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Assessment and Management of Chronic Pain

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Assessment and Management of Chronic Pain Health Care Guideline Assessment and Management of Chronic Pain How to cite this document: Hooten WM, Timming R, Belgrade M, Gaul J, Goertz M, Haake B, Myers C, Noonan MP, Owens J, Saeger L, Schweim K, Shteyman G, Walker N. Institute for Clinical Systems Improvement. Assessment and Manage- ment of Chronic Pain. Updated November 2013. Copies of this ICSI Health Care Guideline may be distributed by any organization to the organization’s employees but, except as provided below, may not be distributed outside of the organization without the prior written consent of the Institute for Clinical Systems Improvement, Inc. If the organization is a legally constituted medical group, the ICSI Health Care Guideline may be used by the medical group in any of the following ways: • copies may be provided to anyone involved in the medical group’s process for developing and implementing clinical guidelines; • the ICSI Health Care Guideline may be adopted or adapted for use within the medical group only, provided that ICSI receives appropriate attribution on all written or electronic documents and • copies may be provided to patients and the clinicians who manage their care, if the ICSI Health Care Guideline is incorporated into the medical group’s clinical guideline program. All other copyright rights in this ICSI Health Care Guideline are reserved by the Institute for Clinical Systems Improvement. The Institute for Clinical Systems Improvement assumes no liability for any adap- tations or revisions or modifications made to this ICSI Health Care Guideline. www.icsi.org Copyright © 2013 by Institute for Clinical Systems Improvement Health Care Guideline: Assessment and Management of Chronic Pain Assessment Algorithm Text in blue in this algorithm indicates a linked corresponding Sixth Edition annotation. November 2013 1 Patient has pain 2 Critical first step: assessment • History and physical 4-7a • Key questions Pain types and contributing • Pain and functional factors are not mutually assessment tools exclusive. Patients frequently do have more than one type 3 of pain, as well as Determine biological overlapping contributing mechanisms of pain factors. 4 5 6 7 Neuropathic pain Muscle pain • Peripheral (e.g., complex Inflammatory pain Mechanical /compressive • Myofascial regional pain syndrome, • Inflammatory pain pain syndrome HIV sensory neuropathy, arthropathies • Low back pain metabolic disorders, (rheumatoid arthritis) • Neck pain phantom limb pain) • Infection • Musculoskeletal pain – • Central (e.g., Parkinson’s • Postoperative pain shoulders/elbow, etc. disease, MS, myelopathies, • Tissue injury • Visceral pain poststroke pain, fibromyalgia syndrome) 8 9 no Is pain chronic? Out of scope yes 10 Is there a 11 yes correctable cause Specialty involvement of pain? where indicated no 12 Other assessment • Work and disability issues • Psychological and spiritual assessment • Contributing factors and barriers 13 To Management algorithm – see next page Return to Table of Contents www.icsi.org Copyright © 2013 by Institute for Clinical Systems Improvement 1 Assessment and Management of Chronic Pain Sixth Edition/November 2013 Management Algorithm Text in blue in this algorithm indicates a linked corresponding 14 annotation. Level I core principles: • Develop plan of care and set goals using the biopsychosocial model • Physical rehabilitation with functional goals • Psychosocial management with functional goals 15 16 17 18 Level I management: Level I management: Level I management: Level I management: mechanical /compressive neuropathic pain muscle pain inflammatory pain pain 19 Level I other management: • Pharmacologic (obtain DIRE score) • Intervention • Complementary 20 Primary care to measure goals and review plan of care 25 21 24 Level II Management: Goals met? Has enough been interdisciplinary team • Function no yes referral, plus a pain • Comfort tried with Level I medicine specialist or pain • Barriers management? medicine specialty clinic yes no 22 Self-management plan of care 23 Outcome assessment Return to Table of Contents www.icsi.org Institute for Clinical Systems Improvement 2 Assessment and Management of Chronic Pain Sixth Edition/November 2013 Table of Contents Work Group Algorithms and Annotations ........................................................................................ 1-52 Co-Leaders Algorithm (Assessment) .......................................................................................................1 W. Michael Hooten, MD Algorithm (Management) .....................................................................................................2 Anesthesiology, Mayo Clinic Evidence Grading ............................................................................................................. 4-5 Richard Timming, MD Physical Medicine Foreword and Rehabilitation, Introduction .....................................................................................................................6 HealthPartners Medical Scope and Target Population ...........................................................................................7 Group and Regions Hospital Aims ................................................................................................................................7 Work Group Members Clinical Highlights ..........................................................................................................8 Fairview Health Services Miles Belgrade, MD Implementation Recommendation Highlights ............................................................ 8-9 Neurology Related ICSI Scientific Documents ..............................................................................10 James Gaul, MD Definitions ............................................................................................................... 10-11 Internal Medicine Kelly Schweim, PharmD Annotations .................................................................................................................. 12-52 Pharmacy Annotations (Assessment) .......................................................................................12-22 Fairview Range Regional Annotations (Management) .................................................................................... 23-52 Health Services Neal Walker, RPh Quality Improvement Support .................................................................................. 53-72 Pharmacy Aims and Measures ...................................................................................................... 54-55 HealthPartners Medical Measurement Specifications ................................................................................... 56-69 Group and Regions Hospital Implementation Tools and Resources .................................................................................70 Michael Goertz, MD, MPH Implementation Tools and Resources Table ................................................................. 71-72 Occupational Medicine Bret Haake, MD Supporting Evidence..................................................................................................... 73-98 Neurology References .................................................................................................................... 74-82 Mary Pat Noonan, PhD, ABPD Appendices ................................................................................................................... 83-98 Psychology Appendix A – Brief Pain Inventory (Short Form) ...................................................83-84 Midwest Spine Institute Appendix B – Patient Health Questionnaire (PHQ-9) .............................................85-86 Louis Saeger, MD, FACPM Appendix C – Physical Functional Ability Questionnaire (FAQ5) .........................87-88 Anesthesiology Appendix D – Personal Care Plan for Chronic Pain .....................................................89 Park Nicollet Health Services Appendix E – DIRE Score: Patient Selection for Chronic Opioid Analgesia ..............90 Galina Shteyman, PharmD Appendix F – Opioid Agreement Form ........................................................................91 Pharmacy Appendix G – Opioid Analgesics .................................................................................92 ICSI Appendix H – Neuropathic Pain Treatment Diagram ...................................................93 Cassie Myers Clinical Systems Appendix I – ICSI Shared Decision-Making Model ...............................................94-98 Improvement Facilitator ........................................................ 99-101 Jacob Owens, MPH Disclosure of Potential Conflicts of Interest Project Manager Acknowledgements .................................................................................................... 102-103 Document History and Development .................................................................. 104-105 Document History ............................................................................................................104 ICSI Document Development and Revision Process .......................................................105 www.icsi.org Institute for Clinical Systems Improvement 3 Assessment and Management of Chronic Pain Sixth Edition/November 2013 Evidence Grading Literature Search A consistent and defined process is used for literature search and review for the development and revision of ICSI guidelines. The literature search was divided into two stages to identify systematic reviews, (stage
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