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Guidance on psychological assessment and management of chronic pain during the COVID-19 crisis
By Kathleen S. Brown, PhD , and Daniel L. Bruns, PsyD April 17, 2020
Pain is one of the most common complaints patients bring to health care providers, documented in about 80% of all medical visits (Centers for Disease Control and Prevention, 2010). Unfortunately, the COVID-19 pandemic has disrupted treatment plans for patients with persistent pain as routine medical office visits, elective pain interventional procedures, physical therapy and medication trials have been cancelled or postponed.
Anxiety, stress and fear reactions to the impacts of the novel coronavirus can intensify the pain experience resulting in worsening psychosocial distress such as depression, sleep problems, physical deconditioning and social isolation, all at a time when physical distancing has been prescribed as one of the primary methods of self-protection.
As psychologists adapt their clinical practices to meet the demands brought on by the COVID-19 crisis, they may find themselves needing to address more of their patients’ needs, including pain management, as specialty care may not be available. This means that many providers may need to become familiar with the basics of psychological pain assessment and treatment that can be delivered via teleconferencing technology.
The purpose of this guide is to assist psychologists to better understand the evidence base and practice recommendations for pain psychological assessment and interventions in a remote, online format, similar to the tele-assessment guidance and teleneuropsychology guidance provided by APA regarding the challenges of providing assessment services when in-person contact is not available. This document will also address issues that should be discussed with patients and their prescribing providers about the use of opioids during this crisis.
Focusing on pain during the pandemic
It is important to address pain in virtually all psychological and mental health care. In the context of the COVID-19 pandemic, people with pain may experience heightened pain intensity, and they may be at risk for pain-associated exacerbations in symptoms of depression, anxiety and PTSD, as well as family and relationship distress.Heightened pain may also be a trigger for relapse during alcohol and substance use disorder treatment.
As such, all psychologists are encouraged to routinely ask patients about the presence and intensity of pain and about any changes in pain intensity and pain quality. It is also important to explore how pain is impacting the patient’s physical and emotional functioning, as well as their capacity to sustain ongoing treatment and daily function.
When significant pain is present, and especially if it is not well controlled, patients should be encouraged to stay in close touch with their primary care and pain specialty care providers during the pandemic.
This is a time when pain symptoms, mental health issues, and marital and family dysfunction could more quickly escalate, and psychologists are encouraged to initiative these important discussions about pain. It is critical for psychologists to reinforce the basics of healthy behaviors especially not smoking, eating well and exercising.
Psychologists are additionally encouraged to inquire about and support clients’ efforts to continue with their current plan of pain care, especially adaptive self-care, and taking pain medications as directed, during the COVID-19 pandemic. Ideally, with the acknowledgement of their patient, psychologists should act on prior authorization to maintain communication with the patients’ other providers to ensure coordination of care.
The nature of pain
The nature of pain, both acute and chronic, is widely misunderstood. Pain is often regarded as a bad thing, when it is actually an indispensable experience.
Acute pain is the body’s alarm system, it warns of potential harm. Acute pain initiates defensive reactions to protect oneself, such as jerking one’s hand away from something hot, or triggering the fight or flight response to escape from a potential threat. Pain resulting from injury normally resolves in a period of a few days to three months. Pain that lasts longer than three months is called chronic pain.
According to the DSM-III, DSM-IV and ICD-10, a defining symptom of pain disorders is the presence of “medically unexplained symptoms” (MUS). Although MUS remains a commonly used clinical construct, recently both the DSM-5 and ICD-11 rejected this diagnostic criterion. The DSM-5 states that the concept of MUS had created “pejorative and demeaning” attitudes towards patients, along with the implications that such symptoms are not “real” (American Psychiatric Association, 2013). To the contrary, over the last 20 years science has discovered explanations for many of these “unexplained” pain conditions.
A biopsychosocial disorder
While chronic pain is sometimes secondary to an identifiable disease process, such as cancer or arthritis, in many other cases the etiology is unrelated to any known disease or “primary”. In the latter case, primary chronic pain can be thought of as a biopsychosocial and sensory disorder.
As an example, consider what happens when someone is taking your picture and flashes a strobe light in your eyes. Immediately afterwards, you will see a blue blob floating around the room. The light from the strobe is gone, but you continue to see a sensory afterimage. Similarly, sometimes pain persists after an injury heals due to a phenomenon reminiscent of a visual sensory afterimage, as the pain experience has become memorized by the pain sensory system (Apkarian, Baliki and Geha, 2009).
In this manner, current conceptualizations of primary chronic pain regard it as a disease in its own right (Nicholas et al., 2019; Treede et al., 2019; World Health Organization, 2019). In contrast to acute pain, primary chronic pain is a false alarm and not an indication of tissue damage.
Chronic pain is known to be 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.
As chronic pain is a multidimensional biopsychosocial disorder, the assessment of pain should be multidimensional as well. The assessment of patients with pain can be conceptualized as a two tier process: assessing both extreme and moderate risk factors (D. Bruns and Disorbio, 2009; D Bruns and Disorbio, 2015; Colorado Division of Workers' Compensation: Chronic Pain Task Force, 2017).
Extreme risk factors for a poor outcome from pain treatment are “red flag” indications, “exclusionary” risk factors or “primary” risk factors. In the assessment of chronic pain, these risk factors are thought to include suicidality, violent tendencies, psychosis, intoxication/active substance abuse and other types of severe conditions. The presence of these risk factors is so destabilizing that the treatment of these conditions generally need to be resolved prior to initiating pain treatment (D. Bruns and Disorbio, 2009).
Alternatively, moderate risk factors for a poor outcome from pain treatment have been called “yellow flag” indications, “cautionary” risk factors or “secondary” risk factors. These risk factors include depression, anxiety, somatic complaints (physical symptoms of stress, 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 (D. Bruns and Disorbio, 2009; D Bruns and Disorbio, 2015; Celestin, Edwards and Jamison, 2009).
Assessment of risk factors can be accomplished in several ways via telehealth platforms. A pain assessment battery can be assembled using a number of one-dimensional questionnaires relevant to the presenting pain-related complaint. Commonly, the battery includes the following: