Guidance on psychological assessment and management of chronic pain

Unfortunately, the COVID-19 epidemic has thrown a wrench in patients' treatment plans, causing normal medical office visits, elective pain interventional procedures, physical therapy, and drug trials to be canceled or postponed.

Anxiety, stress, and fear responses to the novel coronavirus's effects can exacerbate pain, leading to worsening psychosocial distress such as depression, sleep problems, physical deconditioning, and social isolation, all at a time when physical distancing is recommended as one of the primary methods of self-protection.

Because speciality treatment may not be available, psychologists may find themselves needing to address more of their patients' needs, including pain management, as they modify their therapeutic practices to meet the demands brought on by the COVID-19 issue. As a result, many practitioners may need to learn the fundamentals of psychological pain assessment and therapy, which can be given by teleconferencing.

The goal of this guide is to help psychologists better understand the evidence base and practice recommendations for pain psychological assessment and interventions in a remote, online setting, similar to the tele-assessment and teleneuropsychology guidance provided by the American Psychological Association (APA) regarding the challenges of providing assessment services when in-person contact is not possible. This document will also cover topics that should be discussed with patients and their prescribers about the usage of opioids during this crisis.

During the pandemic, the focus was on pain.

In almost all psychological and mental health care, pain must be addressed. People experiencing pain may have increased pain intensity as a result of the COVID-19 pandemic, and they may be at risk for pain-related exacerbations of depression, anxiety, and PTSD, as well as family and relational problems. During alcohol and substance use disorder therapy, increased discomfort can also be a trigger for relapse.

As a result, all psychologists are recommended to question patients about the existence and intensity of pain, as well as any changes in pain intensity or pain quality, on a regular basis. It's also crucial to look into how pain affects the patient's physical and emotional functioning, as well as their ability to continue therapy and function on a daily basis.

Patients should be urged to keep in touch with their main care and pain specialty care providers during the pandemic if they are experiencing substantial pain, especially if it is not well controlled.

This is a time when pain symptoms, mental health difficulties, and marital and family dysfunction may develop more quickly, thus psychologists are advised to lead these essential pain dialogues. The importance of psychologists reinforcing the fundamentals of healthy habits, such as not smoking, eating healthily, and exercising, is crucial.

During the COVID-19 epidemic, psychologists should also question about and support clients' efforts to stick to their existing pain management plan, including adaptive self-care and taking pain medications as prescribed. Psychologists should, ideally, act on prior authorization after receiving a patient's acknowledgement to maintain communication with the patient's other physicians to ensure care coordination.

The nature of suffering

The nature of acute and chronic pain is commonly misunderstood. Pain is frequently misunderstood as a negative experience, whereas it is actually a necessary one.

Acute pain serves as a warning system for the body, alerting it to impending danger. Acute pain causes defensive reactions to protect oneself, such as pulling one's hand away from a hot object or activating the fight or flight response to flee from a potential attack. Injury-related pain usually goes away in a matter of days to three months. Chronic pain is defined as pain that lasts longer than three months.

The presence of "medically unexplained symptoms" is a defining sign of pain disorders, according to the DSM-III, DSM-IV, and ICD-10 (MUS). Despite the fact that MUS is still a widely used clinical construct, it was recently rejected by both the DSM-5 and the ICD-11. According to the DSM-5, the idea of MUS has resulted in "pejorative and humiliating" attitudes toward patients, as well as the inference that such symptoms aren't "genuine" (American Psychiatric Association, 2013). On the contrary, science has identified reasons for many of these "unexplained" pain syndromes in the previous 20 years.

A biopsychosocial condition

While chronic pain might be subsequent to a recognized disease process, such as cancer or arthritis, it is often unconnected to any known disease or "main" cause. Primary chronic pain can be viewed of as a biopsychosocial and sensory illness in the latter situation.

Consider what occurs when someone is taking your photo and a strobe light is flashed in your eyes. After then, you'll notice a blue blob floating around the room. The strobe light has faded, but you may still perceive a sensory afterimage. Similarly, pain can persist after an injury heals due to a phenomena similar to a visual sensory afterimage, in which the pain sensory system has memorized the pain experience (Apkarian, Baliki and Geha, 2009).

In this way, contemporary understandings of primary chronic pain treat it as if it were a disease in and of itself (Nicholas et al., 2019; Treede et al., 2019; World Health Organization, 2019). Primary chronic pain, unlike acute pain, is a false alarm and does not indicate tissue damage.

Chronic pain has been linked to brain circuitry changes in which pain sensory information is connected with cognitions, emotion, arousal, sleep disturbance, and poor functioning. Chronic pain is an excellent illustration of a biopsychosocial illness because of this.

Assessment of Pain

Pain assessment should be multimodal as chronic pain is a multifaceted biopsychosocial illness. The evaluation of pain patients can be thought of as a two-tiered procedure, with high and moderate risk factors being assessed (D. Bruns and Disorbio, 2009; D Bruns and Disorbio, 2015; Colorado Division of Workers' Compensation: Chronic Pain Task Force, 2017).

"Red flag" indications, "exclusionary" risk factors, or "principal" risk factors are all extreme risk factors for a poor outcome from pain therapy. Suicide, aggressive tendencies, psychosis, intoxication/active substance misuse, and other serious illnesses are regarded to be risk factors in the assessment of chronic pain. Because the presence of these risk factors is so disruptive, these issues must usually be addressed before beginning pain therapy (D. Bruns and Disorbio, 2009).

Alternatively, "yellow flag" indications, "cautionary" risk factors, or "secondary" risk factors have been used to describe intermediate risk indicators for a bad outcome from pain therapy. Depression, anxiety, somatic complaints (physical stress symptoms, 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 are all risk factors (D. Bruns and Disorbio, 2009; D Bruns and Disorbio, 2015; Celestin, Edwards and Jamison, 2009).