Psychosocial Assessment

The repeatedly dashed hopes of patients with neuropathic pain, to say nothing of the total emotional burden of the pain problem, can affect all phases of patients' lives. They experience frustration, despair, anger, anxiety, and depression. ^* Their coping skills diminish as do their physical capabilities, and the ravages of time, powerful medications, and dampened spirits affect their ability to "think clearly," remember information, and concentrate. Most patients with neuropathic pain do not have psychiatric disease, although those that are suspected of such should be evaluated by psychiatrists. The majority of patients with neuropathic pain will have problems with anxiety/depression, coping skills, anger management, activity pacing, and pain-related insomnia. These aspects of a pain problem can be assessed by a psychologist.

The psychosocial impact of the pain may ultimately be the arena in which the most unique therapeutic intervention is possible. Assessing the patient with neuropsychological testing or other tests for the patient being considered as a candidate for major nerve blocks, opioid therapy, and high-technology interventional therapies such as spinal cord stimulators or implanted intrathecal pump fosters the selection of patients most likely to benefit from the chosen management. It is important to gain an understanding of the patient's behaviors related to pain and the reinforcing elements, such as (1) using the pain as a convenient excuse to avoid undesired activity, (2) using language that implies tissue damage but which is really covering anxiety and depression, (3) manifesting the lack of genuine motivation to improve (the motivation of possible financial gain from a prevailing lawsuit), (4) noting the influence of external agencies such as workman's compensation or the disability system (the loss of independence, the dictated appointments), and (5) acknowledging the acquired "comfort" of the pain-based lifestyle (the pain serving as an excuse from work, for free time, and being at home).

Pain due to primarily psychological factors is profoundly different from that associated with obvious physical causes. Overall, the thrust, once the primary evaluation is completed, is to distill all available data into a differential diagnosis and a working diagnosis. From this position of knowledge, the patient and referring physician can be informed about treatment that is relevant to and rational for the diagnosis. Thereafter, management planning begins and eventually the primary and secondary treatment strategies can be elaborated.

Follow-up visits are an expected part of the practice of pain medicine. Some of the same evaluation tools used initially have validity when completed by the patient at serial visits. It is likely that the agenda of the follow-up visit will be focused on how the patient has responded to each therapeutic modality. It is also crucial that the patient has time to "talk with the doctor," although non-physician health care professionals have a meritorious role in facilitating the flow of patients in a practice and in educating patients. It is time-efficient to use a protocol in this clinical setting, so that important aspects are not overlooked. It is fundamental that the practice determines what outcomes are desired and/or expected, and acknowledges that most pain conditions have a natural history, the reality of which complicates outcomes research. Even when a patient is participating in a series of treatments (e.g., epidural steroid injections or sympathetic nerve blocks), it is absolutely essential to decide at each visit that the planned treatment is still appropriate for that patient at that time. Because the patient's individual circumstances can change from visit to visit, the setting in which the clinical care is being provided is different.

In general, the goal of treatment in inflammatory pain is to restore the patient to his or her pre-pain lifestyle. In cancer pain patients, the primary goal is to improve the patient's quality of life. In chronic, non-cancer pain, the goals are to decrease the pain to the extent possible and improve the patient's ability to function. As with the primary evaluation, documentation of what is said by and to the patient and the details of treatment is necessary. Also, in patients with neuropathic pain, just because the pain is markedly reduced or eliminated with treatment does not mean that all of the psychosocial consequences of the pain also disappear. Thus, a review of the patient's plan for when he or she is feeling better is needed at early follow-up visits so that guidance can be provided to address this specific point. Furthermore, because one wants to maintain only those treatments deemed to be having a positive effect, the accuracy of the patient's feedback is crucial. Given the extent of neural reorganization and our not knowing how long it takes after injury for the nervous system to revert to normal (if that ever happens), the contemporary theme of pain management is to continue treatment past the expected healing period to the point that the modest goals of treatment are achieved.