Foundations of Assessing and Treating Pain
Assessing Pain
- Pain Assessment. Assessment and Diagnosis for Successful Pain Management. Nursing Times. September 18, 2008. Describes the basic knowledge, skills, and appropriate attitudes towards pain that clinicians need, to provide optimal pain assessment and management.
- BPI: Brief Pain Inventory Patients to rate their pain and ability to complete daily living activities in nine sections.
- Faces Pain Scale – Revised A visual analog pain scale using pictures of faces that can be used with children and those who have difficulty with numerical scales.
- Iowa Pain Thermometer Scale This pain assessment tool is excellent for patients whose cognitive deficits are moderate to severe, or who have difficulty communicating verbally. The patient checks the circle next to the thermometer to indicate the intensity of current pain. Used with permission of Keela Herr, PhD, RN, The University of Iowa, College of Nursing.
- McGill Pain Questionnaire Printable verbal pain assessment questionnaire.
- Pain Evaluation Form A clinical pain evaluation form for the use of physicians or other healthcare providers. The form will help to better understand the type of pain a patient is experiencing and how to best treat the pain.
- Registered Nurses Association of Ontario: Assessment and Management of Pain The Registered Nurses Association of Ontario offered an updated version of their “Assessment and Management of Pain” guidelines in 2007. The RNAO guidelines offer recommendations for patient practice related to pain assessment and management.
Treatment of Pain
- CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. by Dowell D, Haegerich TM, Chou R. MMWR Recomm Rep. 2016;65(1):1-49.
- Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain (APS/AAPM) Recommendations published in 2009 for chronic opioid therapy based on a review of the evidence. Provide guidance on patient selection, risk stratification, informed consent, opioid management plans, and more. Authors: Chou R, Fanciullo GJ, Fine PG, et al.
- Informed Consent for Using Opioids to Treat Pain A very detailed written patient agreement that includes informed consent for opioid use in the treatment of pain. The form includes the effect of opioids at the injury site and the central nervous system, what a patient should and should not expect from the treatment, varying negative effects, common sense rules and other expectations, and potential consequences that may result from the failure to follow the agreement. Author: Michael H. Moskowitz, MD, MPH. 2007
- Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain This set of guidelines aims to improve care and safety in the opioid treatment of patients with chronic, non-cancer pain. Part I aids primary care physicians in treating patients whose acute pain has become chronic, monitoring opioid treatment, and tapering from opioids if necessary. Part II aids primary care physicians in treating patients whose daily morphine equivalent dose is higher than 120 mg. An FAQ also exists which offers answers to questions on many aspects of the documents. Updated in 2010
- Medical Assisted Treatment of Opioid Use Disorder Highlights the prevalence of opioid addiction, along with different treatment methods that have proven effective.
- Noninvasive treatments for acute, subacute, and chronic low back pain: A clinical practice guideline from the American College of Physicians
- Pain Evaluation Form A clinical pain evaluation form for the use of physicians or other healthcare providers. The form will help to better understand the type of pain a patient is experiencing and how to best treat the pain. 2017
- Referral Form for Substance Abuse A referral form which includes both doctor and patient information.
- Registered Nurses Association of Ontario: Assessment and Management of Pain The Registered Nurses Association of Ontario offered an updated version of their “Assessment and Management of Pain” guidelines in 2007. The RNAO guidelines offer recommendations for patient practice related to pain assessment and management.
- Target Chronic Pain Notebook A notebook for tracking chronic pain.
Risk Reduction Strategies for Opioids (Including ER/LA Opioids)
Identifying, Assessing, and Responding to an Aberrant Behavior
- ABC: Addiction Behaviors Checklist An assessment checklist that screens for characteristic addictive behaviors in chronic pain patients prescribed opioid medications.
- The ASAM National Practice Guideline for the Treatment of Opioid Use Disorder. 2020 Focused Update.
- Development and Validation of the Current Opioid Misuse Measure Measure of opioid dependency and addiction for patients already on long-term opioid therapy. Authors: Butler SF, Budman SH, Fernandez KC, Houle B, Benoit C, Katz N, Jimison RN Title: Development and Validation of the Current Opioid Misuse Measure
- DSM 5 Substance-Related and Addictive Disorders The APA’s breakdown on changes to substance-related addictive disorder diagnoses introduced by DSM-5. The document goes over substance use disorder, addictive disorders and briefly states the APA’s position on caffeine use disorder.
- Indiana Polyclinic Combined Pain Scale Developed in 2001 at the Indiana Polyclinic in Indianapolis, Indiana, United States. It is a multidimensional pain scale developed by Dr. Dimitry Arbuck and his team
- Patient Health Questionnaire 9 (PHQ-9) Quick Depression Screening Objectifies degree of depression severity
- PDUQ: Prescription Drug Use Questionnaire An interview format yes or no questionnaire administered by the clinician and designed to detect prescription pain medication addiction in chronic pain patients. (Located at the end of article) Authors: Compton P, Darakjian J, Miotto Karen
- PDUQ: Prescription Drug Use Questionnaire (Self-Report) A self-report questionnaire for the screening of opioid use and dependency in patients with chronic pain. Authors: Compton PA, Wu SM, Schieffer B, Pham Q, Naliboff BD. Title: Introduction to a self-report version of the Prescription Drug Use Questionnaire and relationship to medication agreement noncompliance Issue: 36(4):383-95.
- PMQ: Pain Medication Questionnaire Screening tool used to accurately identify chronic pain patients that are at risk for opioid dependency or abuse. This article examines the predictive validity of the PMQ in risk assessment. Authors: Dowling LS, Gatchel RJ, Adams LL, Stowell AW, Bernstein D Title: An evaluation of the predictive validity of the Pain Medication Questionnaire with a heterogeneous group of patients with chronic pain. Issue: 3(5): 257-66.
Initiating, Monitoring, and Terminating Opioid Treatment (Including ER/LA Opioids)
- ABC: Addiction Behaviors Checklist An assessment checklist that screens for characteristic addictive behaviors in chronic pain patients prescribed opioid medications.
- A Closer Look at State Prescription Drug Monitoring Programs (DEA FAQ’s) These FAQs address common questions regarding prescription drug monitoring programs.
- The ASAM National Practice Guideline for the Treatment of Opioid Use Disorder. 2020 Focused Update.
- Patient Health Questionnaire 9 (PHQ-9) Quick Depression Screening Objectifies degree of depression severity
- CDC Guideline for Prescribing Opioids for Chronic Pain Clinical guidelines, literature review, and analysis of the evidence on the use of opioids for chronic pain. Recommendations are also made for prescribing opioids for acute pain.
- ER LA Opioid Analgesics REMS Safety Information Selected Important Safety Information. Abuse Potential and Risk of Life-Threatening Respiratory Depression for ER/LA Opioid Analgesics
- HHS Guide for Clinicians on the Appropriate Dosage Reduction for Discontinuation of Long-Term Opioid Analgesics. Guide for Clinicians on how to reduce or discontinue opioid dosage in chronic opioid therapy, considering risks vs benefits and steps to take to avoid harms from tapering.
- Oswestry Low Back Pain Disability Questionnaire Oswestry Low Back Pain Disability Questionnaire
- PADT: Pain Assessment and Documentation Tool The PADT is a clinician-directed interview; that is, the clinician asks the questions, and the clinician records the responses. The Analgesia, Activities of Daily Living, and Adverse Events sections may be completed by the physician, nurse practitioner, physician assistant, or nurse. The Potential Aberrant Drug-Related Behavior and Assessment sections must be completed by the physician. Ask the patient the questions below, except as noted.
- PDUQ: Prescription Drug Use Questionnaire An interview format yes or no questionnaire administered by the clinician and designed to detect prescription pain medication addiction in chronic pain patients. (Located at the end of article) Authors: Compton P, Darakjian J, Miotto Karen
- Pharmacological Management of Persistent Pain in Older Persons Guideline recommendations by the American Geriatric Society (AGS) for the pharmacological management of non-opioid, opioid, and other analgesic drugs. The recommendations focus on the prescription and any potential side effects of the medications.
- PMQ: Pain Medication Questionnaire Screening tool used to accurately identify chronic pain patients that are at risk for opioid dependency or abuse. This article examines the predictive validity of the PMQ in risk assessment. Authors: Dowling LS, Gatchel RJ, Adams LL, Stowell AW, Bernstein D Title: An evaluation of the predictive validity of the Pain Medication Questionnaire with a heterogeneous group of patients with chronic pain. Issue: 3(5): 257-66.
- SAMHSA Opioid Overdose Prevention Toolkit This resource on SAMHSA’s website includes several resources: Facts for Community Members; Essentials for First Responders; Safety Advice for Patients; Information for Prescribers; and Resources for Overdose Survivors and Family Members
- State List of HHS Certified Laboratories This document lists the 40 laboratories which meet the Minimum Standards To Engage in Urine Drug Testing for Federal Agencies. Updated May 15, 2014
- Target Chronic Pain Notebook A notebook for tracking chronic pain.
Weighing Risks and Benefits of Opioids (Including ER/LA Opioids)
- The ASAM National Practice Guideline for the Treatment of Opioid Use Disorder. 2020 Focused Update.
- CDC Guideline for Prescribing Opioids for Chronic Pain Clinical guidelines, literature review, and analysis of the evidence on the use of opioids for chronic pain. Recommendations are also made for prescribing opioids for acute pain.
- DSM 5 Substance-Related and Addictive Disorders The APA’s breakdown on changes to substance-related addictive disorder diagnoses introduced by DSM-5. The document goes over substance use disorder, addictive disorders and briefly states the APA’s position on caffeine use disorder.
- Electronic Prescriptions for Controlled Substances; Final Rule The DEA revised regulations to allow electronic prescriptions for controlled substances.
- ER LA Opioid Analgesics REMS Safety Information Selected Important Safety Information. Abuse Potential and Risk of Life-Threatening Respiratory Depression for ER/LA Opioid Analgesics
- FDA announces safety labeling changes and postmarket study requirements for opioids FDA News Release 8/18/2016: FDA announces safety labeling changes and postmarket study requirements for extended-release and long-acting opioid analgesics. New boxed warning to include neonatal opioid withdrawal syndrome.
- Infographic: State-by-state breakdown of opioid regulations State by State Opioid Prescribing Policies
- Official Federal Regulations Regarding Contolled Substances Official federal regulations concerning the use of controlled substances. The regulations address registration, prescription, and schedules of controlled substances, among other topics pertaining to controlled substances.
- Opioid Use Disorder Diagnostic Criteria The Diagnostic criteria for opioid use disorder,
- Patient Health Questionnaire 9 (PHQ-9) Quick Depression Screening Objectifies degree of depression severity
- SAMHSA Opioid Overdose Prevention Toolkit This resource on SAMHSA’s website includes several resources: Facts for Community Members; Essentials for First Responders; Safety Advice for Patients; Information for Prescribers; and Resources for Overdose Survivors and Family Members
- State of Washington Pain Management Resources and Rules State of Washington Department of Health website describes rules for each health profession and offers resources for patients and healthcare providers (including FAQs and Toolkits)
- The Clinical Opiate Withdrawal Scale (COWS) Used with patients to determine if they are experiencing opioid withdrawal.
- WHO Pain Relief Ladder Developed by the World Health Organization in 1986, the Pain Relief Ladder recommends progressively increasing levels of pain treatment for cancer pain until there is pain relief. The ladder is sometimes used for treatment of non-cancer pain.
Understanding Opioids (Including ER/LA Opioids)
- CDC Guideline for Prescribing Opioids for Chronic Pain. Dowell D, Haegerich T, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016 MMWR Recomm Rep. 2016;65(1):1-49. doi:10.15585/mmwr.rr6501e1er
- Drugs@FDA: Searchable Database of FDA Approved Drugs A searchable database from the FDA of FDA-approved drugs. This database also includes product label information.
- ER/LA Opioid Analgesics REMS (2016) Website to search for opioid analgesic REMS and medication guides. This one from 2016 is “The Extended-Release and Long-Acting Opioid Analgesics Risk Evaluation and Mitigation Strategy.” Sections include Important Safety Information, Medication Guides, and U.S. Prescribing Information for each ER/LA opioid.
- FDA announces safety labeling changes and postmarket study requirements for opioids FDA News Release 8/18/2016: FDA announces safety labeling changes and postmarket study requirements for extended-release and long-acting opioid analgesics. New boxed warning to include neonatal opioid withdrawal syndrome.
- FDA Blueprint for Prescriber Education for Extended-Release and Long-Acting Opioid Analgesics Specific education recommendations for providers to have before prescribing ER/LA Opioid Analgesic products. 2018
- TIRF Opioids REMS Access – A Fentanyl REMS Educational program for Transmucosal Immediate Release Fentanyl REMS
Assessment and Treatment Planning Prior to Prescribing Opioids (ER/LA Opioids)
- AMA Guide: Promote safe storage and disposal of opioids and all medications AMA Task Force to Reduce Opioid Abuse produced a brief flier with 3 steps providers should take to promote safe storage and disposal of opioids and all medications with links to resources for patients.
- The ASAM National Practice Guideline for the Treatment of Opioid Use Disorder. 2020 Focused Update.
- CAGE-AID Screening Tool A quick drug and alcohol assessment tool for determining whether a patient may be currently abusing drugs or alcohol. It can be used to detect existing substance use problems prior to prescribing opioid therapy.
- CDC Guideline for Prescribing Opioids for Chronic Pain Clinical guidelines, literature review, and analysis of the evidence on the use of opioids for chronic pain. Recommendations are also made for prescribing opioids for acute pain.
- DIRE Score Assessment of a patient on selection for Chronic Opioid management
- FDA: Disposal of Unused Medicines: What You Should Know FDA publication that describes programs to dispose of unused pain medications and other prescription medications.
- Drug Cutoff Concentrations This document lists the Federal urine drug testing cutoff concentrations for the “Federal Five” drugs (marijuana, cocaine, opiates, PCP and amphetamines/methamphetamines).
- Faces Pain Scale – Revised A visual analog pain scale using pictures of faces that can be used with children and those who have difficulty with numerical scales.
- Facilities – Drug Rehab, Alcohol Rehab and Drug Addiction Treatment and Recovery Programs Provides drug and alcohol addiction treatment, recovery programs and center listings by state.
- McGill Pain Questionnaire Printable verbal pain assessment questionnaire.
- NIDA Quick Screen – Online The NIDA quick screen is an online screening tool for substance abuse filled out by the patient. Based on the patient’s responses, it generates a substance involvement score that suggests the level of intervention needed. This is the short, online version of the longer screening tool, the NIDA Modified ASSIST.
- NINDS Chronic Pain Information Page Defines chronic pain, giving treatment suggestions and prognosis. Lists relevant organizations and relevant publications.
- Opioid Risk Tool (ORT) with Scoring Interpretation This questionnaire developed by Dr. Lynn Webster, to be filled out by the patient, allows health care professionals to determine risk of addiction to prescription opioid medication. Total Score Risk Category information is provided.
- Oswestry Low Back Pain Disability Questionnaire Oswestry Low Back Pain Disability Questionnaire
- Pain Evaluation Form A clinical pain evaluation form for the use of physicians or other healthcare providers. The form will help to better understand the type of pain a patient is experiencing and how to best treat the pain.
- Patient Health Questionnaire (PHQ) Screeners The PHQ-9 and PHQ-2, components of the longer Patient Health Questionnaire, offer psychologists concise, self-administered tools for assessing depression. They incorporate DSM-IV depression criteria with other leading major depressive symptoms into a brief self-report instruments that are commonly used for screening and diagnosis, as well as selecting and monitoring treatment.
- Patient Health Questionnaire 9 (PHQ-9) Quick Depression Screening Objectifies degree of depression severity
- PEG: A Three-Item Scale Assessing Pain Intensity and Interference
- Registered Nurses Association of Ontario: Assessment and Management of Pain The Registered Nurses Association of Ontario offered an updated version of their “Assessment and Management of Pain” guidelines in 2007. The RNAO guidelines offer recommendations for patient practice related to pain assessment and management.
- SAMHSA Opioid Overdose Prevention Toolkit This resource on SAMHSA’s website includes several resources: Facts for Community Members; Essentials for First Responders; Safety Advice for Patients; Information for Prescribers; and Resources for Overdose Survivors and Family Members
- Sample Treatment Agreement for Long-term Controlled Substances Therapy for Chronic Pain A written patient agreement for patients and physicians about to begin treatment with the use of controlled substances. The agreement includes patient and physician responsibilities, realistic expectations, and possible consequences if the agreement is broken.
- Screener and Opioid Assessment for Patients in Pain (SOAPP®) Screener and Opioid Assessment for Patients in Pain (SOAPP) is a brief assessment of chronic pain patients to help in deciding on and planning long-term opioid treatment. Predicts a patient’s susceptibility to developing drug-abusive behaviors.
Expanded Skills in Chronic Opioid Therapy
Minimizing Opioid Diversion and Overdose Risk
- A Closer Look at State Prescription Drug Monitoring Programs (DEA FAQ’s) These FAQs address common questions regarding prescription drug monitoring programs.
- National Association of State Controlled Substances Authorities (ASCSA) A resource on state controlled substance information.
- CDC Guideline for Prescribing Opioids for Chronic Pain Clinical guidelines, literature review, and analysis of the evidence on the use of opioids for chronic pain. Recommendations are also made for prescribing opioids for acute pain.
- Database of statutes, regulations, & other policies for pain management Database of Statutes, Regulations, and Other Policies for Pain Management from the Walther Center in Global Palliative Care at Indiana University
- Disposal of Unused Medicines: What You Should Know Describes programs to dispose of unused pain medications and other prescription medications.
- Electronic Prescriptions for Controlled Substances; Final Rule The DEA revised regulations to allow electronic prescriptions for controlled substances.
- Official Federal Regulations for Prescribing Opioids Official federal regulations concerning the use of controlled substances. The regulations address registration, prescription, and schedules of controlled substances, among other topics pertaining to controlled substances.
- Rx Patrol A web based database created by Purdue pharmaceuticals that collects, collates, and analyzes pharmacy crime data. The site looks for patterns, trends, and similarites in the crimes being commited and dissiminates this information to law enforcement groups to aid in apprehending suspects and also sends it to pharmacies.
- SAMHSA Opioid Overdose Prevention Toolkit This resource on SAMHSA’s website includes several resources: Facts for Community Members; Essentials for First Responders; Safety Advice for Patients; Information for Prescribers; and Resources for Overdose Survivors and Family Members. Published June 2018.
- State Prescription Monitoring Program Contacts NASCSA’s list of each state’s prescription monitoring program contact information.
- The Researched Abuse, Diversion and Addiction-Related Surveillance (RADARS) System The RADARS System is a surveillance system which collects timely product-and geographically-specific data on prescription drug abuse, misuse and diversion.
- VA/DoD Clinical Practice Guideline for the Management of Opioid Therapy for Chronic Pain The guideline provides recommendations for practice interventions and evaluations when using opioid therapy to treat chronic non-cancer pain. It is entirely evidence-based and uses clinical algorithms to optimize the use of opioid therapy.
- The Legal Side of Pain Includes: Zero Unintentional Deaths – A Campaign to teach individuals and doctors about the risk of death by overdose common in chronic pain patients. Sponsored by Life Source.
The High Risk Patient and Opioids
- Acute Pain Management for Patients Receiving Maintenance Methadone or Buprenorphine Therapy This journal article by Alford DP, Compton P, and Samet JH, explores the relationship between addiction, opioid agonist therapies (buprenorphine or methadone), and treating acute pain.
- The ASAM National Practice Guideline for the Treatment of Opioid Use Disorder. 2020 Focused Update. Includes a section on how to manage pain in patients on medication assisted treatment for opioid use disorder.
- CDC Guideline for Prescribing Opioids for Chronic Pain.Dowell D, Haegerich T, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016 MMWR Recomm Rep. 2016;65(1):1-49. doi:10.15585/mmwr.rr6501e1er
- HHS Guide for Clinicians on the Appropriate Dosage Reduction for Discontinuation of Long-Term Opioid Analgesics. Guide for Clinicians on how to reduce or discontinue opioid dosage in chronic opioid therapy, considering risks vs benefits and steps to take to avoid harms from tapering.
- TIP 54: Managing Chronic Pain in Adults With or in Recovery From Substance Use Disorders From Treatment Improvement Protocol (TIP) Series from SAMHSA, published in 2012. Title implies this is related to chronic opioid therapy for patients in recovery from substance use disorders, which it is, but it also is relevant to use of chronic opioid therapy for all patients and preventing substance use disorders.
Coordinating Pain Treatment with Colleagues
- Substance Abuse Confidentiality Regulations SAMHSA’s FAQs regarding Substance Abuse Confidentiality
- Is Your Specialist Certified? Check the specialty board certification status of your doctor.
- Narcotics Anonymous 12 step programs for persons addicted to narcotics.
- Referral Form for Substance Abuse A referral form which includes both doctor and patient information.
