Addiction A chronic neurologic and biologic disease. As defined by pain specialists, it is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving. Continued craving for an opioid and the need to use the opioid for effects other than pain relief. Physical dependence and tolerance are not the same as addiction.
Breakthrough pain (BTP) A transitory increase in pain that occurs on a background of otherwise controlled chronic pain.
Comfort-function goal The pain rating identified by the individual patient above which the patient experiences interference with function and quality of life, that is, activities that the patient needs or wishes to perform.
DSM-IV Diagnostic and Statistical Manual of Mental Disorders. A guide for clinical practice that identifies mental disorders and lists diagnostic criteria. A revised edition, DSM-5, is in progress. The DSM-IV is most commonly used in the studies cited in this section.
Faces Pain Scale-Revised (FPS-R) A series of 6 faces, numbered 0, 2, 4, 6, 8, and 10, beginning with a bland facial expression and subsequent faces that increase in expression of distress. The patient is asked to point to the face that best reflects the intensity of his/her pain.
Hypoalgesia Decreased sensitivity to pain.
Intellectual disability Type of developmental disability that involves cognitive impairment that is evident in childhood and continues throughout life. Sometimes referred to as mental retardation. An intellectual disability may or may not be accompanied by a physical disability.
Malingering Intentionally produced symptom (e.g., pain) motivated by various factors, such as financial gain.
Neuropathic (pathophysiologic) pain Neuropathic (pathologic) pain is distinctly different from physiologic (nociceptive) pain. It is pain sustained by abnormal processing of sensory input by the peripheral or central nervous system, most often as a result of injury or trauma.
Nociceptive (physiologic) pain Normal processing of stimuli that damages normal tissues.
Numerical Rating Scale (NRS) Several types exist. The most commonly used NRS and the one used in this book consists of numbers placed along a horizontal line; the patient is asked to rate pain from 0 to 10, with 0 equaling no pain and 10 equaling the worst possible pain. It is recommended for use in clinical practice. The NRS can be presented verbally, but visual presentation is preferred. This scale may also be presented on a vertical line.
Opioid This term is preferred to narcotic. Opioid refers to codeine, morphine, and other natural, semisynthetic, and synthetic drugs that relieve pain by binding to multiple types of opioid receptors.
Placebo Any medication or procedure, including surgery, that produces an effect in a patient because of its implicit or explicit intent and not because of its specific physical or chemical properties.
Reliability Regarding pain measures, it means that the scale consistently measures what it is intended to measure, such as pain intensity or presence of pain, from one time to the next.
Self-report The ability of an individual to give a report, in this case, of pain, especially intensity. This is considered the “gold standard” of pain assessment. Patients may do this by marking on a scale such as the NRS or pointing to a number on a scale or a face. Head nodding and eye blinking can also be used to signal presence of pain and is sometimes used to rate intensity.
Substance abuse In the pain literature, this term is usually used to indicate problematic opioid use that is not as severe a problem as addictive disease. Based on DSM-IV criteria, which were used for most of the research presented in this book.
Substance dependence A term used in the pain literature to indicate addictive disease. Defined by DSM-IV criteria that differ from the criteria used for addiction proposed by pain specialists (see addiction).
Titration Adjusting the amount (e.g., adjusting the dose of an opioid).
Validity Regarding pain measures, it means that the tool accurately measures what it is intended to measure, such as pain intensity or presence of pain. A fundamental aspect of validity for pain rating scales is that they demonstrate sensitivity to changes in the magnitude of pain.
Verbal Descriptor Scale (VDS) Several types exist. This pain intensity rating scale is a list of adjectives describing different levels of pain intensity. An example that can be placed on a 0 to 10 metric scale is: no pain (0), mild pain (2), moderate pain (4), severe pain (6), very severe pain (8), and most intense pain imaginable (10).
Verbal Numerical Scale (VNS) A verbal presentation of the NRS, often a 0 to 5 scale or 0 to 10 scale; studies suggest that the patient should also be shown a visual of the scale.
Visual Analog Scale (VAS) A horizontal (sometimes vertical) 10-cm line with word anchors at the extremes, such as “no pain” on one end and “pain as bad as it could be” or “worst possible pain” on the other end. The patient is asked to mark the line to indicate intensity of pain, and the length of the mark from “no pain” is measured and recorded in centimeters or millimeters. Impractical for use in daily clinical practice.
The focus of this section is on assessment of the pain report itself, with some attention to how clinicians respond to these assessments. Misconceptions that hamper assessment and subsequent treatment of patients who report that they have pain will be discussed, followed by practical assessment tools for both verbal patients that can self-report and nonverbal patients who cannot self-report such as those with cognitive impairment. These include pain rating scales, pain behavioral scales, initial pain assessment tools, and flow sheets for reassessment of pain. Finally, challenges in pain assessment are addressed and include patients who deny pain or refuse analgesics, patients of different cultural backgrounds, the mentally retarded, and the mentally ill.