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and craving.” Although other definitions exist (e.g., DSMIV), experts consider these terms the most applicable to pain management. A related term, pseudoaddiction, refers to patient behaviors that may occur when pain is undertreated, including increased focus on obtaining medications (“drug seeking”), “clock watching,” and even illicit drug use or deception.153 Pseudoaddiction can be distinguished from true addiction because such behaviors resolve with effective pain management.152 b. Etiology, issues, and concerns Many medications produce tolerance and physical dependence, and some (e.g., opioids, sedatives, stimulants, anxiolytics, some muscle relaxants) may cause addiction in vulnerable individuals.152 Most experts agree that patients who undergo prolonged opioid therapy usually develop physical dependence but do not develop addictive disorders.152 In general, patients in pain do not become addicted to opioids. Although the actual risk of addiction is unknown,152 it is thought to be quite low. A recent study of opioid analgesic use revealed “low and stable” abuse of opioids between 1990 and 1996 despite significant increases in opioids prescribed.154 Drug exposure appears to be only one etiologic factor in the development of addiction,152 and genetic, social, and psychologic factors may be more significant determinants.155-158 Fear of causing addiction (i.e., iatrogenic addiction), particularly with opioid use, is a major barrier to appropriate pain management.8,159-162 This fear sometimes reflects a lack of understanding of the risk of addiction with therapeutic drug use. Although studies suggest that the risk of iatrogenic addiction is quite low (e.g., Perry and Heidrich,163 Zenz et al.164), surveys indicate that clinicians often overestimate this risk.165-167 Alternatively, clinicians may be reluctant to prescribe an opioid because they have witnessed the devastation that addiction can cause in a patient’s life. Clinicians are also often reluctant to prescribe opioids due to concerns about licensing issues, peer review, state disciplinary action, and even legal prosecution (i.e., for over-prescribing, or under-prescribing‚ controlled substances).104 The Federation of State Medical Boards of the United States (FSMB) acknowledges such potential in their 1998 “Model Guidelines for the Use of Controlled Substances for the Treatment of Pain.”160 These guidelines attribute inadequate pain control to three major factors: ■ Physicians’ lack of knowledge about pain management, ■ Inadequate understanding of addiction, and ■ Fear of investigation or sanction by federal, state, and local regulatory agencies.160 These guidelines acknowledge that: “controlled substances, including opioid analgesics, may be essential in the treatment of acute pain due to trauma or surgery and chronic pain, whether due to cancer or non-cancer origins.”160 They assert that physicians should not fear disciplinary action for prescribing, dispensing, or administering controlled substances for a legitimate medical purpose (including pain) in the usual course of professional practice.160 However, they also state that “all such prescribing must be based on clear documentation of unrelieved pain and in compliance with applicable state or federal law.”160 These guidelines and other information about regulatory issues are located at www.fsmb.org/policy.htm and http://www.medsch.wisc.edu/painpolicy, respectively, on the World Wide Web. The latter URL also contains up-to-date information on specific state laws and regulations. National Pharmaceutical Council 17 Section I: Background and Significance Section II: Assessment of Pain A. I NITIAL A SSESSMENT O F PAIN Assessment is an essential, but challenging, component of any pain management plan. Pain is subjective, so no satisfactory objective measures of pain exist. Pain is also multidimensional, so the clinician must consider multiple aspects (sensory, affective, cognitive) of the pain experience. Finally, the nature of the assessment varies with multiple factors (e.g., purpose of the assessment, the setting, patient population, clinician), so no single approach is appropriate for all patients or settings. This section reviews some core principles of pain assessment and management to help guide this process. It then explores approaches that clinicians can use in the initial assessment of pain (i.e., patient history, physical examination, diagnostic studies). Subsequent discussions explore tools that facilitate assessment and address the reassessment of pain. 1. Overcoming Barriers to Assessment Underassessment of pain is a major cause of inadequate pain management (see I.E). In fact, the most common reason for the undertreatment of pain in U.S. hospitals is the failure of clinicians to assess pain and pain relief.1 This situation has prompted recent efforts to raise clinicians’ awareness of the importance of pain assessment. In 1996, the American Pain Society (APS) introduced the phrase “pain as the 5th vital sign.”a,2 This initiative emphasizes that pain assessment is as important as assessment of the standard four vital signs and that clinicians need to take action when patients report pain.1 The Veterans Health Administration recognized the value of such an approach and included pain as the 5th Vital Sign in their national pain management strategy.3 In addition to these efforts, the
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