It is a difficult task determining whether or not your patient should be prescribed opioid medication for non-cancer chronic pains, since this is quite a controversial topic due to the side effects and possible misuse of the drugs. That is why learning how to properly assess a patient for opioid therapy is imperative. The FDA recommends that health care professionals carryout a thorough physical, as well as psychological examination and take any family history for drug abuse into account when prescribing the drug.
Any initial assessments look at the physical exams, chief complaint, present illness history, medical, surgical, and psycho-social history, family history, and assessment of diagnostic tests and imaging. You should also be sure to look at the problem as a whole rather than concentrating on a specific area of complaint.
History and physical exam to properly assess a patient for opioid therapy:
When you evaluate your patient’s physical pain responses, you should focus on the nervous system and sensory functions, and look for Allodynia, Hyperalgesia, or Pain sensitivity. This is usually done through light touch, light pressure, pin prick, cold or vibrations.
For a comprehensive understanding of the patients experience of pain it is important to begin by asking about the pain itself and then moving on to the context and impact of that pain. Some questions that may be asked include:
- Where is the pain?
- What is the pain like? (Shooting, stinging, throbbing, continuous or intermittent, worse at night or in the morning).
- Highest and lowest and usual level of pain on a scale of 0 to 10 on a typical day.
- How and when did the pain start?
- What makes it better or worse, example medication or alcohol?
- Effect of pain on sleep, mood, every day functioning, work, personal life (relationships, sex, or recreation).
- Analysis of past experience/exposure to opioids, past medical/surgical history, family medical history, patient history of drug, alcohol, and tobacco use.
- Psychosocial evaluation which includes history of mental illness
Psychological screening for opioid therapy
Pain can have widespread impact on not just the physical well-being of your patient but also their mental health. It is common for patients with chronic pain to suffer from depression, anxiety and even suicidal thoughts. You should be on high alert for any such signs, and can use many freely available tools for gathering the patient’s psychiatric history. It is important to make referrals to mental health institutions and professionals if the situation is beyond your expertise.
Another thing to be mindful of is how the pain is affecting the patient’s work, family life, relationships and other aspects of life, as the quality of life of chronic pain patients can easily deteriorate rapidly. These issues should addressed during treatment, for example through vocational councilors or social workers, as this is as important as treating the underlying disease.
Risk for abuse
When prescribing drugs like opioids for chronic pain, there is always a possibility of diversion or misuse of the drug. There is no clear evidence that certain groups are more prone, so every patient needs to be treated equally and screened thoroughly to make sure there is no bias and adequate precautions are taken. Nurses and clinicians should assume any patient with chronic pain has the potential of having a drug abuse problem.
That being said, there are certain factors that more obviously increase the risk of abuse of the drug, and these include personal or family history of alcohol and drug abuse, and the presence of psychiatric conditions.
The following are a few characteristic of a patient who might be prone to drug abuse, and health care professionals should look out for these when making prescriptions:
- Medication use is out of control.
- Medication use impairs quality of life instead of improving it.
- Medication use increases or persists despite adverse affects.
- Unaware or in denial of problems that result from drug treatment.
- Violates the practitioner-patient agreement for use of opioids.
- Has no leftover medication.
- Comes up with stories about why more drugs are needed, or frequently loses prescription.
Conclusion
Addiction to opioids is the reason why the drug is met with so much controversy. While it can help control chronic pain and provide a normal quality of life for many of your patients, it might destroy the lives of many others. This is why health care practitioners need to exercise extreme care when diagnosing patients and carry out thorough assessments of physical symptoms, psychological well-being, and personal and family history, and should use their better judgment when prescribing these drugs.
