Background: It is often challenging to assess pain in patients on chronic opioids either in acute care setting or in outpatient centers. Pain assessment in this group is more challenging especially if they are hospitalized with acute or acute on chronic pain. Opioid uses associated with increased pain perception and increased self-report of pain. Further, Pain is underestimated and undertreated in patients on chronic opioids, however these are at higher risk of abuse and overdose. Proper pain assessment is necessary in these patents to treat the pain adequately.
Methods: Here we did a literature search to find out interventions done and tools used to assess the pain appropriately in patients on chronic opioids. The inclusion criteria is adult patients on chronic opioids, the exclusion criteria is cancer patients, patients on hospice, pain related to surgery,
We searched major data bases like Medline, Embase, Cochrane, CINHAL (EBSCO) PsycINFO from 1995 to 2017. We found 65 papers on preliminary search. After reading titles and abstract we found 11 papers where interventions done to assess the pain in patients on chronic opioids. Out of them, 2 studies were done in surgical patients, one in pediatric group and 2 in cancer patients. 6 articles met our inclusion criteria.
Results: We found 6 studies with interventions that may be helpful to hospitalists to assess pain in patients on chronic opioids. We wound 5 pain measurement tools which help to assess pain in patients on chronic opioids (See table). These studies are done in substance abuse detoxification centers, with in the hospitals and methadone treatment centers (See table).
Pain assessment tools
1. PainCAS1® (Clinical Assessment System)/Numerical Rating Scale (NRS).
2. Quantitative sensory testing (QST) in spinal pain patients.
3. Visual analogue scale (VAS).
4. Verbal rating scale (VRS).
5. Pain Assessment and Documentation Tool (PADT).
Out of these we found Pain CAS1/NRS, VAS, and VRS are found to be more useful for hospitalists.
Conclusions: Pain management in patients on chronic opioids is complicated by several factors, including hypersensitivity to pain, high opioid tolerance, illicit substance use, and variable cross-tolerance to opioid pain medications. With the current guidelines pain scores of above 3 or 4 to prescribe opioids could over treat the pain especially in these groups. At the same time there is evidence that the pain is underestimated and undertreated in patients on chronic opioids, however these are at higher risk of overdose. It is challenging for health care providers to reach a balance point here.