Measurement of Chronic Pain and Opioid Use Evaluation in Community-Based Persons with Serious Illnesses

Abstract

Background: Chronic pain associated with serious illnesses is having a major impact on population health in the United States. Accountability for high quality care for community-dwelling patients with serious illnesses requires selection of metrics that capture the burden of chronic pain whose treatment may be enhanced or complicated by opioid use.

Objective: Our aim was to evaluate options for assessing pain in seriously ill community dwelling adults, to discuss the use/abuse of opioids in individuals with chronic pain, and to suggest pain and opioid use metrics that can be considered for screening and evaluation of patient responses and quality care.

Design: Structured literature review.

Measurements: Evaluation of pain and opioid use assessment metrics and measures for their potential usefulness in the community.

Results: Several pain and opioid assessment instruments are available for consideration. Yet, no one pain instrument has been identified as "the best" to assess pain in seriously ill community-dwelling patients. Screening tools exist that are specific to the assessment of risk in opioid management. Opioid screening can assess risk based on substance use history, general risk taking, and reward-seeking behavior.

Conclusions: Accountability for high quality care for community-dwelling patients requires selection of metrics that will capture the burden of chronic pain and beneficial use or misuse of opioids. Future research is warranted to identify, modify, or develop instruments that contain important metrics, demonstrate a balance between sensitivity and specificity, and address patient preferences and quality outcomes.

Keywords: accountability; chronic pain; opioid use; serious illness; symptom assessment; symptom control.

FIG. 1.

Algorithm for pain screening metrics in the setting of Potential Opioid Misuse, Abuse, and Addiction. In this figure, we present a decision tree highlighting the interplay among pain assessment, pain management, opioid risk assessment, opioid benefit, and opioid management for community-based care. BPI-SF, Brief Pain Inventory-Short Form; COMM, Current Opioid Misuse Measure; MOBID, Mobilization-Observation-Behavior-Intensity-Dementia Pain Scale; MPQ-SF, McGill Pain Questionnaire-Short Form; NRS, numeric rating scale; ORT, Opioid Risk Tool; PAINAD, Pain Assessment in Advanced Dementia Scale; PACSLAC, Pain Assessment Checklist for Seniors with Limited Ability to Communicate; PD-Q, painDETECT questionnaire ; PROMIS, Patient-Reported Outcomes Measurement Information System; RAI, Resident Assessment Instrument; SISAP, Screening Instrument for Substance Abuse Potential; SOAPP-R, Screener and Opioid Assessment for Patients with Pain—Revised.

FIG. 2.

Number of deaths related to opioids per year in the United States 2000–2015. CDC Wonder Data. Stratification based on opioid type: Natural and Semi-Synthetics (e.g., morphine, hydromorphone), Methadone, Synthetics excluding Methadone (e.g., fentanyl, carfentanil), Heroin, and All Opioids. CDC, Center for Disease Control.