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Brief Pain Inventory (BPI)
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Practical Information
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Instrument Name:
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Brief Pain Inventory (BPI)
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Instrument Description:
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The Brief Pain Inventory (BPI) is a pain assessment tool used with cancer patients to measure both pain intensity (sensory dimension) and pain interference (reactive dimension) in the patient’s life. (Ref: 1) Patients rate their pain severity at its worst and least in the last week, on the average, and “right now.” (Ref: 1,3) Patients rate their level of pain interference in seven contexts: (1) work, (2) activity, (3) mood, (4) enjoyment, (5) sleep, (6) walking, and (7) relationships. (Ref: 3) The BPI also assesses the patient’s pain intervention, pain quality, and perception of the cause of pain. Other BPI items include: (1) shade-in of patient’s area of pain on a front and back view of a human figure; (2) rating the amount of relief patient feels that the current pain treatments provide; (3) rating the duration of patient’s pain relief after taking prescribed pain medications; (4) assessing patient’s attribution of pain to the disease, the treatment of the disease, or conditions unrelated to the disease. (Ref: 1)
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Price:
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Free; for availability see “Research Contacts.”
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Administration Time:
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10-15 minutes. (Ref: 1-2)
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Publication Year:
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1994
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Item Readability:
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The Flesch-Kincaid grade level was 5.4, indicating that someone with a fifth- grade education could comprehend the items.
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Scale Format:
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The BPI consists of dichotomous response questions (yes/no), open-ended questions, and an 11-point Likert type scale (0 to 10). (Ref: 1)
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Administration Technique:
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Self-administered or used in a clinical interview, depending on the patient. (Ref: 1)
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Scoring and Interpretation:
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On the 0-10 pain intensity scale, 0 refers to ‘no pain’ and 10 to ‘pain as bad as you can imagine.’ (Ref: 5) On the scale for the seven pain interference items, 0 is ‘no interference’ and 10 is ‘complete interference.’ (Ref: 3) The pain interference total score ranges from 0-70. (Ref: 5)
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Forms:
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Brief Pain Inventory (Short Form); translations in Chinese, Filipino, French, German, Greek, Hindi, Italian, Japanese, Spanish, Taiwanese, and Vietnamese.
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Research Contacts
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Instrument Developers:
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Charles S. Cleeland, PhD and K.M. Ryan, BBA
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Instrument Development Location:
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WHO Collaborating Centre for Symptom Evaluation in Cancer Care, University of Wisconsin-Madison
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Instrument Developer Email:
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ccleeland@mdanderson.org
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Instrument Developer Website:
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www3.mdanderson.org/depts/prg/bpi.htm
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Annotated Bibliography
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1. Cleeland CS, Ryan KM. Pain Assessment: Global Use of the Brief Pain Inventory. Ann Acad Med 1994 March;23(2):129-38. [PMID:8080219]
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Purpose:
To describe the development of the Brief Pain Inventory (BPI) and the various applications of the BPI.
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Sample:
Non-applicable
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Methods:
Non-applicable
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Implications:
Other study findings suggest that cancer patients who are in pain from widely different cultural and linguistic backgrounds respond in a similar fashion to rating the severity of their cancer-related pain and the interference caused by their pain. The BPI has demonstrated test-retest reliability, at least over short periods of time. BPI validation has come from other studies that used it with patients with cancer and those with other diseases who had pain. Also, differences in pain severity were found between groups of patients with pain who had the presence or absence of metastases. And pain interference scores with different activities increased as pain severity ratings were higher.
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2. Cleeland CS, Nakamura Y, Mendoza TR, Edwards KR, Douglas J, Serlin RC. Dimensions of the Impact of Cancer Pain in a Four Country Sample: New Information from Multidimensional Scaling. Pain 1996;67:267-73. [PMID: 8951920]
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Purpose:
To examine how cultural and language differences affect relationships among ratings of pain’s interference with functions such as enjoyment of life, activity, mood, work, and sleep.
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Sample:
N = 1843 patients with metastatic cancer and pain. The sample consisted of: 3 US samples (N = 169, N = 180, N= 757), a Philippine sample (N = 267), a French sample (N = 324), and a Chinese sample (N = 146). Demographic characteristics: US samples - 53% male, 47% female, mean age = 59.59 (SD = 13.97), minimum age = 22, maximum age = 83; French sample – 58% male, 42% female, mean age = 58.02 (SD = 12.68), min age = 22, max age = 89; Chinese sample – 58% male, 42% female, mean age = 54.23 (SD = 14.21), min age = 18, max age = 86; Philippine sample – 27% male, 73% female, mean age = 47.66 (SD = 13.20), min age = 23, max age = 83.
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Methods:
The completed BPI served as implied informed consent. Patients excluded from the study were those who indicated no pain in response to the ‘pain worst’ item of the BPI. Non-metric multidimensional scaling (MDS) was used to examine other dimensions of pain interference ratings.
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Implications:
The mean value for the worst pain item on the BPI was higher for the Chinese sample than for the other samples. Although the number of male and female patients were unequal, no significant differences between males and females within any of the country samples were found using MDS. According to the MDS scaling analysis, all four groups similarly used two dimensions: (1) activity (i.e. walking, work, sleep) and (2) activity-related functions (i.e. mood, enjoyment of life, relation with others) to report how they react to pain. The findings of the study indicate that there are limits to the effects of cultural and language factors on ratings of how pain is experienced by cancer patients; however, the differences are not substantial.
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3. Cleeland CS, Gonin R, Baez L, Loehrer P, Pandya KJ. Pain and Treatment of Pain in Minority Patients with Cancer. Ann Internal Med 1997 Nov 1;127(9):813-16. [PMID: 9382402]
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Purpose:
To examine the severity of cancer-related pain and the adequacy of prescribed treatment in minority outpatients with cancer.
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Sample:
N = 281 minority outpatients with recurrent or metastatic cancer. All patients were of Hispanic and non-White backgrounds. The sample consisted of 106 African Americans, 94 Hispanics, and 16 persons of other minority ethnicity. Patients were from 9 university cancer centers, 17 community hospitals and practices, and 4 centers that primarily treat minority patients.
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Methods:
Patients were asked to rate their pain severity by using the BPI on a scale of 0 to 10. They rated their worst, average, and least severe pain during the previous week and at the time of the study; pain severity assessment took place during their clinic appointment. The adequacy of analgesic treatment was estimated by calculating the Pain Management Index (PMI) based on the World Health Organization (WHO) and the Agency for Health Care Policy and Research guidelines. The patients’ treatments of pain in the current study were compared with a subgroup of patients (n = 627) from a previous study who received care in treatment settings in which less than 10% of patients were minorities.
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Implications:
Pain management for minorities was shown to be better in community-based treatment settings rather than in settings designated predominantly for minority patients or in university settings. Patients who were rated as less ill were twice as likely to receive inadequate pain management. Other results reported were: (1) women were more likely to be undermedicated, (2) men whose pain was underestimated by their physicians were six times more likely to be undermedicated than men whose pain had been accurately assessed, (3) many more minority patients than non-minority patients were undermedicated, (4) compared with black patients, more Hispanic patients reported lower levels of pain relief and more Hispanic patients were inadequately medicated, (5) more Hispanics reported concern that they were taking too much medication and needed more information regarding pain management. In addition, this study’s findings suggest that differences in sex, language, and culture may attribute to the difficulty for the patients’ doctors to assess and monitor pain treatment effectiveness.
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4. Mystakidou K, Mendoza T, Tsilika E, Befon S, Pappa E, Bellos G, Vlahos L, Cleeland C. Greek Brief Pain Inventory: Validation and Utility in Cancer Pain. Oncology 2001;60:35-42. [PMID:11150906]
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Purpose:
To translate and validate the Brief Pain Inventory in Greek and to detect cultural and social differences, if any, of pain interference in patients’ lives.
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Sample:
N = 220 cancer patients. The sample consisted of patients from all over Greece. Inclusion criteria: at least 18 years of age, had a pathological diagnosis of cancer- primary or metastatic, and had pain and received treatment for their pain. Demographic characteristics: 56% males (n = 123), 44 % females (n = 97), mean age was 61.3 years (range 21-87 years, SD = 14.84), the majority had at least a senior high school education level, the primary causes of pain were identified as bone pain, abdominal visceral and pleuritic pain.
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Methods:
The study was done between January and June 1998, and June 1999. The BPI was pilot-tested in the two Greek national cancer centers (Areteion Hospital, University of Athens and the Koropi Health Center); patients came to the centers for pain intervention and management of cancer-related symptoms. First, two independent translators translated the BPI into Greek, then it was translated by another two independent translators back into English and finally a crossing-over of these translations was conducted. The means and standard deviations for each severity ( worst, least, average, now) and interference (activity, mood, walk, work, relationships, sleep, enjoyment) item were computed. In addition, the coefficient alphas for the severity pain items were calculated separately to assess the reliability of the Greek BPI. The Pain Management Index (PMI) base on the World Health Organization’s (WHO) guidelines was calculated to describe and compare the analgesic management of the Greek patients. Four levels of analgesic drug therapy were constructed: 0 = no order for analgesic, 1 – non-opioid analgesics, 2 = weak opioids, and 3 = strong opioids; the type or level of analgesic was compared to pain severity/intensity. The PMI compares the type of analgesic recommended for the severity of a patient’s pain relative to the level of the pain reported by the patient; it is calculated by subtracting the pain level from the analgesic level. Negative PMI scores are considered to be an indicator of inadequate pain management, and scores of 0 or greater are considered to be only an approximate indicator of adequate pain management.
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Implications:
Greek patients showed consistently higher composite scores- calculated from the average of the seven interference items- than American, French, Indian, Japanese patients and equal to patients in Beijing and Italy. The majority of patients had a negative PMI score indicating that the prescribed drugs were inadequate by WHO standards. Although the Greek patients had greater pain severity and were more impaired by their disease, they had not received aggressive analgesic treatment. According to the present study findings, the G-BPI is a reliable assessment of pain and its impact on cancer patients.
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5. Chang VT, Hwang SS, Kasimis B. Longitudinal Documentation of Cancer Pain Management Outcomes: A Pilot Study at a VA Medical Center. J Pain Symptom Management 2002 Nov 5;24(5):494-505. [PMID:12547049]
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Purpose:
To measure and examine the effects of pain relief, pain severity, change in pain severity, interference scores, symptom distress, quality of life, and satisfaction in patients with cancer pain; BPI measured pain relief, pain severity, changes in pain severity, and pain interference.
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Sample:
N = 74. The sample was composed of cancer pain patients from the VA New Jersey Health Care System (VANJHCS), the hospital that provides hematology/oncology services for veterans living in New Jersey. Patient recruitment began January 1996 and ended March 1997 and participants signed an informed consent to participate. All patients recruited had a worst pain score of 4 or more a 0-10 numeric pain scale. The median age was 63 years (range 40-82)); median education level was 12th grade (range 6-18); 39 inpatients, 35 outpatients, 45 patients had a caregiver at home. Also, 59 patients had a history of alcohol (48 patients) or illicit drug use (11 patients).
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Methods:
All patients completed four instruments: Brief Pain Inventory (BPI), Functional Assessment Cancer Therapy (FACT-G), Memorial Symptom Assessment Scale-Short Form (MSAS-SF), and a Visual Analogue Scale Global Quality of Life (VASQOL) assessment. An independent interviewer conducted most of the interviews with the different instruments but sometimes the care providers in the Hematology/Oncology section conducted the interviews. Cancer pain management guidelines were from the Agency of Healthcare Policy and Research (AHCPR) and all patients and their family members received the guidelines upon participation. The study had follow-up assessment on weekly basis for 3 weeks. Each follow-up visit assessed change in medications, side effects, BPI, global VASQOL, and patient satisfaction. The last follow-up assessed the patients VASQOL, BPI, FACT-G, MSAS-SF, KPS, and patient satisfaction. It took about 20 minutes to complete the first package and 10 minutes for the follow-up packages.
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Implications:
The most common pain interventions were to increase opioids and opioid adjustments at week 1 and week 2 follow-up visits, respectively. A vast majority of patients reached pain relief with significant mean reduction in worst pain severity of 2 points or more and substantially improved pain interference scores over a period of one week; improved interference scores continued over the next two weeks. The findings suggest that pain relief, pain severity, and pain satisfaction are different constructs but “move in a parallel way with better pain control.” These results also indicate that the BPI is sensitive to changes in treatment regimen for pain.
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6. Cleeland CS, Gonin R, Hatfield AK, Edmonson JH, Blum RH, Stewart JA, Pandya KJ. Pain and its Treatment in Outpatients with Metastatic Cancer. NEJM 1994 Mar 3;330:592-6. [PMID: 7508092]
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Purpose:
To determine the amount of cancer patients who have pain related to functional impairment, the types of pain treatment received by cancer pain patients, and the characteristics of patients who are at greater risk for undermedication with analgesic drugs.
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Sample:
N = 1308. All patients had recurrent or metastatic cancer. Out of the 1308 patients, 871 reported having pain that differed from everyday pain in the seven days before the study and they took analgesic drugs on a daily basis; the rest were classified as having pain by their doctor at the time of the study. Patients with a score of 5 or more were classifies as having substantial pain.
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Methods:
Patients were recruited from three types of Eastern Cooperative Oncology Group (ECOG) affiliations: 12 university cancer centers; 12 cooperative group outreach programs, which are community-based hospitals and practices; and 30 community clinical oncology programs. Patients completed the BPI during their regular appointment and their physician rated the patient’s level of pain control and pain interference with activities and sleep on a scale of 0 to 10; the physician’s did not see the patient’s responses to the BPI. The Pain Management Index (PMI) was also computed for the 597 patients with pain; a negative PMI indicates inadequate orders for analgesic drugs.
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Implications:
There were no major differences in the amount of patients with pain or disease-related pain according to the location of the disease. There was no difference between the proportions of patients with pain who had negative PMI scores among the various types of ECOG affiliations. The community clinical oncology programs had a higher percentage of minority patients with negative PMI scores, primarily Black and Hispanic patients. Overall, minority patients were more likely to receive inadequate analgesia, as were patients who were rated as less ill or looked less ill and those whose pain was recognized by their physicians as non-cancer related causes.
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Factors and Norms
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Factor Analysis Work:
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The validity of the Greek BPI was assessed using principal axes factor analysis with oblique rotation. Two factors with an eigenvalue over 1 were extracted which accounted for 62.5% of the variance. Factor 1 (pain interference) accounted for 44% of the variance and Factor 2 (pain severity) accounted for 19% of the total variance. Activity had the highest loading (0.83) on Factor 1 and average pain had the highest loading (-1.01) on Factor 2. To further validate the G-BPI an activity measure performance status (Karnofsky) was correlated with composite pain severity and pain interference using the Spearman rank correlation coefficient. The composite based on pain interference (Factor 1) is more correlated (r = 0.386, p< 0.0005) with the Karnofsky scale than the composite based on pain severity (Factor 2) which is r = 0.203, p = 0.003, although both show a moderate correlation. (Ref: 3)
Item-factor loadings were compared across samples from the USA, Italy, France and China. In the USA sample, the highest loadings were 0.83 for ‘enjoyment of life’ (on pain interference factor) and 0.87 for ‘least pain and average pain’ (on pain severity factor); the highest loadings in the Italian sample were 0.79 for ‘relationships’ (pain interference) and 0.77 for ‘pain now’ (pain severity); the highest loadings in the French sample was 0.81 for ‘relationships’ (pain interference) and 0.82 for ‘least pain and pain now’ ( pain severity); the highest loadings in the Chinese sample was 0.93 for ‘relationships’ (pain interference) and 1.03 for ‘average pain’ (pain severity). (Ref: 3)
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Normative Information Availability:
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No information found.
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Reliability Evidence
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Test-retest:
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“Good” test-retest reliability was reported, but no numerical values were provided. (Ref: 1)
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Inter-rater:
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No information found.
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Internal Consistency:
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The alpha coefficients for pain interference and pain severity scales were 0.85 and 0.89. (Ref: 3) Coefficient alphas for the pain interference scale (factor 1) in the following samples were 0.91 (USA, n = 1106), 0.77 (Italy, n = 110), 0.90 (France, n = 324), 0.91 (China, n = 147). The coefficient alphas for the pain severity scale (factor 2) in the same samples mentioned above were: 0.87 (USA), 0.78 (Italy), 0.86 (France), and China (0.89).
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Alternate Forms:
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No information found.
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Validity Evidence
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Construct/ Convergent/ Discriminant:
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No information found. There were at least two studies that demonstrated a sensitivity of the BPI to treatments for pain. This provides some evidence for construct validity.
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Criterion-related/ Concurrent/ Predictive:
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No information found.
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Content:
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No information found.
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Responsiveness Evidence:
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No information found.
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Scale Application in VA Populations:
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Yes. (Ref: 5)
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Scale Application in non-VA Populations:
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Yes. (Ref: 1-4,6)
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Comments
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The BPI is widely used in assessment of pain in both research and clinical settings. While developed for cancer-related pain assessment, the BPI has been used successfully in a variety of other disease-specific and generic applications as well.
Overall Usefulness for a Certain Population: Useful for all known patient populations; successfully implemented in minority and veteran populations.
Advantages: Relative ease of administration and scoring, and familiarity of instrument. Reliability information is available from applications across numerous cultures and languages. Strong correlations of cancer pain levels with other disease-specific pain levels and positive correlation of the two main factors, pain severity and pain interference, have been reported.
Disadvantages: Despite its name, the BPI is not particularly brief, and patients with low literacy may need assistance in completing some items. Other than correlation evidence described above, specific validity information is scant.
Recommendation: We support use of the BPI as a main component of a pain assessment battery that includes other pain measures as well. Particularly in clinical use, we emphasize the need for triangulating results of any single measure with data from other measures. Since there are numerous well-established pain assessment tools in publication, users should not have difficulty deciding on other measures to use alongside the BPI.
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