Pain is defined as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” (International Association for the Study of Pain)

Pain can be separated into two broad categories: acute pain and chronic pain. This distinction is not perfect- cancer pain, for example, may have components of both. Nevertheless, it remains a useful way to classify pain.

Assessment of Pain

One of the main problems in assessing patients with chronic pain is that the physical examination and laboratory tests often do not provide the information necessary to gauge severity and assess outcomes. Various survey instruments and visual analogue scales that allow precise measurements of pain are available but used only rarely. Pain is generally assessed indirectly, which why it is so important to listen to–and believe–patients when they say that they are in pain.

Some physicians apparently have difficulty with that. Many of my patients with chronic pain have been refused treatment by previous caregivers who apparently believed that their pain was not real. Even after undergoing painful procedures and surgeries that failed to bring relief, some of these patients were labeled as drug-seekers when they continued to ask for help. They had to contend not only with the pain but also with feelings of frustration, isolation, and abandonment by those on whom they had most relied.

In some cases, physicians may be well informed about pain mechanisms but lack an organized approach to the individual assessment of pain. A comprehensive evaluation of patients with chronic pain syndromes can be time-consuming and often requires more data than can be obtained in a few brief clinic visits. I have found the following operational format to be particularly useful, both in gauging the severity of pain and in determining the degree of disability:

1) The patient’s perception. Asking the patient to keep a pain diary that includes numerical scales can help to objectify the pain. If it is understood that the physician will review the diary carefully, the patient will not have to act out a month’s worth of pain at every appointment. The diary can also be an important aid in identifying exacerbating or ameliorating factors and developing more effective strategies to cope with the pain such as behavioral changes or the preemptive use of analgesics in certain situations.

2) The patient’s emotional state and somatic preoccupation. This relates to the degree to which the patient remains focused on bodily symptoms to the exclusion of other issues and often can be best assessed by interviewing a close family member.

3) Functional status at home. The first things that many patients in pain stop doing are usually non-work-related activities such as going out with family and friends, attending church, or engaging in hobbies. Some patients continue to report pain or discomfort even though their condition has improved. By keeping track of daily activities, both patient and physician have some measure of how disabling the pain actually is.

4) Functional status at work. The number of work days missed and the specific work activities curtailed because of pain are also useful indices of pain severity. Since these variables can be expected to change with analgesic treatment, they provide a way to gauge the patient’s response to different therapies.

5) Use of analgesic medications. If the patient is given an adequate supply of effective short-acting rescue medications and told to take them as needed, the number consumed can be a measure of pain. It can also be a way to assess whether the patient is benefiting from other medications or nonpharmacologic treatments. The physician should make it plain that the other treatments are not designed to get the patient to stop using the pain medication but to stop needing it.