Guidance on psychological assessment and management of chronic pain during the COVID-19 crisis

Pain is one of the most common complaints patients bring to health care providers, documented in about 80% of all medical visits (Centers for Disease Control and Prevention, 2010). Unfortunately, the COVID-19 pandemic has disrupted treatment plans for patients with persistent pain as routine medical office visits, elective pain interventional procedures, physical therapy and medication trials have been cancelled or postponed.

Anxiety, stress and fear reactions to the impacts of the novel coronavirus can intensify the pain experience resulting in worsening psychosocial distress such as depression, sleep problems, physical deconditioning and social isolation, all at a time when physical distancing has been prescribed as one of the primary methods of self-protection.

As psychologists adapt their clinical practices to meet the demands brought on by the COVID-19 crisis, they may find themselves needing to address more of their patients’ needs, including pain management, as specialty care may not be available. This means that many providers may need to become familiar with the basics of psychological pain assessment and treatment that can be delivered via teleconferencing technology.

The purpose of this guide is to assist psychologists to better understand the evidence base and practice recommendations for pain psychological assessment and interventions in a remote, online format, similar to the tele-assessment guidance and teleneuropsychology guidance provided by APA regarding the challenges of providing assessment services when in-person contact is not available. This document will also address issues that should be discussed with patients and their prescribing providers about the use of opioids during this crisis.

It is important to address pain in virtually all psychological and mental health care. In the context of the COVID-19 pandemic, people with pain may experience heightened pain intensity, and they may be at risk for pain-associated exacerbations in symptoms of depression, anxiety and PTSD, as well as family and relationship distress.Heightened pain may also be a trigger for relapse during alcohol and substance use disorder treatment.

As such, all psychologists are encouraged to routinely ask patients about the presence and intensity of pain and about any changes in pain intensity and pain quality. It is also important to explore how pain is impacting the patient’s physical and emotional functioning, as well as their capacity to sustain ongoing treatment and daily function.

When significant pain is present, and especially if it is not well controlled, patients should be encouraged to stay in close touch with their primary care and pain specialty care providers during the pandemic.

This is a time when pain symptoms, mental health issues, and marital and family dysfunction could more quickly escalate, and psychologists are encouraged to initiative these important discussions about pain. It is critical for psychologists to reinforce the basics of healthy behaviors especially not smoking, eating well and exercising.

Psychologists are additionally encouraged to inquire about and support clients’ efforts to continue with their current plan of pain care, especially adaptive self-care, and taking pain medications as directed, during the COVID-19 pandemic. Ideally, with the acknowledgement of their patient, psychologists should act on prior authorization to maintain communication with the patients’ other providers to ensure coordination of care.

The nature of pain, both acute and chronic, is widely misunderstood. Pain is often regarded as a bad thing, when it is actually an indispensable experience.

Acute pain is the body’s alarm system, it warns of potential harm. Acute pain initiates defensive reactions to protect oneself, such as jerking one’s hand away from something hot, or triggering the fight or flight response to escape from a potential threat. Pain resulting from injury normally resolves in a period of a few days to three months. Pain that lasts longer than three months is called chronic pain.

According to the DSM-III, DSM-IV and ICD-10, a defining symptom of pain disorders is the presence of “medically unexplained symptoms” (MUS). Although MUS remains a commonly used clinical construct, recently both the DSM-5 and ICD-11 rejected this diagnostic criterion. The DSM-5 states that the concept of MUS had created “pejorative and demeaning” attitudes towards patients, along with the implications that such symptoms are not “real” (American Psychiatric Association, 2013). To the contrary, over the last 20 years science has discovered explanations for many of these “unexplained” pain conditions.

A biopsychosocial disorder

While chronic pain is sometimes secondary to an identifiable disease process, such as cancer or arthritis, in many other cases the etiology is unrelated to any known disease or “primary”. In the latter case, primary chronic pain can be thought of as a biopsychosocial and sensory disorder.

As an example, consider what happens when someone is taking your picture and flashes a strobe light in your eyes. Immediately afterwards, you will see a blue blob floating around the room. The light from the strobe is gone, but you continue to see a sensory afterimage. Similarly, sometimes pain persists after an injury heals due to a phenomenon reminiscent of a visual sensory afterimage, as the pain experience has become memorized by the pain sensory system (Apkarian, Baliki and Geha, 2009).

In this manner, current conceptualizations of primary chronic pain regard it as a disease in its own right (Nicholas et al., 2019; Treede et al., 2019; World Health Organization, 2019). In contrast to acute pain, primary chronic pain is a false alarm and not an indication of tissue damage.

Chronic pain is known to be associated with altered circuits in the brain, where pain sensory information becomes intertwined with cognitions, mood, arousal, sleep disturbance and poor functioning. This makes chronic pain a perfect example of a biopsychosocial disorder.

As chronic pain is a multidimensional biopsychosocial disorder, the assessment of pain should be multidimensional as well. The assessment of patients with pain can be conceptualized as a two tier process: assessing both extreme and moderate risk factors (D. Bruns and Disorbio, 2009; D Bruns and Disorbio, 2015; Colorado Division of Workers' Compensation: Chronic Pain Task Force, 2017).

Extreme risk factors for a poor outcome from pain treatment are “red flag” indications, “exclusionary” risk factors or “primary” risk factors. In the assessment of chronic pain, these risk factors are thought to include suicidality, violent tendencies, psychosis, intoxication/active substance abuse and other types of severe conditions. The presence of these risk factors is so destabilizing that the treatment of these conditions generally need to be resolved prior to initiating pain treatment (D. Bruns and Disorbio, 2009).

Alternatively, moderate risk factors for a poor outcome from pain treatment have been called “yellow flag” indications, “cautionary” risk factors or “secondary” risk factors. These risk factors include depression, anxiety, somatic complaints (physical symptoms of stress, autonomic arousal or vegetative depression), pain intensity, poor pain coping/cognitive distortions (e.g. catastrophizing and kinesiophobia), addictive tendencies, poor physical functioning, insufficient support systems, advanced age, longer pain duration and pain-related litigation (D. Bruns and Disorbio, 2009; D Bruns and Disorbio, 2015; Celestin, Edwards and Jamison, 2009).

Assessment batteries

Assessment of risk factors can be accomplished in several ways via telehealth platforms. A pain assessment battery can be assembled using a number of one-dimensional questionnaires relevant to the presenting pain-related complaint. Commonly, the battery includes the following:

• Patient Health Questionnaire-9 (PHQ-9) (PDF, 434KB)
• Generalized Anxiety Disorder-7 (GAD-7) (PDF, 130KB)
• Patient Health Questionnaire-15 (PHQ-15) Somatic Symptom Severity (PDF, 18KB)
• Pain Catastrophizing scale (PDF, 3.49MB)
• Tampa Kinesiophobia scale
• PROMIS measure of physical function

Pain psychological evaluations also specifically target the assessment of one’s vulnerability to opioid overuse. A variety of brief screening tools can be used for opioid risk assessment but there is little empirical data available on their sensitivity and specificity.In a comparison of four opioid risk measures, the clinical interview showed the best sensitivity for predicting risk (Jones et al., 2012).

A telehealth option for administration of some of these brief measures may already be available in some settings, as they are commonly embedded in electronic health records. Some or all of these could be administered verbally via telehealth when software is not available.

Alternately, assessment of the variables above may be accomplished with a single multidimensional health psychology inventory, such as the Brief Battery for Health Improvement-2 (BBHI-2), Battery for Health Improvement-2 (BHI-2), Millon Behavioral Medicine Diagnostic (MBMD) or MMPI-2-RF. The advantage of multidimensional inventories such as these is that they incorporate measures of validity and may have HIPAA-compliant software that can be used via telehealth.

Whichever inventory is used, the goal of the psychological assessment of a patient with chronic pain is to understand the attitudes and comorbidities that impact the patient’s pain experience, so that a treatment plan can be developed accordingly.

Psychological treatments for pain are effective. The following evidence-based treatments have been reviewed in several pain guidelines (Agency for Healthcare Research and Quality, 2018; American College of Occupational and Environmental Medicine, 2017; Colorado Division of Workers' Compensation: Chronic Pain Task Force, 2017):

Cognitive behavioral therapy (CBT)

CBT is identified by multiple guidelines as the psychological treatment with the most evidence of efficacy for chronic pain. In CBT, distorted or inaccurate cognitions about pain are corrected and replaced with ones that are more accurate and helpful to improve the patient’s functioning. Two types of cognitions pertaining to chronic pain, catastrophizing and fear avoidance (kinesiophobia) have been shown to negatively impact one’s pain experience. It is beneficial to address these cognitions because they appear to increase one’s level of perceived pain and depression, as well as decrease functioning.

Emotional awareness and expression therapy (EAET)

EAET is a new treatment that adds additional dimension to psychological treatments for pain. While cognitive therapy focuses on altering cognitions, EAET focuses on clarifying and expressing emotional experiences. This treatment has been shown to be effective with certain types of centralized pain syndromes, such as fibromyalgia.

Relaxation training

Because of chronic pain’s association with hyperarousal, psychological treatments that reduce the activation of the sympathetic nervous system can be of benefit. These treatments include relaxation training, progressive relaxation and related treatments. Both relaxation training and progressive relaxation can be done over the phone. Alternately, patients can download an app, or be sent a CD or a link to a recording of relaxation activities to complete at home.

Mindfulness based stress reduction (MBSR)

MBSR is a skill that many patients find useful to regulate their pain. Patients with chronic pain may rarely allow themselves to experience their pain in a nonjudgmental fashion. MBSR allows patients to experience the sensory aspects of their pain without the overlay of negative thought and feelings, and this can reduce their level of perceived suffering.

Sleep hygiene training/cognitive behavioral therapy for insomnia

Patients with chronic pain often have sleep disorders. Many complain of sleeping four hours a night or less, which is another manifestation of hyperarousal. As exhaustion tends to increase pain, treating the sleep disorder may also reduce the level of perceived suffering.

Focus on functional gains

Guidelines have pointed out that when treating chronic pain, it is better to avoid becoming exclusively focused on pain complaints by attending to improving the patient’s level of functioning. In general, focusing on increasing function, range of motion and strength often leads to better pain management than focusing on the elimination of pain. Simple activities like going for daily walks can lead to significant benefits.

Pain, opioids and the immune system

It is important for patients and health care providers to understand that pain itself, as well as some medications (e.g. steroids, opioids), can weaken the immune system, the body’s primary defense against the novel coronavirus.

Persistent pain, and the subsequent stress it creates in the body, increases the level of cortisol, the body’s stress-induced hormone. When chronically elevated, stress can impair the cells of the immune system. This breakdown in immune function can interfere with one’s ability to fight infections and the healing processes, which make some pain patients more vulnerable to COVID-19.

The immune system plays a critical role in various physiological and pathophysiological processes. Because opioids, like the novel coronavirus, can cause respiratory problems, patients should be advised to discuss with their prescribing providers their current medical risks as well as to seek guidance on any changes to their pain management treatment plan that may impact their physical functioning and quality of life.

A multi-modal approach

As noted above, pain management is most effective when it uses multiple modalities, such as rehabilitative therapies (e.g., physical therapy and exercise programs), cognitive and behavioral therapies to change thoughts, feelings and actions, pharmacotherapy to reduce inflammation and attenuate pain, and lifestyle changes such as stretching, sleep and weight management.

A risk assessment for opioid analgesics is an important component of the process when considering pharmacotherapy options given the epidemic rise in opioid related deaths over the past two decades. Pain and opioid risk assessment can help providers more easily identify psychosocial factors, such as nonadherence patterns in care, ineffectiveness despite increased doses, underlying mood disorders and addiction to mitigate potential problematic behavioral outcomes specific to opioid use, such as overmedication.

It helps to remember and evaluate the multidimensional components and think in terms of what the patient has identified as their pain treatment goals.

Monitoring opioid treatment

If the prescribing provider has asked you to monitor the outcomes of the patient’s long-term opioid therapy as part of their pain management treatment, the “4 A’s” can provide beneficial information to guide the treatment plan (Passik et al., 2004):

• Analgesia: Best, average and worst daily pain intensities
• Activities: What are they physically doing? What are they not doing?
• Adverse effects: What and how severe are side effects?
• Aberrant behavior: Any evidence of opioid misuse, abuse or addiction? Concurrent use of alcohol or other substances?

In contrast to physical dependence (an expected consequence of extended opioid use), addiction involves the aberrant use of a substance. Addiction is characterized by the 4C’s:

• Continual use despite harm
• Craving
• Compulsive use
• Control that is impaired

Aberrant behaviors can result for a variety of reasons and must be evaluated to determine if they are problematic. The provider will be seeking specific information to help guide their decision-making around continued opioid prescribing such as:

• Patterns of patient’s functioning, i.e. if no improved function despite attempts at optimizing dosage
• Issues of co-morbidity, e.g. substance abuse
• Poorly understood or persistent adherence problems
• A high index of suspicion that the opioids are being diverted for another purpose

Finally, one way for psychologists treating patients with chronic pain to track outcomes is using an instrument such as the Pain Assessment and Documentation Tool (PADT). The PADT is a clinician-directed interview based on the 4 A’s, designed to focus on key outcomes. It provides a consistent way to document progress in pain management therapy over time and can be easily incorporated into your documentation of the session.

Sharing information with physicians

Given the professional pressures and personal stressors that all health care providers are experiencing during this pandemic, succinct, clear and “to the point” communication should be used with physicians regarding any recommended changes in plans.

Within medical settings the SBAR (Situation, Background, Assessment and Recommendation) technique (Haig, Sutton and Whittington, 2006) is traditionally used to relay information efficiently. All the usual caveats around confidentiality, consent and documentation apply in the telehealth environment as they do for face-to-face interactions.