(108) Instruments Assessing Long-Term Opioid Therapy for Chronic Pain: A Scoping Review

Background & Introduction: In the United States, an estimated 11.2% of adults experience daily, bothersome chronic pain, with approximately 3-4% prescribed long-term opioid therapy (LTOT) (Dowell et al., 2016). Due to the debilitating nature of chronic pain, limited therapeutic alternatives, and the effectiveness of opioids as analgesics, reliance on opioid medications in the management of chronic pain has been widespread (Volkow & McLellan, 2016). However, opioids carry risks such as misuse, diversion, adverse events, and fatalities (Cheatle et al., 2019). To address these concerns, the CDC issued guidelines in 2022, recommending frequent reassessment of LTOT and consideration of tapering or discontinuing opioids in favor of alternative pain management strategies when the benefits no longer outweigh the harms (Dowell et al., 2016). While the guidelines represent an important step toward improving care for patients on LTOT, implementation has been suboptimal due to a lack of specific tools to help clinicians determine which patient factors are most relevant and predictive of opioid-related safety, efficacy, and misuse. Additionally, existing resources for monitoring these factors vary widely in their methods. Therefore, the aim of this scoping review is to review the variables assessed in clinical instruments and describe the content of published pain and LTOT assessment instruments.

Methods: This scoping review was conducted according to the Arksey and O’Malley framework updated by the Joanna Briggs Institute (JBI) and was reported per the PRISMA Extension for Scoping Reviews (PRISMA-ScR) guidelines. Eligible studies included adults with chronic non-cancer pain (≥ 3 months duration) prescribed long-term opioid therapy (>90 days) and tested instruments assessing ongoing LTOT for harm and benefit. Literature was obtained from the following databases: MEDLINE (Ovid), Embase (Ovid), Psycinfo (Ovid), Web of Science, and Cochrane, with no date or language restrictions. The following established definitions guided this review: safety was defined as “adverse effects, harmful interactions, and opioid-related problems”; efficacy as “treatment or therapy ability to produce desired outcomes, including pain relief, quality of life, and improved functioning”; and misuse as “opioid use not in accordance with prescribed directions, regardless of harm.” After the systematic search, three screening rounds were conducted. In round one, two of three reviewers (AC, AG, and MA) independently screened abstracts for inclusion. In round two, two reviewers assessed full texts and voted on inclusions. Discrepancies were resolved by a third reviewer. In round three, two reviewers extracted data, while a third reviewer reviewed the extractions and established consensus.

Results: A total of 153 full-text studies were reviewed, identifying 36 studies representing 22 unique screening instruments. The majority (n=18) were designed for patient self-administration, and all assessed opioid-related harms. Fewer than half of instruments evaluated treatment efficacy (n=9) or opioid safety (n=6). These 22 instruments contained 422 total items, with most items (n=385/422; 91%) addressing current or potential opioid-related harms. Only 9% of items (n=37/422) assessed treatment benefits or efficacy. Items were categorized as assessing misuse (n=317/422; 75%), efficacy (n=37/422; 9%), or safety (n=147/422; 34%). Among the items assessing opioid prescription misuse (n=317), 33% (n=105) assessed current misuse while 67% (n=212) assessed risk of future misuse. The predominance of misuse-related items highlights a disproportionate focus on misuse over treatment safety and effectiveness.

Conclusion & Discussion: This scoping review aims to map the literature on existing tools to evaluate patients with chronic pain on long-term opioid therapy (LTOT). Most existing instruments disproportionately focus on harms rather than benefits, with 91% of items assessing harm and only 9% of items assessing benefits. This imbalance limits their utility in weighing both the current and potential harms versus the benefits of LTOT for chronic pain. The lack of balanced assessment is concerning, as prior research demonstrates that placing treatment benefits on equal footing with treatment risks prevents misalignment between patients and prescribers, enhances patient satisfaction with care, and promotes overall well-being in support of shared goals (Edmond & Becker, 2024). Our review reveals that most existing tools prioritize screening for opioid misuse over assessing treatment efficacy. This disproportionate emphasis on misuse screening may inadvertently shape clinical practice in a way that does not fully weigh the harms versus benefits of LTOT. Therefore, developing a new screener tool that incorporates a balanced assessment of harms and benefits of LTOT for chronic pain could enhance the value of longitudinal assessment in clinicians’ pain and opioid management decisions and improve collaborative decision-making.

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