It used to be that there were only a finite number of assessment and treatment tools available in pain medicine. Nowadays, a clinician cannot open a journal or text, or attend a conference without being introduced to a new tool to guide best practice (see a list on the next page).1-6
I truly felt the impact and enormity of the issue while doing research for this article and discovered that I was not the first to pose the question. Gregory and Richardson were interested in identifying which pain assessment tools were used in clinical practice at their institution, how consistently they were used, and what outcomes they provided. While Gregory and Richardson found that there were preferred tools consistently used among individuals with similar education and clinical focus, their survey also revealed that “… there is no one accepted assessment tool in use across the organizations represented and it is important that nurses are aware which pain assessment scale is used in their organization to ensure consistency.”1
With tools available that are diagnosis specific, such as fibromyalgia;7,8 characteristic specific (ie, acute/chronic/functional);9-11 and treatment specific, such as opioid prescribing,12 how do we best approach the uniquely individual patient? Yes, generalizability is one hallmark of a superior tool, but what do you do when one size doesn’t fit all?
Could the evolution of pain biomarkers make tools and scales redundant? Xu and Huang recently proposed that, “In the future, the emergence of magnetic resonance spectroscopy and cell labeling in MRI would encourage the investigation on metabolic and cellular pain biomarkers. The incorporation of machine learning algorithms with neuroimaging or behavior analysis could further enhance the specificity and accuracy of objective pain assessments.”13
If continuity of use is important, how does a group decide which tools to use and where does the consensus begin? Can professional organizations provide guidance? Many organizations including the American Academy of Pain Medicine, American Society for Pain Management Nursing, American Association of Nurse Practitioners, American Academy of Physician Assistants, American Society of Clinical Oncology, Oncology Nurses Society, and the International Association for the Study of Pain have recommendations and preferred tools for the assessment and management of pain. Such tools, as well as scales and guidelines, are commonly adopted by different organizations.6,14,15
The reality of day-to-day clinical practice, however, is that clinicians working in a multispecialty group within an institution use the tool that is most readily available to them, such as what is built into their electronic medical record,16,17 or possibly what the local pharmaceutical representative brings to their office.18,19 As one question generally begets another, I must ask, is convenience to the clinician a sound and rational reason for choosing a tool or scale?
Do compliance and usability matter? What about validity? Are the assessment tools that we ask a patient to self-complete potentially less reliable than the ones we complete on behalf of a patient? I believe that one of the more important components of a pain assessment tool is usability. A tool that has been tested and validated, and that provides reliable and clinically relevant information is one that I will consistently use.
Are there legal consequences to the tools we choose to use, or not use? The tools that are consistently used and documented in the medical record, but which do not reflect independent decision-making can be a liability. In a court of law, the inclusion of a decision-making tool that is used inconsistently, inappropriately, or does not reflect clinical judgment unique to the patient and situation, could be argued as incompetence.
Overall, the use of tools for assessment and treatment of pain have significant value to clinical practice. The evidence suggests that the proper use of tools can have a positive effect on care and treatment outcomes. The key to successful pain management hinges upon the ability of the clinician to use the tools made available. To ensure an accurate assessment, therefore, a tool that enables a reliable and valid assessment should be chosen.
From there, the clinical value of the selected tool ultimately relies on a clinician’s understanding of how to use it, the clinical information that the tool is meant to provide, the validity of the tool, and consistency of its use. Only then can the tool’s quality correlate to its ability to consistently identify risk factors, reduce clinical errors, and predict or improve a patient’s outcome.