Event 2: Pain Management

Head and shoulders shot of Eric, a young, clean-shaven man wearing a baseball hat

Eric's Pain Assessment

Unidimensional scales (e.g. 0-10) that capture self-reported pain intensity ratings undervalue to the complexity of the pain experience. Pain is a biopsychosocial experience and assessment is a complex social transaction and an exchange of the meaning of pain that demands a more comprehensive approach.

A comprehensive pain assessment includes questions about the onset of pain; its location and whether or not the pain radiates from one place to another; the duration of pain (whether it’s constant, intermittent, constant with intermittent flares or breakthrough pain); the quality of pain, including words that help to determine whether the pain is nociceptive (physiologic), neuropathic (pathophysiologic), or of mixed type.

Assessment is not complete without determining the impact of pain on the person on their ability to function and perform activities of daily living. Ask about the effect of pain on sleep, appetite, mood, energy, mobility, ability to enjoy life, etc. In the acute care setting, the effects of unrelieved pain also include the inability to turn, cough, deep breathe, ambulate effectively and participate in therapy. Use self-report to assess pain intensity whenever possible. Determine the potential causes of pain, if known. Examples are inflammatory pain, musculoskeletal pain, neuropathic pain etc. Valid and pragmatic assessment of pain is essential for effective pain management.

This video describes how Eric rated his pain while in the hospital, why he lied about how much pain he felt, when he became more truthful about his pain, and whether his providers thought he was drug seeking.

Question: What information is missing in the following pain assessment note?

“Patient reports severe burning pain in the right lower leg during wound care."

Select all that may apply.


Eric's Pain Due to Tolerance

The video describes how opioids were ineffective to control Eric's pain because of his tolerance, why communication was helpful, and why it would have been nice for Eric to have non-pharmacologic opitons for pain.

Multimodal Analgesia

Combining medications with different mechanisms of action results in superior pain control and may lessen the doses needed to control pain.

Note: If you need to review foundational concepts about multimodal analgesia, visit the "Principles of Acute Pain Management in Patients with OUD" tab.

Pain, Sleep, and Trust

The following describes how withdrawal affected Eric's pain and sleep, his frustration with certain healthcare providers, and why you need to "humanize" patients.

When offering a patient with a history of prescription opioid use disorder music to help distract during a painful dressing change and to help review/practice deep breathing exercises beforehand, he/she says, "You think my pain is all in my head; my pain is excrutiating. I don't understand why you can't just give me more pain medicine."

Which of the following would be the most appropriate response?

1. "Continually increasing your opioid would be unsafe."


2. "Music and deep breathing work better if you use them together."


3. "There is scientific evidence that using non-medicine strategies can help control pain."


Summary of General Principles for Acute Pain Management for Patients with the Disease of Addiction

  • Team approach with case conferences
  • Set realistic goals for pain and addiction treatment
  • Treat depression and comorbid psychiatric problems
  • If possible, treat the cause of the pain
  • Incorporate nondrug methods of pain control
  • Maximize nonopioids and adjuvants
  • Use oral opioids when possible
  • Minimize PRN IV doses unless necessary
  • Consider tolerance - patients with opioid use disorder usually require higher doses

The team approach with ongoing case conferences is the foundation of managing pain in patients with the disease of addiction. The history of addiction should be openly discussed. Everyone involved with the patient’s care should understand the treatment plan and goals.

Principles of pain management in the presence of addictive disease involve the use of multimodal therapy including nonopioid and nondrug interventions. When parenteral is needed, IV PCA may be best. Be alert to other contributors to behavior and stress such as depression and anxiety. Patients with addictive disease or prior substance abuse may have tolerance and require high doses of opioids to control pain.

Additional Resources for Pain Management

To learn more about:

  • The components of comprehensive pain assessment
  • Tools to assess pain (QISS-TAPED, and the CAPA-Tool)
  • Strategies and suggested phrasing for difficult conversations
  • Education and engagement
  • Balanced rationale multi-modal analgesia
  • Non-pharmacologic strategies

Click the "Principles of Acute Pain Management in Patients with OUD" tab.

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