Assessment of the Patient With Pain

When a patient presents with pain, it is important that physicians and other health care professionals accept the reality of the pain for the patient. Chemically dependent individuals may feign pain in order to obtain opioid medications, but this is a rare occurrence apart from emergency settings where patients do not have ongoing relationships with their physicians. Previous studies have suggested that 3%-19% of patients in chronic pain clinics also may have substance abuse problems. These patients may inappropriately seek opioid medications, but it is unfair and misleading to think of these patients as lying about their pain. A great deal of overlap exists between "mental" and "physical" pain in patients with chronic pain.

One of the major difficulties health care professionals encounter in assessing patients with pain is the lack of a clear correlation between the amount of pain reported and the amount of tissue pathology as revealed by diagnostic tests and physical examination. Individuals can experience severe pain in the presence of minimal organic pathology or little or no pain despite extensive disease processes. For example, Gore et al. (1987) found no relationship between radiological findings and the severity of neck pain experienced. Jensen et al. (1994) reported that only 36% of the asymptomatic subjects had normal lumbar spines on magnetic resonance imaging scans. Any attempt to determine whether pain is in excess of what might be expected runs aground on the multiple psychosocial factors that influence the clinical pain experience, including the amount of threat to the person and his or her interests associated with the pain, cultural expectations about pain, and the family's history of coping with pain. It is very tempting but dangerous to resort to concepts such as "exaggerated pain" or "psychogenic pain" in patients with significant mismatch between pain reports and physical findings. Variance between pain reports and physical findings is common in clinical pain problems, and no validated method exists for determining when the mismatch is typical or "pathological."