What are the key considerations for a pain management follow-up visit?

Key Considerations for Pain Management Follow-up Visits

A comprehensive pain assessment at each follow-up visit is essential to ensure proper pain management and improve patient outcomes related to morbidity, mortality, and quality of life. 1

Pain Assessment Components

Pain Intensity Evaluation

• Use standardized pain rating scales at every follow-up visit:
  • 0-10 numeric rating scale (NRS) - ask about "current," "worst," and "usual" pain in past 24 hours
  • For comprehensive assessment, include worst pain in past week, pain at rest, and pain with movement 1
  • For patients who cannot use numeric scales, use alternative tools like the Faces Pain Rating Scale 1

Pain Characteristics Assessment

• Document changes in pain quality (aching, burning, sharp, shooting) 1
• Assess location, radiation pattern, and referral patterns 1
• Identify factors that exacerbate or relieve pain 1

Medication Evaluation

• Review current pain management plan and response to therapy 1
• For opioid-tolerant patients:
  • Calculate previous 24-hour total requirement
  • Assess need for dose adjustments (increase by 50-100% if pain score unchanged after 2-3 cycles) 1
  • Convert to oral medications when feasible, including extended-release agents with rescue doses 1

Special Assessment Considerations

For Non-verbal Patients

• Use validated observational pain assessment tools:
  • For patients with dementia: Assessment of Discomfort in Dementia Protocol (ADD), Checklist of Nonverbal Pain Indicators (CNPI), or Pain Assessment in Advanced Dementia Scale (PAINAD) 1, 2
  • For intubated/unconscious patients: Behavioral Pain Scale (BPS) or Critical-Care Pain Observation Tool (CPOT) 1

Psychosocial Assessment

• Evaluate for depression and anxiety, which significantly correlate with pain intensity 3
• Assess pain catastrophizing (negative distorted perception of pain) 3
• Identify passive vs. active coping strategies 3

Risk Assessment

• Monitor for risk factors for aberrant use or diversion of pain medications using tools such as:
  • SOAPP-R (Screener and Opioid Assessment for Patients with Pain-Revised)
  • ORT (Opioid Risk Tool) 1

Treatment Plan Updates

Medication Adjustments

• For uncontrolled pain (patient goals not met):
  • Titrate short-acting opioids appropriately
  • For opioid-naïve patients with moderate pain (4-6/10), initiate short-acting opioids 1
  • For opioid-tolerant patients with unchanged pain scores, increase dose by 50-100% after 2-3 cycles 1

Side Effect Management

• Begin or adjust bowel regimen to prevent constipation 1
• Monitor for and address both acute and chronic adverse effects 1

Functional Assessment

• Evaluate impact on:
  • Self-care activities
  • Daily activities
  • Physical activities
  • Sleep quality
  • Emotional well-being
  • Social functioning 4

Documentation and Communication

Written Follow-up Plan

• Provide written follow-up pain plan at each contact, including:
  • Prescribed medications
  • Patient's goals for comfort and function 1

Patient Education

• Instruct patients on:
  • Importance of following the documented pain plan
  • Maintaining clinic appointments
  • Contacting clinician if pain worsens or side effects develop 1
  • Setting realistic goals 1

Common Pitfalls to Avoid

1. Inadequate assessment frequency: Pain should be assessed during each outpatient contact or at least daily for inpatients 1

2. Focusing only on pain intensity: Pain assessment should include impact on function and quality of life 1, 5

3. Overlooking psychosocial factors: Depression, anxiety, and catastrophizing significantly impact pain experience and should be addressed 3

4. Poor care transitions: Ensure adequate access to prescribed medications, especially during transitions between sites of care 1

5. Failing to use standardized tools: Using validated pain scales improves detection of changes in pain intensity compared to verbal categorical rating scales 5, 6

6. Neglecting non-verbal patients: Alternative assessment methods must be used for patients unable to self-report pain 1, 2