Measurement-based care for complex pain

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What a single axis misses

A patient who reports 7 out of 10 may be describing untreated depression, an untreated sleep disorder, a trauma history that makes procedural care intolerable, a substance problem nobody has asked about, or a housing situation that makes adherence impossible. All five present as pain. Only one of them is pain.

The problem is not that clinicians do not know this. It is that asking takes time nobody has, the answers are uncomfortable to raise in person, and what is not measured does not appear in the note. Patients also under-report to a clinician’s face: in emergency assessment of acute musculoskeletal injury, nurse and patient pain ratings agreed only 27% of the time, with a mean difference of 2.4 points on an 11-point scale and 63% of patients under-assessed.¹ Nearly two thirds of chronic pain patients report feeling stigmatized by their own providers.²

A screen a patient completes on their own, on a device, before anyone is in the room, gets different answers than a conversation does. That is the whole design premise.

Thirteen domains, thirty-two instruments

Every instrument in the bank is validated, self-completed and scored. Nothing here is a homemade questionnaire.

Domain	Instruments
Pain	PEG, PPRS
Function and fear	RMDQ, TSK-11, PSEQ
Mood	PHQ-9, GAD-7, DASS-21, WHO-5, Y-BOCS
Suicidality	C-SSRS
Trauma	PCL-5, PCL-C, PC-PTSD-5, ACE
Emotion regulation	DERS-18
Sleep	ISI
Somatic burden	PHQ-15
Opioid risk and misuse	ORT, COMM
Substance use	AUDIT, CAGE, DAST-10, DUDIT, CUDIT-R, SDS, FTND, mYFAS-2
Neuropathy	MNSI Part A, DN4 interview
Social isolation	UCLA Loneliness Scale
Social determinants	AHC-HRSN (CMS core)

It does not ask everything every time

A thirty-two instrument battery would be abandoned halfway through, and a patient who resents the questions answers them badly. So each visit carries two fixed instruments and one drawn from the rest.

• Every follow-up visit: PEG and PHQ-9. Pain interference and mood, tracked continuously, so there is a trend line rather than a series of unrelated snapshots.
• One rotating instrument, drawn at random from everything the patient has not seen in their last six visits. Over a year of visits the picture fills in without any single visit being long.
• Instruments that do not apply are dropped. A patient who does not smoke is not walked through six cigarette questions — they say so once, a different questionnaire is substituted, and the refusal is remembered so it is not asked again next time.
• Sex-specific scoring is handled where it exists. The ORT weights three of its items differently for men and women; the DUDIT scores identically but is read against a different threshold. Both ask first.

What comes back

The clinician gets a printed sheet before the visit, and the patient gets their own copy. Each scored instrument carries its raw score and its published screening band — a PHQ-9 of 18 reads moderately severe, an AUDIT of 21 reads possible dependence, an ISI of 25 reads severe — so nobody is converting numbers in their head at the desk.

Six instruments deliberately print no band. PEG, RMDQ, PSEQ, DERS-18, SDS and the social determinants screen have no single accepted cut-off, and a printed band carries an authority a raw number does not. Inventing one would be worse than leaving it off.

Two findings escalate immediately. A positive C-SSRS puts a notice on the patient’s own screen asking them to speak to staff before they sit down. A positive interpersonal safety screen does the opposite: it reaches staff on the printout and shows the patient nothing at all, because the person harming them may be sitting beside them in the waiting room.

Why this matters in complex patients

The average new patient arriving at Padda Institute has been in pain more than two and a half years and is taking more than 90 MME per day. Some are inherited from primary care at 400 to 500 MME. These are not patients whose problem is one number.

Under active interventional treatment, 21% are completely weaned off opioid pain medication within 90 days and 34% within one year. Of those who cannot be fully weaned, the large majority are brought below 30 MME per day. Across the established population, fewer than 1% remain above 90 MME.

These are practice-reported figures from our own population, not trial outcomes, and individual results vary.

Measurement is what makes that defensible rather than anecdotal. A taper is a clinical decision that has to be justified against what the patient is actually experiencing — their function, their mood, their sleep, their misuse risk, whether they have somewhere stable to live. When those are measured on a schedule, the reduction is a result you can point at. When they are not, it is an assertion.

Where this meets opioid stewardship

Stewardship here is not abstinence and it is not a policy imposed on the patient. It is the management of complex, difficult situations and harm reduction in the context of human frailty. The practice does not treat pain with opioids as the answer; it takes patients who are already on them, treats the problem interventionally, and brings the dose down without putting them into withdrawal.

That is only defensible if you know what else is going on. A taper attempted against untreated depression, an untreated sleep disorder or an unrecognised substance problem is a taper that fails, and the failure gets attributed to the patient. Measurement is what separates a reduction you can justify from one you are hoping for.

The positions this rests on

• No medication-only management. Opioids are not offered as the treatment. They are what a patient often arrives on, and reduction is a result of treating the problem rather than a target imposed on them.
• Reducing pill counts by switching to long-acting agents is not stewardship. Receptor cycling and opioid-induced hyperalgesia mean a lower tablet count can carry a worse pharmacological position — the mechanism is set out here.
• Counting tablets is not monitoring. Pill counts versus pharmacology.
• Benzodiazepines alongside opioids get weaned, and the reasoning is published rather than asserted — Benzodiazepines and opioids: why not both.
• Deprescribing in older adults is a falls question, not only a pain question — deprescribing and falls risk, which is also where the cognitive and balance testing on Measura earns its place.
• Risk is stratified with instruments, not impressions. The ORT before opioid therapy is considered, the COMM for misuse in progress. Different questions; neither substitutes for the other.

The full clinical position — medical necessity, documentation, urine drug testing, PDMP use, co-prescribing and the MME figures behind all of it — is set out for referring clinicians and pharmacists in Opioid stewardship for pharmacists and physicians.

Watch and read

• Benzodiazepines and Opioids: Why Not Both — video
• Deprescribing and Falls Risk in Older Adults — video
• How many chances do you get at pain management?
• International Overdose Awareness Day — press release, where the practice-reported weaning figures were first published
• Padda Institute news and press

How this handshakes with Measura

MediMetRx measures what the patient can tell you. Measura measures what they cannot.

The questionnaires on this page capture symptom, function, mood, trauma, sleep, substance use and social circumstance — everything that depends on the patient reporting it. Cardiometabolic and autonomic testing capture the physiology underneath: arterial stiffness and endothelial function, cardiac autonomic reflexes, heart rate variability, resting metabolic rate, body composition, and the sudomotor and small-fibre changes that precede a neuropathy diagnosis by years.

The two halves check each other, and the neuropathy pathway is the clearest example. A patient completes MNSI Part A and the DN4 interview at the kiosk and reports burning, numbness and night-worse symptoms. That is a symptom pattern, not a diagnosis. Autonomic and small-fibre testing then says whether there is measurable dysfunction behind it, how far it has progressed, and whether it is changing under treatment. Symptoms without physiology is a guess; physiology without symptoms misses the patient’s actual experience.

• Cardiac autonomic reflex tests and heart rate variability — autonomic function, which chronic pain and long-term opioid exposure both alter
• Arterial stiffness and endothelial function — vascular contribution to pain and to healing
• Indirect calorimetry and bioimpedance body composition — metabolic status, which drives inflammation and recovery
• Cognitive assessment and vestibular and balance testing — the fall-risk axis that pain, medication and neuropathy all feed
• Measura for physicians — adding the testing to your own practice

A patient can be positive on one side and clean on the other, and that discrepancy is itself the finding. Neither platform is trying to be the other.

Referring a patient

Patients referred to Padda Institute enter the same measurement program from their first follow-up visit. There is no questionnaire at registration — a first visit is for registration and a photograph, nothing more. If you want the measurement record for a patient you have referred, ask and we will send it.

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About Dr. Padda

Dr. Gurpreet Singh Padda, MD, MBA, MHP is an interventional pain physician and addiction medicine specialist in St. Louis, and the physician behind the measurement program described on this page. His practice is interventional-first: procedures and metabolic management rather than medication-only maintenance, with opioid reduction treated as a result of treating the problem rather than a target imposed on the patient.

He is a residency-trained anesthesiologist with fellowship training in interventional pain management, holds an MBA and a Master of Health Professions education degree, teaches and lectures on pain and addiction, and is a published author. A fuller biography and his credential detail are on painmd.tv.

Sources

1. Pierik JGJ, IJzerman MJ, Gaakeer MI, Vollenbroek-Hutten MMR, Doggen CJM. Painful Discrimination in the Emergency Department: Risk Factors for Underassessment of Patients’ Pain by Nurses. J Emerg Nurs. 2017;43(3):228–238. PMID 28359711. Dutch cohort, n=539, nurse assessment of acute musculoskeletal pain after extremity injury.
2. U.S. Pain Foundation. A Chronic Pain Crisis. Survey fielded 29 March – 12 April 2022, n=2,378. 63% reported feeling stigmatized by their providers.
3. Opioid figures are practice-reported from the Padda Institute population and are stated separately for arriving and established patients. They are not trial outcomes.

Written and medically reviewed by Dr. Gurpreet Singh Padda, MD, MBA, MHP. This page describes a clinical measurement program and is not medical advice. Screening scores are screening bands, not diagnoses.