors and functional limitations. BPI and Oswestry are particular scales that try to tease out functional issues from pain perception issues so that we may target the appropriate treatments toward functional recovery and adaptive coping.
Other tools such as the Pain Catastrophizing Scale and Pain Self Efficacy Questionnaire (PESQ) review the coping mechanisms that have become a part of the chronic pain management by the patient. The goal is to use objective tools which will promote objective measures. These two simple scales help us decipher the chronic pain patient’s emotional response. For example, the PSEQ assesses the confidence people with ongoing pain have in performing activities while in pain. In the context of chronic pain management, this enables us to understand how limited the injured worker perceives he is and how much structure he needs to accept new treatment approaches.
The tools above help us to detangle the biopsychosocial components and address chronic pain as a multidimensional problem.