The management algorithm ( FIGURE 2 ) now leads with “core principles”—a term suggesting greater importance than the former term, “general management,” implied. Clinical highlights, a synthesis of key recommendations, have been revised to better align with the guideline’s main components—assessment, functional goals, patient-centered/biopsychosocial care planning, Level-I versus Level-II approaches, and medication and patient selection.
Other changes in the guideline may contribute to clinicians’ understanding of chronic pain and its complex presentation. The guideline now includes a statement about allodynia and hyperalgesia to indicate that both may play an important role in any pain syndrome—not just in complex regional pain syndrome. Information about fibromyalgia symptoms and myofascial pain has been added. The definitions page now has an entry for “biopsychosocial model,” as well as language designed to stress the differences between untreated acute pain and ongoing chronic pain.
FIGURE 2 Chronic pain management
* DIRE, diagnosis, intractability, risk, efficacy.
Source: Institute for Clinical System Improvement. Reprinted with permission.
A limitation, an improvement
A limitation of the guideline is the lack of studies addressing the effectiveness of a comprehensive, multidisciplinary treatment approach to chronic pain management; most studies consider single-therapy management. An improvement, on the other hand, is that the evidence levels for each strategy are now listed within the section describing it—a notable change that makes it easier to identify the quality of individual recommendations.
As has been the case in the past, this latest edition of the guideline offers a number of tools for physicians. The assessment and management algorithms walk clinicians through decision-making. In addition, the following nine appendices provide practical guidance to physicians in various aspects of patient evaluation and care:
- Brief Pain Inventory (Short Form)
- Patient Health Questionnaire (PHQ-9)
- Functional Ability Questionnaire
- Personal Care Plan for Chronic Pain
- DIRE (diagnosis, intractability, risk, efficacy) Score: Patient Selection for Chronic Opioid Analgesia
- Opioid Agreement Form
- Opioid Analgesics
- Pharmaceutical Interventions for Neuropathic Pain
- Neuropathic Pain Treatment Diagram.
As noted, the source document for this guideline is: Assessment and Management of Chronic Pain. 3rd ed. Bloomington (Minn): Institute for Clinical Systems Improvement (ICSI); 2008 July.
The complete guideline is available at: pain__chronic__assessment_and_management_of__guideline_.html " target="_blank"> http://www.icsi.org/pain__chronic__assessment_and_management_of_14399/
pain__chronic__assessment_and_management_of__guideline_.html . (Accessed August 18, 2009.)