Pain management in a crisis

Pain is one of the most common complaints patients bring to health-care providers, documented in about 80% of all medical visits. Unfortunately, the COVID-19 pandemic has disrupted pain patients’ routine medical office visits, elective pain intervention procedures, physical therapy and medication trials, putting these patients at risk.

Here are some important points psychologists should keep in mind as they work with patients experiencing physical pain during the coronavirus outbreak.

Note: This article is a brief summary of the full guidance provided by APA on pain assessment and management during the COVID-19 crisis. The guidance offers practice recommendations for pain psychological assessment and interventions in a remote, online format when in-person contact is not available. APA has also published guidance on psychological tele-assessment during the COVID-19 crisis and teleneuropsychology guidance on CPT codes, technical requirements and more during the public health emergency.

The nature of pain is widely misunderstood. Acute pain is the body’s alarm system — it warns of potential harm. Acute pain initiates our defensive reactions to protect ourselves, such as jerking a hand away from a hot stove, or triggering the fight-or-flight response to escape from a threat. Pain caused by a physical injury normally resolves in a period of a few days to three months. Pain that lasts longer and interferes with daily functioning is known as chronic pain.

While chronic pain is sometimes secondary to an identifiable disease process, such as cancer or arthritis, in many cases the etiology is unrelated to any known disease or “primary” condition.

Chronic pain is 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.

Pain assessment is a two-tier process that looks at extreme and moderate risk factors for poor outcomes.

Extreme risk factors for a poor outcome from pain treatment are “red flag” indications, or “exclusionary” risk factors. These risk factors include suicidality, violent tendencies, psychosis, intoxication/active substance abuse and other types of severe conditions.

Moderate risk factors for a poor outcome from pain treatment have been called “yellow flag” indications, or “cautionary” risk factors. They include depression, anxiety, somatic complaints (physical symptoms of stress, autonomic arousal or vegetative depression), pain intensity, poor pain coping/cognitive distortions, addictive tendencies, poor physical functioning, insufficient support systems, advanced age, longer pain duration and pain-related litigation.

Psychologists can conduct a pain assessment battery using several one-dimensional questionnaires relevant to the patient’s complaint. Alternately, assessing the risk factors may be accomplished with a single multidimensional health psychology inventory (See the full guidance for specific recommendations).

Pain psychological evaluations also target the assessment of a patient’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.

The following evidence-based treatments have been reviewed in several pain guidelines:

• Cognitive behavioral therapy
• Emotional awareness and expression therapy
• Relaxation training
• Mindfulness based stress reduction
• Sleep hygiene training/cognitive behavioral therapy for insomnia
• Focus on functional gains

Patients and providers should understand that stress can impair the immune system. This breakdown in immune function can interfere with a patient’s ability to fight infections and heal, which make some pain patients more vulnerable to COVID-19.

If another provider has asked you to monitor the outcomes of the patient’s long-term opioid therapy as part of their pain management treatment, the “Four A’s” can provide beneficial information to guide the treatment plan:

• Analgesia: Best, average and worst daily pain intensities.
• Activities: What are they physically doing? 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, which is an expected consequence of extended opioid use, addiction involves the aberrant use of a substance. Addiction is characterized by the “Four C’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.

Given the professional pressures and personal stressors that all health-care providers are experiencing during this pandemic, if a change in plan is recommended, communicating with physicians needs to be succinct and clear so that they can quickly amend the medical treatment plan.