What are key questions to assess pain in a patient on chronic opioids (opioid analgesics) for back pain after a traumatic accident?

Pain Assessment Questions for Chronic Opioid Patients with Post-Traumatic Back Pain

For a patient on chronic opioids for 10 years following a traumatic accident, your pain assessment must focus on current pain control, functional status, opioid dosing patterns, risk factors for misuse, and evidence of benefit versus harm from continued opioid therapy.

Current Pain Characteristics and Control

Ask about current pain intensity using a 0-10 numeric rating scale, distinguishing between baseline pain and breakthrough pain episodes 1. Specifically inquire:

• What is your pain level at rest versus with activity right now?
• How many days per week do you experience severe pain (7-10/10)?
• What is your average daily pain score over the past month?
• Do you have neuropathic pain features (burning, shooting, electric-like sensations)? 1

Document pain location, radiation patterns, and whether pain has changed in character or distribution over the 10-year period 1. This helps identify if new pathology has developed versus chronic stable pain.

Functional Assessment and Quality of Life

Determine specific functional limitations and whether opioids have improved or maintained function 1:

• What activities can you perform now that you couldn't do without opioids?
• What activities are you still unable to do despite opioid therapy?
• How many hours per day can you be active before pain limits you?
• Are you employed? If not, is pain the primary barrier? 2
• Can you perform basic self-care, household tasks, and social activities?

The 2022 CDC guideline emphasizes that opioids should improve both pain AND function—pain relief alone without functional improvement suggests inadequate benefit 1.

Current Opioid Regimen Details

Calculate the total daily morphine milligram equivalents (MME) the patient is currently taking 1:

• What opioid medication(s) are you taking? (name, dose, frequency)
• How many pills do you actually take per day versus what's prescribed?
• Are you taking short-acting, long-acting, or both formulations?
• Do you ever run out early or need early refills?

A patient on ≥90 MME/day for 10 years faces substantially elevated overdose risk and should prompt serious consideration of tapering 1. Use the conversion table: hydrocodone and morphine = 1x, oxycodone = 1.5x, hydromorphone = 4x, fentanyl patch (mcg/hr) = 2.4x 1.

Assessment of Opioid Effectiveness Over Time

Directly ask whether opioids are still providing meaningful benefit after 10 years 1:

• When you first started opioids, how much did they help your pain (percentage improvement)?
• How much do they help now compared to when you started?
• If you miss a dose, is it worse pain or withdrawal symptoms you experience?
• Have you needed increasing doses over time to get the same relief?

Research shows that many patients on long-term opioids experience tolerance, and a 1-month trial period is typically sufficient to determine true responders 2. After 10 years, reassessing benefit is critical.

Screening for Opioid Misuse and Aberrant Behaviors

The 2022 CDC guideline and HIV/IDSA guidelines mandate routine monitoring for signs of misuse 1:

• Are you obtaining opioids from any other doctors or sources? 3
• Have you ever taken more than prescribed or used someone else's pain medication?
• Have you used any illicit drugs in the past year (marijuana, cocaine, methamphetamine)? 4, 3
• Have you ever felt you needed to cut down on your pain medication?
• Do family members express concern about your medication use?

Document any history of substance use disorder, as this significantly increases risk 1. Studies show 9% of chronic pain patients on opioids demonstrate opioid abuse behaviors, and 16% use illicit drugs 3.

Concurrent Medications and Risk Factors

Identify dangerous drug combinations and overdose risk factors 1:

• Are you taking benzodiazepines (Xanax, Valium, Ativan, Klonopin)? 4
• Are you taking muscle relaxants like carisoprodol (Soma)? 4
• Do you have sleep apnea or breathing problems?
• Do you drink alcohol? How much and how often?
• Have you ever had an overdose or needed naloxone?

The combination of opioids with benzodiazepines dramatically increases overdose risk and should be avoided 1. Research shows 35% of chronic pain patients were on benzodiazepines before presenting to pain management 4.

Previous and Current Non-Opioid Treatments

Document what non-opioid therapies have been tried and their effectiveness 1:

• Have you tried NSAIDs (ibuprofen, naproxen)? What happened?
• Have you tried acetaminophen regularly?
• Have you tried medications for neuropathic pain (gabapentin, duloxetine, tricyclic antidepressants)?
• Have you participated in physical therapy, exercise programs, or cognitive behavioral therapy?
• Have you tried interventional procedures (injections, nerve blocks)?

The 2022 CDC guideline emphasizes that nonopioid therapies should be maximized before continuing long-term opioids 1. For chronic low back pain specifically, opioids show only small short-term improvements with moderate-quality evidence 1, 5.

Adverse Effects from Chronic Opioid Use

Screen for common and serious opioid-related harms 1, 6:

• Do you experience constipation? How severe and how do you manage it?
• Do you feel sedated, drowsy, or have difficulty concentrating?
• Have you experienced falls or injuries while on opioids?
• Do you have decreased libido or sexual dysfunction?
• Do you feel depressed or anxious?
• Do you have difficulty urinating?

Adverse effects occur in up to 85% of patients on chronic opioids, with constipation and sedation being most common 1.

Psychosocial Factors and Support

Assess psychological factors that influence pain and treatment response 1:

• Do you have depression or anxiety? Are you receiving treatment?
• What does this pain mean to you—do you fear it indicates worsening damage?
• Do you have adequate family and social support?
• Have you experienced trauma, abuse, or PTSD?
• What are your goals for pain management—what level of pain and function would be acceptable?

Red Flags Requiring Immediate Attention

Ask about symptoms suggesting serious pathology that requires urgent evaluation 1:

• Have you developed new weakness in your legs or difficulty walking?
• Have you lost control of your bladder or bowels?
• Do you have fever, chills, or unexplained weight loss?
• Is the pain dramatically worse or different in character than usual?

Documentation of Prescribing History

Clarify who has been prescribing opioids over the 10-year period 4:

• Who originally started you on opioids after your accident?
• Have you been seeing the same prescriber or multiple doctors?
• Have you been to the emergency department for pain medication?
• Have you ever been discharged from a pain clinic or had prescriptions discontinued?

Research shows that 94% of patients presenting to interventional pain management were already on long-term opioids prescribed by primary care physicians, often at high doses 4. Understanding this history is essential.

Critical Clinical Pitfall

The most common error is continuing opioids indefinitely without reassessing benefit versus harm. After 10 years on opioids for post-traumatic back pain, many patients experience tolerance, hyperalgesia, and functional decline rather than improvement 1, 5. If the patient cannot demonstrate clear functional improvement attributable to opioids, or if they are on ≥90 MME/day, a gradual taper should be strongly considered 1, 6. The 2022 CDC guideline emphasizes that opioid therapy should be continued only when benefits for pain and function outweigh risks 1.