Evidence-based Synthesis Program 

Assessment and Management 

of Acute Pain in Adult Medical 

Inpatients: A Systematic Review

Department of Veterans Affairs

Health Services Research & Development Service

April 2008

Investigators:

Mark Helfand, MD, MPH

Director

Michele Freeman, MPH

Research Associate

Prepared for: 

Department of Veterans Affairs

Veterans Health Administration

Health Services Research & Development Service

Washington, DC 20420 

Prepared by:

Portland Veterans Affairs Healthcare System

Oregon Evidence-based Practice Center

Portland, OR
Assessment and Management of Pain in Inpatients 

VA-ESP April 2008 ii

PREFACE

VA’s Health Services Research and Development Service (HSR&D) works to improve 

the cost, quality, and outcomes of health care for our nation’s veterans. Collaborating 

with VA leaders, managers, and policy makers, HSR&D focuses on important health care 

topics that are likely to have significant impact on quality improvement efforts. One 

significant collaborative effort is HSR&D’s Evidence-based Synthesis Program (ESP). 

Through this program, HSR&D provides timely and accurate evidence syntheses on 

targeted health care topics. These products will be disseminated broadly throughout VA 

and will: inform VA clinical policy, develop clinical practice guidelines, set directions for 

future research to address gaps in knowledge, identify the evidence to support VA 

performance measures, and rationalize drug formulary decisions. 

HSR&D provided funding for the two Evidence Based Practice Centers (EPCs) 

supported by the Agency for Healthcare Research and Quality (AHRQ) that also had an 

active and publicly acknowledged VA affiliation—Southern California EPC and 

Portland, OR EPC—so they could develop evidence syntheses on requested topics for 

dissemination to VA policymakers. A planning committee with representation from 

HSR&D, Patient Care Services, Office of Quality and Performance, and the VISN 

Clinical Management Officers, has been established to identify priority topics and to 

ensure the quality of final reports. Comments on this evidence report are welcome and 

can be sent to Susan Schiffner, ESP Program Manager, at Susan.Schiffner@va.gov. 
Assessment and Management of Pain in Inpatients 

TABLE OF CONTENTS

EXECUTIVE SUMMARY............................................................................... iii 

INTRODUCTION

 Historical Background ...........................................................................1 

METHODS

 Topic Development ..............................................................................3 

 Search Strategy ...................................................................................6 

 Study Selection ...................................................................................7 

 Data Abstraction and Quality Assessment ....................................................7 

 Data Synthesis .................................................................................8 

 Rating the Body of Evidence ...................................................................8 

 Peer Review ....................................................................................9 

RESULTS

 KEY QUESTION #1: 

How do differences in timing and frequency of assessment, severity of pain, and 

follow-up of pain affect choice of treatment, clinical outcomes, and safety? .......9 

In medical inpatients with acute pain, does routine assessment of pain

affect choice of treatment, clinical outcomes, and safety? .............................9 

Does the choice of assessment measure affect choice of treatment, clinical 

outcomes, and safety? .....................................................................10 

Do protocols for assessing pain improve outcomes? ..................................11 

Are there gaps in quality even when pain is assessed routinely? ....................13 

Specific condition – abdominal pain ....................................................14 

 KEY QUESTION #2: 

How do the timing and route of administration of pain interventions compare 

in effectiveness, adverse effects, and safety in inpatient care settings? ..............15 

Do acute pain management teams and other institutional initiatives 

improve effectiveness, adverse effects, and safety in medical inpatients? .........16 

Do acute pain management teams and other institutional initiatives 

improve effectiveness, adverse effects, and safety in other settings? ...............18 

How does coordination with the patient’s primary care physician 

affect outcomes? ...........................................................................19 

How does the choice of treatment modality affect effectiveness, adverse 

effects, and safety in inpatient care settings? ...........................................19 

Effectiveness and safety of patient-controlled analgesia (PCA) .....................21 

Specific conditions 

 Renal colic and biliary stone pain ...................................................22 

 Phantom limb pain .....................................................................23 

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 KEY QUESTION 3: 

For inpatients with impaired self-report due to any of several factors, including 

delirium or confusion, pre-existing severe dementia, closed head injury, stroke, 

and psychosis, how do differences in assessment and management of acute pain 

affect clinical outcomes or safety? ......................................................25 

 KEY QUESTION 4: 

For inpatients with dependencies on tobacco, alcohol, stimulant, marijuana, or 

opioids, how do differences in assessment and management of acute pain affect 

clinical outcomes or safety?................................................................ 28 

How do the assessment and management of acute pain differ between patients 

on pre-existing opioid therapy and patients with opiate addiction?.......................29 

CONCLUSIONS

Summary of evidence by key question.................................................. 31 

Recommendations for future research................................................... 36 

REFERENCES....................................................................................... 39 

TABLES

 Table 1. Self-Assessment Pain Measures ................................................10 

 Table 2. Some elements of institution-wide efforts to improve pain assessment 

 and management ................................................................................16 

 Table 3. Treatments for acute pain ..........................................................19 

 Table 4. Pain observation scales .............................................................28 

 Table 5. Summary of systematic evidence review by key question ..................32 

 Table 6. Examples of indicators for measuring aspects of pain management .........37 

FIGURES

 Figure 1. Analytic framework showing relationships among key questions ............5 

 Figure 2. Inpatient nursing acute pain algorithm ..........................................12 

 Figure 3. Pain algorithm evaluated in Vila et al. ..........................................13 

APPENDIX A. Search strategy and table of systematic reviews 

APPENDIX B. Inclusion/exclusion criteria 

APPENDIX C. Quality rating criteria 

APPENDIX D. Table of reviewer comments and responses 

APPENDIX E. Evidence Summary Tables 

Summary Table 1. Studies on the effectiveness and safety of patient-controlled 

analgesia for acute pain 

Summary Table 2. Studies on the timing and frequency of pain assessment, and 

timing of treatment 

Summary Table 3. Studies on the effectiveness and safety of patient-controlled 

analgesia for acute pain 

Summary Table 4. Studies on the management of acute pain in renal colic and 

biliary stone 

Summary Table 5. Studies on the effectiveness and safety of neural blockade 

for acute pain
Assessment and Management of Pain in Inpatients 

INTRODUCTION

“With the exception of the PACU, the floor will be the most common place where 

hospitalized patients may need acute pain management.” 1

Many guidelines and previous reviews address pain assessment and management in 

surgical inpatients, trauma patients, inpatients with cancer, and inpatients with sickle cell 

crisis. In contrast, pain in medical inpatients with other conditions has received little 

attention. The prevalence of pain on the inpatient medical ward is lower than that of a 

surgical service, but is still substantial. In one hospital survey, 43% of medical ward 

patients experienced pain, and 12% reported unbearable pain. Twenty per cent of elderly 

care and general medical patients reported pain scores greater than or equal to 6.2

 In a 

survey of patients consecutively admitted to a London hospital, 13% had severe pain 15% 

had moderate pain at rest, and half had moderate or severe pain with movement.3

 A few 

more European surveys have also tried to assess the prevalence of pain among hospital 

patients.4-6

On a medical service the etiology of pain is diverse, and may be hard to ascertain. Data 

on the course and treatment of pain in medical inpatients are absent. Little is known 

about how intravenous opioid therapy, considered the treatment of choice for patients 

with severe, acute pain, is used on a medical service. In contrast to the post-operative 

setting, on a medical service the patient’s course is less predictable, making it difficult to 

establish standards for when and how to change pain therapy and how to deliver it. 

Textbooks and professional societies provide relatively straightforward guidance for 

managing acute pain in the perioperative setting and acute or chronic cancer pain. In 

contrast, in the U.S. no guidelines have not been proposed for the management of pain in 

acute inpatient medical care settings. Similarly, there are currently no performance 

measures in place to enhance pain management. The current VA Office of Research and 

Development pain-relevant research portfolio has no projects designed to examine the 

quality of pain care in the general medical or neurology ward setting. 

HISTORICAL BACKGROUND 

In 1986, the National Institutes of Health held a consensus development conference 

entitled “The Integrated Approach to the Management of Pain.” 7

 It focused on causes of 

undertreatment of pain, in particular, excessive concern about the problems of addiction 

and respiratory depression. The panel endorsed the principle that the most reliable 

measure of acute pain is the patient’s self-report, but recognized limitations in the 

evidence, recommending future research on the “appropriateness of using existing 

research measures in clinical settings and...their validity as adjuncts to clinical judgments 

in pain assessment.” They also cited innovations such as patient-controlled analgesia, 

but noted that clinical evaluation of PCA, sustained release formulations, epidural 

administration, and transdermal absorption of narcotic drugs to improve pain 

management were inadequate. 

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Assessment and Management of Pain in Inpatients 

Since 1986, it has been widely recognized that a large minority of surgical patients have 

moderate to severe pain throughout their postoperative hospital course. 8

 Poor pain 

management in inpatient surgical settings has been associated with slower recovery, 9

greater morbidity, longer lengths of stay, lower patient satisfaction, and higher costs of 

care, suggesting that optimal pain care in these settings is of utmost importance in 

promoting acute illness management, recovery, and adaptation. 

In February, 1992, the Agency for Health Care Policy and Research released a guideline 

for the management of acute pain in trauma patients and in patients undergoing surgical 

or medical procedures.10 In 1994, AHCPR published a guideline for managing cancer 

pain.11The AHCPR guidelines brought attention to deficiencies in the quality of care and 

endorsed several principles that became the foundation of inpatient pain management, 

including 

• Clinicians should reassure patients and their families that most pain can be 

relieved safely and effectively. 

• Clinicians should assess patients and, if pain is present, provide optimal relief 

throughout the course of illness. 

• Health professionals should ask about pain, and the patient's self-report should be 

the primary source of assessment. 

• Giving patients pain medicine only "as needed" resulted in prolonged delays 

because patients may delay asking for help. 

• Aggressive prevention of pain is better than treatment because, once established, 

pain is more difficult to suppress. 

• Physicians need to develop pain control plans before surgery and inform the 

patient what to expect in terms of pain during and after surgery. 

• Fears of postsurgical addiction to opioids are generally groundless. 

• Patient-controlled medication via infusion pumps is safe.12

The VHA National Pain Management Strategy, initiated November 12, 1998, established 

Pain Management as a national priority. The goals of the strategy included (1) the 

provision of a system-wide VHA standard of care for pain management to reduce 

suffering from preventable pain; (2) assurance that pain assessment is performed in a 

consistent manner and that pain treatment is prompt and appropriate; (3) the inclusion of 

patients and families as active participants in pain management; (4) the provision for 

continual monitoring and improvement in outcomes of pain treatment; (5) an 

interdisciplinary, multi-modal approach to pain management; and (6) assurance that 

clinicians practicing in the VA healthcare system are adequately prepared to assess and 

manage pain effectively. In 2000, VA published a toolkit for implementing these goals. 

(http://www1.va.gov/pain_management/docs/TOOLKIT.pdf) 

The strategy led to rapid improvement in performance as measured by documentation of 

a pain assessment and pain care plans in the medical record and a lower proportion of 

patients with moderate or severe pain on study units.13, 14 In 2000, for example, a survey 

conducted in VA inpatients with cancer found that only 42% of charts showed evidence 

VA-ESP April 2008 2
Assessment and Management of Pain in Inpatients 

15 that a pain rating scale was used The VA and Institute for Healthcare Improvement 

initiated a collaborative project that used learning sessions, monthly team conference 

calls, and monitoring of results and sharing of improvement methods via Internet to 

promote routine assessment of pain and related goals. The learning sessions emphasized 

reliable and standardized measurement, strategies for interval sampling, and strategies for 

plotting and analyzing data. From May 2000 to January 2001, when the VA-IHI Joint 

Collaborative was conducted; moderate or severe pain on study units dropped from 24% 

to 17%; pain assessment increased from 75% to 85%; pain care plans for patients with at 

least mild pain increased from 58% to 78%; and number of patients provided with pain 

educational materials increased from 35% to 62%.13, 14 By 2003, chart audit indicated that 

approximately 98% of veterans receiving care at a VHA facility had a documented pain 

score within the past 12 months.16 

In July, 2002, VA/DoD developed a Clinical Practice Guideline for the management of 

acute post-operative pain. The basis for many of the recommendations was expert 

consensus rather than empirical evidence. To assess intensity, the VA/DOD CPG 

recommended use of a visual 1-10 numeric rating scale in the context of a complete pain 

history. Most of the guideline consists of site-specific recommendations for 

pharmacologic and nonpharmacologic therapy. 

In 2003, VHA DIRECTIVE 2003-021 solidified previous accomplishments, leading to 

creation of a national pain management infrastructure. It requires implementation of 

“Pain as the 5th Vital Sign” in all clinical settings; establishment of pain management 

protocols in all clinical settings; and, for each patient, comprehensive pain assessment 

and development of a pain treatment plan.. It also encourages use of the pain reminders 

and dialogs sponsored by the VHA National Pain Management Strategy Coordinating 

Committee. 

 In 2004, the VHA National Pain Management Strategy Coordinating Committee issued a 

consensus statement on Assessing Pain in the Patient with Impaired Communication 

(available from http://www1.va.gov/Pain_Management/page.cfm?pg=41.) 

METHODS

Topic Development 

This project was nominated by Robert Kerns, Ph.D, VA National Coordinator for Pain 

Management, with input from a technical expert panel. Dr. Kerns proposed that we 

integrate the existing literature on the delivery of effective pain care in the acute inpatient 

medical ward. The results will be used to inform the VA’s National Pain Management 

Strategy. 

Key questions were discussed and finalized during a conference call that included the 

Steering Committee of the Evidence Synthesis Project and the Portland VAMC project 

site director. The questions apply only to the target population of inpatients on medical 

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Assessment and Management of Pain in Inpatients 

VA-ESP April 2008 4

and neurology wards, not to surgical patients, patients with cancer, or patients with sickle 

cell crisis. 

The final key questions are: 

1. For inpatients who have acute pain, how do differences in timing and frequency of 

assessment, severity of pain, and follow-up of pain affect choice of treatment, clinical 

outcomes, and safety? 

2. How do the timing and route of administration of pain interventions compare in 

effectiveness, adverse effects, and safety in these inpatient care settings? 

3. For inpatients with impaired self-report due to any of several factors, including 

delirium or confusion, pre-existing severe dementia, closed head injury, stroke, and 

psychosis, how do differences in assessment and management of acute pain affect clinical 

outcomes or safety? 

4. For inpatients with dependencies on tobacco, alcohol, stimulant, marijuana, or 

opioids, how do differences in assessment and management of acute pain affect clinical 

outcomes or safety? How do the assessment and management of acute pain differ 

between patients on prexisting opioid therapy and patients with opiate addiction? 

We developed an analytic framework (Figure 1) to depict the clinical logic underlying 

these questions and the rationale for study selection. Figure 1 shows the relationship 

between pain assessment and improved pain outcomes. For Key Question 1, we sought 

direct evidence linking improved pain assessment to improvements in pain outcomes 

(Arrow 1a), earlier or better treatment (Arrow 1b), or better detection and monitoring 

(Arrow 1c). Interventions to improve pain assessment could include a better choice of 

pain measure or different protocols for the frequency and timing of assessment. 

Most interventions to improve pain assessment are part of broader systemwide programs 

that combine strategies to improve the timeliness and frequency of assessment with 

strategies to increase awareness and responsiveness to pain. When it comes to assessing 

effects on treatment and pain outcomes, the components aimed at assessment cannot be 

separated from other components, such as acute pain management teams. We discuss 

these interventions in the section about Key Question 2. 

For Key Question 2, we assessed the timing and route of administration of therapy affect 

outcomes. At a system level, systemwide programs, acute pain management services, 

preprinted orders, clinical algorithms, and other management interventions may affect the 

timing and route of administration of pain treatments. At a more clinical level, we 

evaluated the use of intravenous versus other routes, prn orders, and patient-controlled 

analgesia. 

Key Questions 3 and 4 follow the logic depicted in Figure 1, applied to patients with 

cognitive impairment and substance abuse problems, respectively.
Assessment and Management of Pain in Inpatients 

VA-ESP April 2008 

Inpatients

general wardrenal colicabdominal painwith cognitive impairment (KQ3)with addiction, tolerance (KQ4)

Programs to improve pain assessment

1c *

Adverse effects of

treatment

1

Earlier and more effective treatment ** 2

* KQ 1a, b, c The following types interventions 

might improve assessment:

• Better choice of pain measure• Systemwide programs to improve the timeliness and frequency of assessment

• numerical pain assessment algorithms• clinical pathways, guidelines, performance measurement

Better communication about painÆBetter detection & monitoring of painÆ•identify patients who have pain but have not complained•identify patients with pain faster•quantify pain intensity and response to treatments 

Lower pain intenBetter satisfactioBetter recovery fmedical illness

** KQ 2 Interventions include

• Acute pain management services asystem interventions • Greater use of patient-controlled a• Greater use of IV vs. IM and PO r• Greater use of scheduled adminisinstead of just prn orders

2

1b *

Figure 1. Analytic Framework Showing Relationships among Key Questio
Assessment and Management of Pain in Inpatients 

Search Strategy

Initially, we searched for previous systematic reviews in Medline, PubMed Clinical 

Queries, and the Cochrane Database of Systematic Reviews (1996 to April, 2007.) We 

identified several previous reviews: 

Acute Pain Management: Scientific Evidence, 2nd 17 edition (2005) . The ANZCA 

review and guideline covers scientific articles published after 1998; it does not specify 

the closing date of the searches. ANZCA is a good-quality systematic review and 

guideline from Australia that provides the best available summary of research findings 

and recommendations for future research for many of the questions addressed in our 

report.17 The guideline covers post-operative pain as well as acute pain associated with 

non-surgical conditions such as spinal cord injury, burns, cancer, acute zoster, 

neurological diseases, haematological disorders (e.g. sickle cell disease) and HIV/AIDS, 

as well as abdominal (e.g. renal and biliary colic), cardiac, musculoskeletal and orofacial 

pain and headache. It also covered acute pain management in the elderly, opioid-tolerant 

patients, patients with obstructive sleep apnea, renal or hepatic impairment or a substance 

abuse disorder.18

Institutional Approaches to Pain Assessment and Management (2003). This National 

Institute of Clinical Studies Literature Review, also from Australia, covers literature 

published between 1995 and May, 2002.19 This systematic review covers multi-level 

institutional strategies, Acute Pain Services, and other dedicated-service strategies to 

improve pain assessment and management. 

ICSI Healthcare Guideline: Assessment and Management of Acute Pain, 5th ed. 

2006. This guideline provides algorithms for managing acute somatic, visceral, and 

neuropathic pain. It cites some pertinent articles published 2005 or before, and suggests 

some performance measures, 20 but is not based on a systematic review. 

Pain: Current Understanding of Assessment, Management, and Treatments (2001) 

21 and Improving the quality of pain management through measurement and action 

(2003),22 address the application of continuous quality improvement techniques to pain 

assessment and management and the implementation of performance measurement 

processes. Both reports were prepared by the National Pharmaceutical Forum in 

collaboration with JCAHO. 

International Association for the Study of Pain consensus guidelines on assessing 

pain in the elderly (2007) 23 While not evidence-based, these guidelines cite a large 

body of evidence about different approaches to assessing pain and includes a section 

about assessing pain in patients with cognitive impairment. 

We proceeded to conduct a targeted search in Medline for primary research studies 

published from 1950 to July 2007 that address KQ1 or KQ2, the use of PCA for nonsurgical pain. A list of studies included in the previous reviews, as well as the search 

terms and MeSH headings for the various search strategies, are found in Appendix A. 

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Assessment and Management of Pain in Inpatients 

Study Selection

Two reviewers assessed for relevance the abstracts of citations identified from literature 

searches, using the criteria described in Appendix B. Full-text articles of potentially 

relevant abstracts were retrieved and a second review for inclusion was conducted by 

reapplying the inclusion criteria. Eligible articles had English-language abstracts and 

provided primary data relevant to the key questions. We included studies that were 

conducted in inpatients with acute pain and reported data on any of the following: 

Association between timing and frequency of pain assessment, severity of pain, and 

choice of treatment (e.g. regional blocks, medications, or other therapies); method of pain 

assessment (e.g. 11-point pain scale, visual analog scale, verbal descriptor scale; timing 

and route of administration of pain interventions (e.g. oral intermittent pharmacotherapy, 

intravenous therapy, psychological interventions, positioning, neural blockade, and 

patient-controlled analgesia); timeliness of enactment of treatment plans, changes in 

treatment plans; effect of coordination of care with the patient’s primary care physician 

or with a pain consultation service on choice of treatment, clinical outcomes, and safety; 

patient outcomes, including degree of pain relief, pain intensity, emotional well-being, 

patient satisfaction, physical function, and fitness for rehabilitation of the underlying 

condition; safety outcomes; severity and frequency of side effects (including somnolence, 

respiratory depression, confusion, constipation, ileus, vomiting, non-allergic itching, 

weakness/numbness, and use of naloxone); length of stay; or follow-up of pain. We 

excluded studies of interventions that were not routinely available in the VA health 

system. We excluded studies of post-operative pain, sickle cell disease, cancer pain, 

chronic pain in patients hospitalized 10 days or longer for whom pain is chronic or 

refractory, except when studies of adverse effects were not available in the target 

population. 

Data Abstraction and Quality Assessment

We abstracted the following data from included studies: Study Design/setting, Objective, 

eligibility criteria / method for assembling cohort, exclusion criteria, sample size, years of 

enrollment/observation, duration of follow-up, demographics, clinical category/baseline 

pain, method used to assess pain, intervention/exposure of interest, outcomes measured, 

potential confounders considered, results, conclusions. Although the studies were 

heterogeneous in design, objectives, and outcomes, we rated the quality of evidence of 

studies when applicable, using the criteria of the U.S. Preventive Services Task Force for 

evaluating randomized controlled trials and cohort and studies (Appendix C).24 For 

example, for randomized trials, we abstracted data on treatment allocation; \ the method 

of randomization; concealment of treatment allocation; similarity of groups at baseline 

regarding the most important prognostic indicators; blinding of the outcome assessor, 

care provider; and patients; loss to followup and use of intention-to-treat analysis. 

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Assessment and Management of Pain in Inpatients 

Data Synthesis 

We constructed evidence tables showing the study characteristics and results for all 

included studies, organized by key question, intervention, or clinical condition, as 

appropriate. We critically analyzed studies to compare their characteristics, methods, and 

findings. We compiled a summary of findings for each key question or clinical topic, and 

drew conclusions based on qualitative synthesis of the findings. 

Rating the body of evidence 

We assessed the overall quality of evidence for outcomes using a method developed by 

the Grade Working Group, which classified the grade of evidence across outcomes 

according to the following criteria: 

o High = Further research is very unlikely to change our confidence on the estimate of 

effect. 

o Moderate = Further research is likely to have an important impact on our confidence 

in the estimate of effect and may change the estimate. 

o Low = Further research is very likely to have an important impact on our confidence 

in the estimate of effect and is likely to change the estimate. 

o Very Low = Any estimate of effect is very uncertain. 

GRADE also suggests using the following scheme for assigning the “grade” or strength 

of evidence: 

Criteria for assigning grade of evidence 

Type of evidence 

Randomized trial = high 

Observational study = low 

Any other evidence = very low 

Decrease grade if: 

• Serious (-1) or very serious (-2) limitation to study quality 

• Important inconsistency (-1) 

• Some (-1) or major (-2) uncertainty about directness 

• Imprecise or sparse data (-1) 

• High probability of reporting bias (-1) 

Increase grade if: 

• Strong evidence of association-significant relative risk of > 2 (< 0.5) 

based on consistent evidence from two or more observational studies, 

with no plausible confounders (+1) 

• Very strong evidence of association-significant relative risk of > 5 

(< 0.2) based on direct evidence with no major threats to validity (+2) 

• Evidence of a dose response gradient (+1) 

• All plausible confounders would have reduced the effect (+1) 

For this report, we used both this explicit scoring scheme and the global implicit 

judgment about “confidence” in the result. 

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Assessment and Management of Pain in Inpatients 

Peer Review 

Four peer reviewers provided feedback on the draft version of this report. Their 

comments and our responses are presented in Appendix D. One peer reviewer identified 

a potentially relevant article25 and criticized the search strategy. In response, we 

conducted supplemental searches that identified 76 citations, two of which proved 

relevant to this report. The remaining citations concerned surgical, trauma, prehospital, 

emergency, and chronic patient settings. 

RESULTS 

There is much more evidence about outpatients with chronic pain, post-operative 

inpatients and patients with cancer than patients within the target population for this 

report. Throughout this report, we give precedence to the few studies that directly 

observed medical inpatients. We did not systematically review the literature about 

chronic pain, post-operative pain, or cancer pain assessment and management, but we 

invoke evidence from other populations when it is pertinent. 

Key Question #1. How do differences in timing and frequency of 

assessment, severity of pain, and follow-up of pain affect choice 

of treatment, clinical outcomes, and safety? 

Routine standardized pain assessment is usually implemented as part of a broader effort 

to coordinate pain management, particularly for post-operative patients. Usually, it is not 

possible to isolate timing and frequency of assessment from other components of these 

programs, which are discussed below in Key Question #2. 

In medical inpatients with acute pain, does routine assessment of pain (for 

example, as the 5th vital sign) affect choice of treatment, clinical outcomes, 

and safety (Arrows 1a and 1b)? 

We found no evidence that directly linked the timing, frequency, or choice of measure for 

assessment with the timeliness, choice, or safety of treatment specifically in medical 

inpatients. In the postoperative setting, routine numerical assessment of pain intensity 

increased utilization of intravenous analgesics and patient-controlled analgesia26 and 

improved patient and staff satisfaction with pain management, but had unclear effects on 

pain severity and length of stay. In the emergency department, the addition of a 

mandated numeric pain scale to the medical record resulted in a significant increase in the 

proportion of patients in the ED who received analgesia, from 25% before 

implementation to 35% after implementation (Appendix E, Summary Table 1).27 

However, the extent of use on a medical ward of patient-controlled analgesia, regional 

analgesia, and specialized procedures is not well-documented, and experience in the 

postoperative and emergency care should not be generalized to this setting.

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Assessment and Management of Pain in Inpatients 

Does the choice of assessment measure affect choice of treatment, clinical 

outcomes, and safety? 

As described above, since the 1980’s there has been almost universal agreement that 

routine assessment of self-reported pain intensity is a better measure than pain assessed 

by a nurse or physician. This is because providers underestimate the severity of patients’ 

pain in as many as half of cases. The disparity is greatest (60-68%) among patients with 

severe pain, and lowest (28-36%) among patients with mild pain.28, 29 Routine 

assessment is encouraged because many patients, especially those who have cognitive 

impairment, do not always mention pain unless asked. 

To be suitable for routine use as a vital sign, a self-reported pain assessment method must 

be simple to administer, easy for patients to understand, and responsive to changes in 

pain over time. Table 1 describes the most commonly used pain assessment measures. 

In case series, these measures have high internal consistency (Cronbach α 0.85 or 

greater) and at least fair test-retest reliability (r>0.5) in alert, cognitively intact 

individuals.17, 23, 30 They are highly correlated with one another in such individuals, 

subject to patients’ preferences for visual, numerical, or verbal descriptions and their 

willingness to use them. However, none of these assessment measures is intended to 

diagnose the cause of pain, and none are perfect across the entire spectrum of etiologies, 

pain types, comorbid conditions, and patient preferences encountered in a general 

medical ward. 

The single dimension measures assess pain intensity. A 10-point verbal numeric rating 

scale (VRS or VNRS) is used widely within the VA health care system. Like all of these 

measures, the VRS has been evaluated more thoroughly in chronic pain and long-term 

care settings than in acute care settings, although there is one evaluation in medical 

inpatients undergoing common procedures.31 That study compared a ten-point (N = 100) 

and five-point scale in 30 inpatients and found that the five-point scale exhibited better 

subject discrimination between experiences. 

Table 1. Self-Assessment Pain Measures 

Single Dimension 

Scale Description 

Visual analog scale 100 mm scale. Requires examiner to bring printed or on-screen scale 

and means for the patient to make a mark. 

Verbal numeric rating 

scale 

0 to 10 rating. 

Verbal description scales None-mild-moderate-severe. 

Facial pain scales Seven faces (0-6) or 10 faces (0-9) ranging from a neutral face (no 

pain) to a grimacing face 

(worst pain). 

Multi Dimension

Brief pain inventory Assesses pain intensity and disability 

McGill pain 

questionnaire 

Assesses sensory, affective, and evaluative dimensions of pain 

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It is important to note the absence of evidence or consensus on what constitutes the 

minimal clinically important difference (MCID) for acute pain management in the 

hospital setting. The minimal clinically important difference is “...the smallest difference 

in score in the domain of interest which patients perceive as beneficial and which would 

mandate, in the absence of troublesome side effects and excessive cost, a change in the 

patient’s management.”32 The MCID helps define a clinically significant response. A 

systematic review of pain intensity measurement found that the MCID was defined 

consistently across studies in chronic pain patients,33 but this is not the case for acute 

nonsurgical pain. Determining the MCID for the VRS used in the VA system is a first 

step in studying and improving inpatient pain management. 

 

Do protocols for assessing pain improve outcomes? 

Many algorithms for assessing pain intensity and acting on the information are in use (for 

an example, see Figure 2.) Most algorithms directly link the intensity of pain to specific 

therapeutic actions, such as rapid administration of IV opioids. 

We found no evaluations specifically of the effect of algorithms, preprinted orders, 

clinical pathways, or other protocols for assessing pain in the target population. In most 

cases, these algorithms are part of larger, institution-wide strategies to improve pain 

management. Although routine standardized assessment of self-reported pain severity is 

the cornerstone of these efforts, it is not possible to separate the effect of the assessment 

component from that of other components of these programs, such as an acute pain 

management service. The effect of these programs is addressed in Key Question #2. 

With respect to safety, a study in cancer patients found that opioid-related oversedation 

and other adverse effects increased substantially after implementation of pain assessment 

on a numerical scale routinely with other vital signs.34 This was the only study we 

identified that looked specifically at the association of routine use of numerical pain 

rating and adverse treatment effects. It was a retrospective review of records of patients 

who had experienced an adverse drug effect at the H. Lee Moffitt Cancer Center and 

Research Institute before (~1999) versus after (2002) implementation of a numerical pain 

treatment algorithm (Figure 3). Following implementation of the algorithm, there was a 

2-fold increase in the risk of opioid oversedation (RR 2.22, 95% CI 1.07– 4.60), 

corresponding to an incidence from 11.0 per 100,000 inpatient hospital days to 24.5 per 

100,000 inpatient hospital days post-NPTA (P < 0.001). 

In the outpatient medical setting, VA has instituted several measures to improve pain 

management, including routine standardized assessment (or pain as the fifth vital sign), 

audit and feedback to clinical staff, specialist-level pain consultation services, nurse-level 

pain services, and palliative care services. A retrospective chart review study35 and a 

prospective diagnostic test evaluation36 cast doubt on the effectiveness of these 

interventions and on the accuracy of routine pain assessment, respectively, in the VA 

outpatient setting. 
Assessment and Management of Pain in Inpatients 

VA-ESP April 2008 

Figure 2. Inpatient Nursing Acute Pain Algorithm
Assessment and Management of Pain in Inpatients 

Figure 3. Pain Algorithm evaluated in Vila et al. 34 

Are there gaps in quality even when pain is assessed routinely? 

We did not identify any studies of the timing or frequency of assessment of pain that 

focused on medical inpatients. However, evaluations conducted in the emergency room 

are relevant to medical inpatients, because patients headed for nonsurgical, noncancer 

wards are less likely to get adequate attention in the emergency room. 

Surveys conducted in the late 1990’s37, 38 as well as more recent ones,39 suggest that pain 

in emergency room patients is underdiagnosed and undertreated. . Potential risk factors 

for delayed or inadequate analgesia include female sex, less severe pain, and daytime 

admissions. Instituting routine assessment of pain, usually with an educational 

component, improved rates of assessment and treatment.40, 41 In a University-based, 

single-institution, retrospective chart review study comparing outcomes in 521 medical 

encounters before and 479 after introduction of routine pain assessment of all patients in 

an emergency department, the addition of a mandated numeric pain scale increased the 

proportion of patients who received analgesia from 25% before implementation to 35% 

after implementation (p<0.001).27 The time from triage to administration of analgesia 

improved on average from 152 to 113 minutes (but p>0.05). The standard triage form 

was revised to include a verbal numeric pain scale ranging from 0 to 10 in the vital signs 

section, and pain was measured at the same time as vital signs. The series included 

patients who presented with renal colic, extremity trauma, headache, ophthalmologic 

trauma or soft tissue injury (Appendix E, Summary Table 1).27 A retrospective beforeafter study at a single hospital had similar results.42

VA-ESP April 2008 13
Assessment and Management of Pain in Inpatients 

Several chart review studies conducted in emergency departments focus on gaps in 

quality that remain even after institution of system changes. In the Nelson study just 

described, for example, patients with diagnostic uncertainty were less likely to receive 

analgesia compared with patients who received no workup (27% v. 34% respectively, 

p=0.0220). In a large, retrospective series from an Australian ED, patients who had a 

lower-priority triage score were nine times as likely as others to have a delay in treating 

pain; advanced age (>80 years) and admission to hospital were also associated with 

delays.43 Documentation and treatment of pain deteriorates when the ED is busy 

(Appendix E, Summary Table 2).44.

45

Specific Condition: 

Abdominal Pain

Treating acute abdominal pain has traditionally been delayed until after evaluation by a 

surgeon, for concern that analgesia may alter the findings of physical examination, 

leading to misdiagnosis and management errors. A 1996 survey of 131 general surgeons 

in Iowa determined that 89% preferred to withhold analgesia for patients with acute 

abdomen until examined by a surgeon.46 

In fact, there is good evidence that analgesia for acute abdomen is not only safe but 

beneficial because it facilitates more accurate diagnosis by localizing physical signs and 

allowing for more detailed examination by reducing patient stress.47-49 More liberal use 

of analgesia has become common in practice. In a 2003 survey of ED physicians in 60 

hospitals, 98.3% responded that it is the practice of their ED to administer narcotic 

analgesia to patients with acute abdomen prior to surgical consultation. Only 15.3% 

indicated that it is their practice to always verbally inform the surgeon prior to dosing the 

patient, and 49.2% reported the belief that analgesics aid in diagnostic accuracy.50 

In a recent, good-quality systematic review and meta-analysis (Ranji et al), opioid 

administration had a negligible impact on clinical management and operative decision.51 

The review included 12 placebo-controlled RCTs of opioid analgesia in children and 

adults, reporting a total of 15 drug/dose comparisons. The combined findings of 11 

comparisons from 9 studies in adults revealed a non-significant increase in changes in the 

physical examination with opioid administration, with a summary RR of 1.51 (95%CI 

0.85 - 2.69). There was significant heterogeneity among the studies, and pain relief 

reported by the opioid group did not significantly differ from placebo in 3 of the 

comparisons. Most studies did not distinguish between potentially beneficial changes 

such as improved localization of tenderness and potentially harmful changes such as 

changes in peritoneal signs. Only 2 studies (including a study in children) specified that 

loss of peritoneal signs after analgesia occurred in 5.6% to 18.7% of patients with 

opioids, compared with 2.6% to 7.7% of those in the control group. 

In an analysis of diagnostic accuracy in 4 adult studies, there was no significant change in 

VA-ESP April 2008 14
Assessment and Management of Pain in Inpatients 

the rate of incorrect management decisions with opioids compared with placebo (+0.3% 

absolute increase; 95%CI –4.1% to +4.7%). Analgesia was adequately greater than 

placebo in these studies, and no significant heterogeneity was found. The frequency of 

possible unnecessary surgeries was similar between opioid and control groups (7.6% v 

7.9%). Meta-analysis showed non-significantly fewer unnecessary surgeries among 

patients with opioids. The reviewers concluded that opioid administration appears to 

have negligible impact on clinical management, in that 909 patients would need to 

receive opioids to result in 1 potential management error.51 A trial intravenous morphine 

vs. placebo, published too recently to be included in the Ranji review, supported these 

findings.52

Waiting for a surgical consultant is only one cause of delay in treating abdominal pain. 

One systematic review51 53 and one primary study examined the timing of assessment and 

analgesia for acute abdominal pain. Three studies examined the relation of severity of 

pain, ED crowding, and other factors to timing of assessment and treatment (Appendix E, 

Summary Table 2).39, 43, 44 Immediate referral to surgery when the patient with acute 

abdominal pain comes to the ED reduces, but does not eliminate, delay in analgesia. A 

2004 study in such a setting examined the factors associated with waiting time from 

prescription to administration of analgesia among 100 consecutive patients presenting 

with acute abdomen at a hospital in the UK.53 Despite having direct access to an on-call 

surgical service, thus eliminating the referral delay and the need to withhold analgesia in 

the interim, the administration of analgesia to patients in this setting was heterogeneous. 

Sixty-seven percent of patients received analgesia within 1 hour, and 22% waited 2-14 

hours after presentation. The study found that severe pain was more likely to be treated 

quickly, that females had a longer mean wait time than males (129 min v. 69 min, 

p=0.09), and patients admitted at night waited less time (mean 76 min) than those during 

the day (mean 114 min). The timing of analgesia was not associated with clinical 

diagnosis or patient age. Diclofenac was the most commonly prescribed analgesic (37%), 

followed by pethidine (26%). No patients received analgesia intravenously, and 80% 

received analgesia through the intramuscular route. Nearly a fourth of patients reported 

that the analgesia received was inadequate. 

Key Question #2. How do the timing and route of administration 

of pain interventions compare in effectiveness, adverse effects, 

and safety in inpatient care settings? 

In general, pain in medical inpatients is managed by the primary team, with involvement 

from an acute pain team on a consultation basis. There are no programs directed mainly 

at improving pain management in medical inpatients who do not have cancer and are not 

suffering from a terminal disease. For clinicians, one of the main clinical management 

questions is when to use pain and palliative care consultants for such patients, and 

whether they improve outcomes in this setting. Another important question is whether 

use of PCA and other modalities improve control of pain and satisfaction of patients and 

staff. 

VA-ESP April 2008 15
Assessment and Management of Pain in Inpatients 

Do acute pain management teams and other institutional initiatives 

improve effectiveness, adverse effects, and safety in medical inpatients? 

Most institution-wide efforts to improve pain assessment and management aim to 

influence the timing and route of administration of pain interventions. As mentioned 

earlier, it is usually not possible to isolate the effect of administration of treatments from 

other elements of multifaceted programs. However, it is worth examining the overall 

effects of these programs and their effect on how treatments are administered. 

Table 2. Some elements of institution-wide efforts to improve pain 

assessment and management. 

Identify key opinion leaders from relevant disciplines to form a steering committee. 

Identify pain assessment problems. 

Critically evaluate the applicability of guidelines and other scientific literature on pain 

assessment to a particular setting. 

Form continuous quality improvement team to map, monitor, and evaluate care 

processes. 

Develop and implement pain management standards. 

Develop critical pathways, preprinted or prespecified electronic orders, paper or 

electronic pain assessment and management algorithms. 

Staff education “pain management toolbox” (printed materials, videotapes, weekly “pain 

rounds”, invited lectures) 

Form an acute pain management consultation service. 

Monitoring to determine whether pain treatments have been effective (Pain as a fifth vital 

sign.) 

Chart audit, surveys of patient satisfaction. 

Elements of institution-wide interventions vary, but most incorporate a majority of the 

elements listed in Table 2. 19 For example, the VHA/Institute for Healthcare 

Improvement (IHI) Pain Management Collaborative, employed system-wide strategies to 

modify existing pain assessment and management practices within the VHA.16 Seventy 

teams from 22 VISNs throughout the U.S. participated in the 6-month joint 

Collaborative, with the following measurable objectives: to reduce the prevalence of 

severe pain by 25%; increase assessment such that 100% of patients will have their pain 

assessed; increase by 20% the documentation of plan of care among patients with a pain 

score >=4; and to provide appropriate pain management education to at least 50% of 

patients with a pain score of >=4. The strategic goals included: 1) provision of a systemwide VHA standard of care for pain management; 2) assurance that pain assessment is 

performed in a consistent manner and that pain treatment is prompt and appropriate; 3) 

the inclusion of patients and families as active participants in pain management; 4) 

continual monitoring and improvement in outcomes of pain treatment; 5) an 

interdisciplinary, multi-modal approach to pain management; and 6) assurance that 

clinicians practicing in the VA health care system are adequately prepared to assess and 

manage pain effectively. 

VA-ESP April 2008 16
Assessment and Management of Pain in Inpatients 

The VHA/IHI Collaborative used learning sessions, monthly team conference calls, and 

monitoring of results and sharing of improvement methods via Internet. The learning 

sessions emphasized reliable and standardized measurement, strategies for interval 

sampling, and strategies for plotting and analyzing data. Data collection methods were 

specific to each clinical setting: for inpatients and long-term care settings, at least 2 

patients each day were selected randomly; for Emergency Departments, teams could 

either select time points (e.g. 10AM and 3PM) or to select 2 charts randomly each data 

for data abstraction; for ambulatory settings, medical records of patients who visited 

during the month were sampled, excluding patients who were being seen for the first time 

in primary care. The project did not include a concurrent control group. Three of the 4 

objectives were met, and most of the improvements occurred during the first 3 months of 

the collaboration, and sustained during the next 3 months. The goal of 100% patient 

assessment was not met, although the frequency of pain assessment increased from 58% 

to 85% of patients during the collaboration period. 

Most primary studies in this review focused on postoperative or cancer pain, and were 

uncontrolled (see next section.) We identified one controlled trial, published since this 

review, which included medical inpatients. It found that a multifaceted intervention 

improved assessment of pain, but did not affect pain intensity or duration.54 The trial 

enrolled a random sample of 3964 English-speaking, cognitively intact subjects admitted 

to matched medical/surgical units (3 general medicine, 2 general surgery, 2 specialty 

surgery, 1 oncology, and 1 mixed oncology/general medicine) at Mount Sinai Hospital in 

New York. Usual care required that pain be assessed at least once per shift using a 4-

point scale. The intervention included, in phases: education, standardized pain 

assessment using a 1- or 4-item (enhanced) pain scale, audit and feedback of pain scores 

to nursing staff, and a computerized decision support system to guide analgesic 

prescribing. The enhanced pain assessment asked patients to rate current pain, worst 

pain, pain relief, and whether the level of pain was acceptable on 4-pt scales. Patients 

were interviewed within 48 hrs of admission and then once daily. An enhanced pain 

assessment that asked inpatients to rate current pain, worst pain, pain relief, and whether 

the pain level was acceptable on 4-point scales increased the likelihood of pain 

assessment, improved documentation of pain, and resulted in increased analgesia 

prescribing.54 The percentage of patients who received at least 1 pain assessment per 

day increased from 32.1% with the standard pain assessment to 79.3% when the 

enhanced pain scale was combined with the CSS, and to >80% when combined with 

audit and feedback. 

Although the enhanced pain scale and other interventions improved pain assessment and 

increased analgesic prescribing, the intervention did not alter severity of pain. The 

percentage of patients who had 72-96 hours of persistent pain following study enrollment 

and overall mean pain scores remained relatively constant across both blocks and all 

phases of the study. 

VA-ESP April 2008 17
Assessment and Management of Pain in Inpatients 

Do acute pain management teams and other institutional initiatives 

improve effectiveness, adverse effects, and safety in other settings? 

In patients with cancer, most programs include one or more of the following components: 

professional and patient education, instituting regular pain assessment (pain as a vital 

sign), audit of pain results and feedback to clinical staff, computerized decisional support 

systems, and specialist-level pain consultation services.55 Techniques for improving 

assessment and documentation of cancer pain included graphic recording on bedside 

charts, standardized pain assessment flow sheets, incorporation of both formal education 

and assessment tools, and institution-wide multidisciplinary programs. A 2007 

systematic review identified 10 studies of these interventions; several of them included at 

least some medical inpatients who did not have cancer. These studies demonstrated that 

routine pain assessment improved patient and staff satisfaction with pain management 

and improved documentation, but did not improve overall pain scores or pain severity. 55

There is much more evidence from the post-operative setting. A 2003 systematic review 

on institutional approaches to pain assessment and management, conducted in Australia 

by the Department of Public Health and the National Institute of Clinical Studies (NICS) 

identified 3 comparative studies and 29 before-and-after studies of the effect of 

institutional pain management programs on treatment and patient outcomes.19 Most of 

these programs implemented routine numerical pain assessment and some form of a pain 

management team. Overall, interventions improve pain assessment indicators such as use 

of pain intensity scales, pain flow sheets, a pain plan of care, and documentation of 

location and quality of pain, and response to treatment. Interventions also increase 

administration of scheduled (rather than prn) pain medication, reduce use of the IM route, 

and increase the use of intravenous analgesia and of PCA. 

While pain management teams and other system interventions improved the timeliness 

and frequency of pain assessment, evidence for improvements in pain outcomes was 

conflicting. The NICS review included 10 studies on dedicated service strategies.19 

These included 9 studies on the introduction of pain management teams, most commonly 

an Acute Pain Service, and 1 before-and-after study of the introduction of a pain 

monitoring specialist. Two studies were multi-center studies that compared an 

intervention group with a control group where standard patient care was maintained (i.e. 

did not introduce a dedicated pain management service). 

The results of the controlled studies suggest that Acute Pain Services in tertiary settings 

reduce the intensity of pain experienced by patients and improve their functional ability, 

although these effects were not always determined to be clinically important. The use of 

a dedicated service strategy increased use of patient-controlled analgesia and IV opioids, 

while IM administration decreased substantially. Prescribing practices also appeared to 

be altered in that NSAID and paracetamol use increased significantly. A statistically and 

clinically important improvement in patient satisfaction with pain management was also 

observed. Analgesia-related adverse effects, such as nausea, vomiting, sedation, diarrhea, 

and hypotension, appear to be reduced after the introduction of a dedicated service 

strategy. 

VA-ESP April 2008 18
Assessment and Management of Pain in Inpatients 

The review also examined multi-level strategies, in which strategies were developed to 

modify existing pain assessment and management policies, procedures, and practices at 

all levels of the institution. Most multi-level strategies included staff education and the 

use of standardized pain assessment methods. The integration of pain assessment as a 

“5th vital sign” was included in two studies. The effects of multi-level strategies on pain 

reduction, functional ability, and patient satisfaction were variable. Only one study of a 

multi-level strategy used a control group. The body of evidence on institutional 

approaches to pain assessment and management was of limited quality overall.19 

In summary, institutional interventions improved pain assessment and documentation and 

staff awareness of pain, and increased use of analgesics. There was only poor-quality 

evidence that these programs improved safety. Most importantly, the programs’ effect on 

patient levels of pain was inconsistent; in the relatively higher-quality studies, programs 

did not improve pain. 

How does coordination with the patient’s primary care physician affect 

outcomes? 

We found no evidence about the value of coordinating care with the patient’s primary 

care physician. 

How does the choice of treatment modality affect effectiveness, adverse 

effects, and safety in inpatient care settings? 

Treatment options for pain management are listed in Table 3 below.1, 17, 20 There is a 

glaring lack of comparative studies of different agents and methods of administration in 

the general inpatient setting. 

Table 3. Treatments for acute pain 

TREATMENTS COMMENTS

Psychological and physical methods --- 

 Providing information 

 Relaxation 

 Attentional techniques 

 Hypnosis 

 Cognitive-behavioral interventions 

 TENS 

 Acupuncture 

 Positioning 

 Manual and massage therapies 

 Heat and cold 

VA-ESP April 2008 19
Assessment and Management of Pain in Inpatients 

TREATMENTS COMMENTS

Non-steroidal anti-inflammatory drugs, 

acetaminophen, topical therapies, 

combinations 

Bleeding, renal, coagulation problems and 

fluid retention (NSAIDs) 

Nitrous oxide, corticosteroids, ketamine, 

clonidine 

Role in inpatient medical patients unclear. 

Opioids First-line treatment for severe, acute pain. 

 

 Delivery methods No clear evidence that any opioid is better 

 oral intermittent in medical inpatients. 

 subcutaneous 

 transdermal Requires good staffing levels to minimize 

delay between need and injection (or 

between need and setting up PCA) 

 IM 

 IV administered by a nurse on request 

 IV administered by a nurse on a 

schedule Risks of PCA vs. other methods of 

administration are similar in surgical 

patients but have not been studied in 

medical inpatients. 

 Patient-controlled analgesia 

 Adjuvant drugs 

 Antiemetics 

 Ketamine Respiratory depression, diminished level of 

consciousness, constipation, urinary 

retention, and other complications are 

common side effects. 

 Naloxone 

 Clonidine 

Regional Analgesia Role in inpatient medical patients unclear. 

 

 Neuraxial blockade 

 Peripheral,n. blockades 

 Paravertebral, intercostal, interpleural, 

etc 

Epidural Analgesia Role in inpatient medical patients unclear. 

 Thoracic or Lumbar 

 Usually opioid+local anesthetic and 

sometimes epinephrine 

The risks are those of an epidural 

(neurological damage, epidural hematoma, 

epidural abscess)l +those of the drugs 

(local anesthetic+opioid) 

 Sometimes patient-controlled 

Specialized procedures (eg, joint injection, 

wound infiltration) 

SYSTEM INTERVENTIONS

Use of acute pain management team 

Coordination of care with primary care physician 

VA-ESP April 2008 20
Assessment and Management of Pain in Inpatients 

Effectiveness and safety of patient-controlled analgesia (PCA) 

PCA refers to methods of pain relief that allow a patient to self-administer small doses of 

an analgesic agent as required. The concept of PCA was introduced in 1970, but the 

method did not become popular until the 1980’s, when improvements in infusion pump 

technology made wider use of PCA in post-operative patients feasible. 56

The vast majority of studies on the use of PCA pertained to postoperative pain or acute 

pain due to exacerbation of chronic medical conditions such as sickle cell crisis or cancer. 

PCA has also been evaluated in patients with fractures or other traumatic injury (see 

Appendix E, Summary Table 3).57-60 

Early trials of PCA compared it with intermittent, intramuscular opioid injections 

administered by a nurse. More recent trials compare PCA to epidural analgesia. All of 

these trials were conducted in the setting of post-anesthesia care units or, subsequently, a 

(postoperative) surgical ward. 

In post-operative patients, regional and epidural analgesia have been compared with 

intravenous opioids, administered intermittently or by patient-controlled analgesia (PCA). 

Recent systematic reviews identified surgical conditions in which regional analgesia 

provides superior pain relief compared with opioids, but could not confirm or deny a 

relationship between the choice of postoperative analgesic techniques on major mortality 

or morbidity.61, 62 Other systematic reviews have found that, after surgery, patients using 

PCA consumed higher amounts of opioids and had better pain control and higher 

satisfaction than patients treated with prn or scheduled opioid treatments, with no higher 

incidence of most side effects 63-65 Comparative evidence is generally favorable to 

regional analgesia for certain surgeries, but overall evidence comparing continuous 

epidural analgesia and PCA is not conclusive. 66-70 

The evidence summarized in these reviews has low applicability to medical inpatients, 

where the course of pain as well as staffing and monitoring procedures differ from those 

of the post-anesthesia unit. There is almost no information on the use or safety of PCA in 

a medical ward setting. A fair-quality, non-blinded RCT compared the effectiveness of 

morphine delivered by nurses as needed versus by IV-PCA in 86 patients who presented 

to the ED with a pain score of 7+ due to traumatic injury, most commonly fracture (74% 

in the PCA group, 53.4% of controls), and found that pain relief and patient satisfaction 

were similar between the treatment modalities.58 Pain scores and physiological 

measurements were collected at 0, 5, 15, 30, 45, 60, 90, and 120 minutes. Although the 

PCA group used more than twice as much morphine than controls (mean total 18.83 mg 

vs. 7.65; mean usage rate 7.26 mg/h v. 4.03 mg/h), the mean VAS pain scores were the 

same (4.8) in treatment both groups, and there were no significant differences between 

groups in the satisfaction questionnaires. An area-under-the-curve analysis of VAS 

scores confirmed no significant difference between groups. The investigators noted the 

limitation that nurse behavior might have been influenced by the presence of researchers 

to optimize delivery of pain relief, given the non-blinded design of the study. 

VA-ESP April 2008 21
Assessment and Management of Pain in Inpatients 

Most of the evidence on the adverse effects of PCA was derived from the experience of 

patients with postoperative pain or chronic conditions.17, 71-73 The opioid-related side 

effects from IV PCA are the same as those for intermittent opioid analgesic regimens, 

and include respiratory depression, sedation, constipation, pruritis, nausea, and vomiting. 

Patient factors and misuse of the PCA device by family members, however, may lead to 

the inappropriate use of PCA,71 and cases of oversedation caused by equipment 

programming mishaps have been reported.73 

In patients with acute thoracic pain from traumatic injury, analgesia with IV-morphine 

PCA was equivalent to morphine administered PRN in one study58 and to nebulized 

morphine in another study,57 but inferior to epidural analgesia in 2 studies.59, 60 Most 

patients in these studies had suffered fractures, though the populations varied in the type 

and severity of the injuries. 

The lack of data on the use and safety of PCA in medical patients is concerning, for there 

are protocols for post-op management but not for medical patients. Pain improves 

predictably in the post-operative period, making weaning protocols easier to implement. 

Also, use of PCA is integrated into staff routines and monitoring protocols. None of 

these characteristics apply to medical inpatients. 

Specific Conditions 

Renal colic and biliary stone pain

Most evidence about treating renal colic is old and addresses whether to use IM, SC, or 

IV analgesics. The main findings, discussed in more detail below, are (1) NSAIDs 

provide effective analgesia for acute renal colic, and act more quickly through the IV 

route than by IM or PR 2) Opioids provide analgesia that is equivalent to NSAIDs but 

result in a higher incidence of vomiting and other adverse events, particularly pethidine 

3) Hydromorphone provided superior pain relief and led to fewer hospital admissions 

compared with meperidine in one study. 4) Intramuscular injection of opioids should not 

be used because it causes more discomfort and complications than subcutaneous injection 

and relieves pain no faster. Many studies excluded patients who had negative followup 

investigations for biliary stone or renal calculi, which may limit the applicability of 

findings to all patients presenting with pain from these suspected causes (see Appendix E, 

Summary Table 4). 

A 1998 systematic review of NSAIDS included 3 trials in renal colic in which the same 

drug was compared by different routes.74 Two trials compared 50 mg intravenous vs. 100 

mg rectal indomethacin.75, 76 The 3rd trial compared IV with IM administration of 

dipyrone and diclofenac in 6 comparisons: dipyrone 1g or 2g IM + placebo IV; dipyrone 

1g or 2g IV + placebo IM; diclofenac 75 mg IM + placebo IV; diclofenac 75 mg IV + 

placebo IM.77 In all 3 trials, the NSAID acted more quickly through the intravenous 

route than rectal or intramuscular. The difference was significant, but evident only 

during the first 10 to 20 minutes. 

VA-ESP April 2008 22
Assessment and Management of Pain in Inpatients 

A 2007 Cochrane review of NSAIDS vs. opioids for acute renal colic found that both 

NSAIDs and opioids provide effective analgesia in acute renal colic, but opioids, 

particularly pethidine, result in a higher incidence of vomiting and other adverse events.78 

Five different NSAIDS (diclofenac, indomethacin, indoprofen, ketorolac, tenoxicam) and 

7 opioids were studied in 20 trials from 9 countries with a total of 1613 participants.78 

The intramuscular route was most commonly used for each drug type (10 trials), followed 

by the intravenous route (7 trials). Patients receiving NSAIDs reported lower pain scores 

than patients receiving opioids in 10 of 13 studies, though the differences were small. 

Pooled results on efficacy were not available due to heterogeneity between studies. 

Patients treated with NSAIDs were significantly less likely to require rescue analgesia 

(RR 0.75, 95%CI 0.61-0.93). A higher incidence of adverse events occurred with opioids 

than with NSAIDs in the majority of trials, and pethidine in particular was associated 

with a higher rate of vomiting. Most studies included only participants with renal calculi 

confirrmed on subsequent testing and excluded patients with negative results on followup 

tests. These exclusions may limit the applicability of findings to all patients who present 

with the clinical picture of renal colic. 

A 2007 Cochrane review of hydromorphone in acute and chronic pain79 identified one 

trial in patients with renal colic,80 and one trial in patients with biliary stone pain.81 In a 

fair-quality double-blind RCT, patients with renal colic were randomized to receive either 

50 mg meperidine or 1 mg hydromorphone IV, and their pain scores were measured on a 

10-cm VAS were recorded at t=0, 15, 30, 60, and 120 minutes.80 Patients who received 

hydromorphone achieved more pain relief, required less rescue medication, underwent 

fewer IV pyelograms, and avoided hospital admission more frequently than did patients 

who received meperedine. A poor-quality unblinded trial in 42 patients with biliary stone 

pain compared subcutaneous injection of 1mL dihydromporphinone with 50 mg 

indomethacin IV.81 Eight initially enrolled patients were excluded from analysis because 

follow-up X-ray or ultrasonogram investigations were negative for these patients. Pain 

was evaluated by VAS at baseline and at 10 and 30 minutes after drug injection. 

Indomethacin and dihydromorphinone were equally effective at reducing pain in patients 

with acute attacks of biliary stone pain. VAS scores at 0, 10, and 30 minutes were 71.8, 

44.1, and 14.2 in the dihydromorphinone group, compared with 68.5, 32.4, 15.8 in the 

indomethacin group, and the differences between groups were not statistically significant. 

No serious side effects were observed with either drug. The lack of patient blinding was 

a limitation in this study, and the exclusion of patients who were later found to be 

negative for biliary stone may limit applicability of findings to all patients who present 

with biliary stone pain. 

Phantom Limb Pain

Phantom limb pain is a form of neuropathic pain perceived in the missing limb after 

amputation that is distinct from pain in the residual portion of the limb or stump, and 

other non-painful sensation of the missing limb. In trials of perioperative interventions, 

the prevalence of phantom limb pain after amputation among control subjects ranged 

from 56-82% at day 7, 39-73% at 6 months, and 27-78% at 12 months.82 A survey in 

1980 identified more than 50 different therapies in use for the treatment of phantom limb 

pain 83, suggesting limited consensus on the effectiveness of treatment. 

VA-ESP April 2008 23
Assessment and Management of Pain in Inpatients 

A good-quality systematic review sought to determine the optimal management of acute 

and chronic phantom limb pain, and identified 12 controlled trials that reported phantom 

pain as an outcome (see Appendix E, Summary Table 5).82 The included studies were 

published between 1985-1997, and the 12 trials included a combined total of 375 male 

and female patients, ages 47-75. Trials were included if they involved a control group 

and examined any intervention for PLP, regardless of methodology. Interventions 

involving treatments before and during the amputation were included, as well as 

treatments for chronic pain. 

Trials were divided into 2 groups based on the timing of intervention (early vs. late): 8 

trials of preoperative, intraoperative, and early postoperative interventions at <2 weeks, 

and 4 trials of late (>2 weeks) postoperative interventions. Among the 8 early 

intervention trials, 3 used epidural anesthesia, 3 used regional nerve blocks, 1 used 

intravenous calcitonin, and 1 used transcutaneous electrical nerve stimulation (TENS). 

Controls in these studies received a placebo consisting of a saline infusion or epidural 

anesthesia consisting of on-demand opioid analgesia. The 4 trials of late postoperative 

interventions studied the use of TENS, a crossover study comparing the use of a metal 

threaded sock (Farabloc) vs. no treatment, vibratory stimulation vs. placebo stimulation, 

and intravenously infused ketamine vs. saline. Subjects served as their own controls in 

these studies, and in most of the early treatment studies the control group received active 

treatment with opioid analgesics. No trials examined commonly recommended oral 

drugs, such as membrane stabilizers or tricyclic antidepressants. 

Among the 8 early intervention trials, 3 trials of preoperative epidural pain relief reported 

mixed results. Three other trials assessed sciatic or posterior tibial nerve blocks with 

perineural and intraneural bupivacaine blocks during or immediately after surgery, and 

found no differences in pain between the intervention and control groups in the postacute 

period, measured at various timepoints up to 12 months after surgery. In a trial of 

calcium calcitonin (200 IU) and a trial of early TENS, reduced phantom limb pain was 

observed in the early postoperative period but not in longer-term followup. In trials of 

the late postoperative phase, Farabloc, low-frequency TENS applied to the ear, and 

ketamine provided a modest short-term reduction in phantom limb pain and paresthesia. 

Another late-treatment trial examined TENS at the site of pain but findings were 

inconclusive. Several studies were limited by small sample sizes, and high loss rates 

from dropouts, re-amputations, and mortality. 

The review82 concluded that there is little evidence from randomized trials to support any 

particular treatment of phantom limb pain either in the acute perioperative period or later. 

Evidence on preemptive epidurals, early regional nerve blocks, and mechanical vibratory 

stimulation provides inconsistent support for these treatments. 

Studies of the effectiveness of other treatments for phantom limb pain were identified in 

the ANZCA report.17 Early postoperative infusion salmon calcitonin was effective at 

reducing phantom limb pain compared with placebo, in a double-blind crossover trial 

(n=21). One week after the first treatment, 90% of patients had pain relief of more than 

VA-ESP April 2008 24
Assessment and Management of Pain in Inpatients 

50%, 76% were completely pain free, and 71% never experienced phantom limb pain 

again. One year later, 8 (62%) of the 13 surviving patients still had more than 75% 

phantom limb pain relief.84 In single studies, ketamine,85 86 oral slow-release morphine,

IV infusion of morphine,87 and gabapentin88 were also effective in reducing phantom 

limb pain. Lidocaine had no effect on phantom limb pain, but significantly reduced 

stump pain in one study.87

The ANZCA report also identified three studies of interventions to prevent phantom limb 

pain.17 A small observational study found that in 14 patients given a bolus dose of 

ketamine followed by an infusion, begun preoperatively and continued for 72 hours 

postoperatively, the incidence of severe phantom limb pain was reduced, compared with 

no ketamine in 14 historical controls.89 An RCT that compared perioperative intravenous 

ketamine infusion to saline infusion in 45 patients found the incidence of phantom limb 

pain at 6 months post-amputation was lower in the ketamine group than the control group 

(47% v. 71%) but the difference was not statistically significant.90 A review of the 

efficacy of perioperative epidural analgesia determined that the incidence of severe of 

phantom limb pain was reduced though not completely abolished 12 months after 

amputation (NNT = 5.8, 95% CI 3.2-28.6).91 A non-pharmacological treatment for 

phantom limb pain was effective in a study of sensory discrimination training.92

Overall there is a paucity of evidence to guide specific specific treatment of phantom 

limb pain. Single studies showed evidence of the effectiveness of various therapies 

(calcitonin, morphine, ketamine, gabapentin, and sensory discrimination training), and 

perioperative studies of ketamine and epidural analgesia showed reduced incidence of 

phantom limb pain, but these studies were limited by small sample size. 

Key Question #3. For inpatients with impaired self-report due to 

any of several factors, including delirium or confusion, preexisting severe dementia, closed head injury, stroke, and 

psychosis, how do differences in assessment and management 

of acute pain affect clinical outcomes or safety? 

Cognitive impairment complicates assessment and treatment of pain. Several studies 

have reported underestimation by providers of pain in cognitively impaired patients.93 

Most studies of pain in cognitively impaired individuals were conducted in nursing 

homes,94 where chronic dementia is the most prevalent cause of cognitive impairment. A 

large bibliography of articles, guidelines, and quality indicators for pain management in 

nursing homes is available at http://medqic.org/ 

Briefly, most guidelines for the management of pain in patients with cognitive 

impairment emphasize principles set forth in a 1993 article by Parmelee95 and modified 

by others96-98: 

1. Assess all patients for cognitive impairment using a Mini-Mental State 

Examination (MMSE). 

VA-ESP April 2008 25
Assessment and Management of Pain in Inpatients 

2. Mildly impaired individuals are almost as able as cognitively intact individuals to 

accurately report their pain. 

3. Impaired patients with communication skills will not neglect reporting of pain 

when queried specifically. 

4. In moderately and severely impaired individuals, try several different scales. 

Most moderately and severely impaired individuals can understand at least one 

pain assessment scale (verbal, horizontal visual, or faces)99,100

5. Self-report can also be improved by other strategies, such as asking the patient to 

describe painful events that have been experienced that correspond to different 

pain intensities. Patients can be prompted by asking about common events that 

occur in a clinical setting such as needle sticks. 98

6. Markedly impaired patients report less intense pain and a smaller number of pain 

complaints than the mildly impaired. 

7. For patients who are impaired and deny pain or do not respond to questions about 

pain, use an observational assessment tool to screen for pain. 

This guidance, intended for use in nursing homes, has limited applicability to the medical 

inpatient setting, where delirium is a much more common cause of cognitive impairment. 

Buffum reviewed the sparse literature on assessing and managing pain in delirious 

patients and identified a long list of research gaps and priorities.97 Except for some 

surveys of the prevalence of delirium among inpatients (cited in Buffum), we identified 

no relevant studies of pain assessment or management in patients with delirium. 

Most studies of pain and cognitive impairment focus on assessment. There is fair 

evidence from one prospective cohort study99 that most cognitively impaired individuals 

can understand at least one self-assessment measure. This study was conducted in a 

series of 160 consecutive inpatients, recruited from 2 Swiss hospitals and referred for 

dementia consultation. The investigators administered 4 self-assessment scales 

(horizontal VAS, vertical VAS, faces pain scale, verbal rating scale) and one 

observational rating scale (the Doloplus scale, developed to assess pain in older people 

with communicative disorders).99 Patients were considered to have understood a scale if 

on both self-assessments the patient was able to explain it use and could correctly 

indicate which position on the scale corresponded to no pain at all, and which position 

corresponded to the most severe pain. Comprehension of at least 1 scale was 

demonstrated by 40% of patients with severe dementia, 90% of patients with moderate 

dementia, and 97% of patients with mild dementia. The correlation between the selfassessment scales was high (Spearman’s rs = 0.81-0.95, p<0.001). The Doloplus 

observational rating scale correlated only moderately with self-assessment by the patient 

(Spearman’s rs = 0.31-0.40, p<0.05), and the strength of the correlations did not increase 

in patients with moderate to severe pain. The investigators in this study concluded that 

the majority of hospitalized patients with dementia can reliably use self-assessment pain 

scales, and that observational scales tend to underestimate pain intensity and should be 

reserved for patients who have demonstrated that they cannot complete a self-assessment. 

One limitation of this study is that none of the severely demented patients who could 

demonstrate appropriate use of the self-assessment scales reported experiencing any pain. 

This means that, at best, the authors’ conclusions about the usefulness of the selfVA-ESP April 2008 26
Assessment and Management of Pain in Inpatients 

assessment scales may apply only to distinguishing between some pain and none—that is, 

the study provides no evidence about the scaling properties of self-assessment scales in 

severely demented patients. 

Another study compared the psychometric properties of 4 established pain scales between 

moderately impaired (MMSE 13-21, n=42) and cognitively unimpaired (MMSE 22-30, 

n=33) hospitalized older adults (mean age 76 yrs) with pain at admission.101 Patients 

participated in the study for 14 days. On days 1-7, participants were visited 3 times per 

day and asked to rate their current pain on each of 4 scales: 1) a 5-pt verbal rating scale; 

2) a 7-pt faces scale; 3) a horizontal 21-point box scale; 4) 2 vertical 21-point box scales. 

Patients were also asked to make retrospective ratings at the end of the day and at weekly 

time points, with reference to usual, worst, and least pain levels, using each of the 4 

scales for each rating. The study sought to determine the effect of mental status on pain 

rating; scale redundancy, scale reliability, validity/current pain bias (whether a 

retrospective pain rating represents the actual pain experienced over a given period of 

time); and whether retrospective pain ratings (memory of pain) were biased by current 

pain to indicate greater than the average pain experienced by the patient. The horizontal 

21-pt box scale emerged as the best scale with respect to psychometrics and validity, 

regardless of mental status. Little evidence of response perseveration was found on any 

of the tests. Pain intensity did not vary with mental status. The cognitively impaired 

group had difficulty with the ratings of least pain, showing a high level of bias in the 

extent to which memory of pain was influenced by current pain. The investigators 

concluded that older, cognitively impaired patients are able to rate pain reliably and 

validly. 

Three recent systematic reviews102-104 and part of a broader guideline for assessing pain 

in the elderly23 examined studies of observational methods to assess pain in cognitively 

impaired adults (Table 4). These instruments rely on examiners to observe facial features 

and behavior in order to guess how much pain a patient has. 

All three reviews concluded that among the numerous scales of nonverbal behavioral 

pain indicators that currently exist, none are more reliable or valid than others, and none 

are convincingly appropriate for use in this population. A total of 13 scales were 

identified in these reviews. Taking all 3 reviews together, the PACSLAC and PAINAD 

appeared to have the best psychometric properties. Unfortunately, as van Herk and 

colleagues note, the value of these measures in decision-making is unclear because cutoff 

values for these scales have not been established. 

It is important to note that there is no gold standard for judging the validity of these 

measures. Most evaluations reported the psychometric properties of these measures 

rather than their validity.30 Validity was assessed as agreement with self-report or report 

of relatives to assess validity; these comparisons are of limited value (if self-report were 

known to be reliable, there would be little need for using an observational measure.) 

VA-ESP April 2008 27
Assessment and Management of Pain in Inpatients 

Table 4. Pain observation scales. From van Herk et al.103

 

Key Question #4. For inpatients with dependencies on tobacco, 

alcohol, stimulant, marijuana, or opioids, how do differences in 

assessment and management of acute pain affect clinical 

outcomes or safety? 

Addiction, physical dependence and tolerance are common among inpatients. The 

ANZCA 2005 report17suggested the following for managing acute pain in opioid-tolerant 

patients: 

1) Withdrawal from opioids should be prevented by maintenance of normal 

preaadmission opioid regimens, or appropriate substitutions with another opioid, 

or the same opioid via another route. Opioid-tolerant patients are at risk of 

withdrawal if non-opioid analgesic regimens or tramadol alone are used. 

2) Opioid-tolerant patients report higher pain scores and have a lower incidence of 

opioid-induced nausea and vomiting. 

3) Ketamine may reduce opioid requirements in opioid-tolerant patients. 

4) Intravenous PCA is a useful modality in opioid-tolerant patients, and larger bolus 

doses ad a background infusion to replace the usual opioid dose may be needed. 

5) Neuraxial opioids can be used although higher doses may be required, and these 

doses may be inadequate to prevent withdrawal. 

VA-ESP April 2008 28
Assessment and Management of Pain in Inpatients 

6) Patient education regarding prescribed opioids and communication with the 

primary physician are advisable upon discharge. 

The ANZCA 2005 report17 makes the following suggestions for the management of acute 

pain in patients with substance abuse disorder: 

1) Management of pain in these patients should focus on prevention of withdrawal, 

effective analgesia, and symptomatic treatment of affective disorders and 

behavioral alterations. 

2) Naltrexone should be stopped at least 24 hours prior to elective surgery, and be 

replaced by multimodal analgesic regimens. 

3) Patients who have completed naltrexone therapy should be regarded as opioid 

naïve; in the immediate post-treatment phase they may be opioid-sensitivie. 

4) Maintenance methadone regimens should be continued where possible 

5) Buprenorphine maintenance may be continued; if buprenorphine is ceased prior to 

surgery, conversion to an alternative opioid is required. 

6) There is no cross-tolerance between CNS stimulants and opioids. 

The evidence on which these recommendations are based is weak, being derived from 

case reports, retrospective studies and expert opinion.17 

How do the assessment and management of acute pain differ between 

patients on pre-existing opioid therapy and patients with opiate addiction? 

In 2001, the American Academy of Pain Medicine, the American Pain Society, and the 

American Society of Addiction Medicine issued a statement 105 agreeing upon the 

following definitions: 

Tolerance: “Tolerance is a state of adaptation in which exposure to a drug induces 

changes that result in a diminution of one or more of the drug’s effects over time.” 

Physical Dependence: “Physical dependence is a state of adaptation that often includes 

tolerance and is manifested by a drug class specific withdrawal syndrome that can be 

produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, 

and/or administration of an antagonist.” 

Addiction: “Addiction is a primary, chronic, neurobiological disease, with genetic, 

psychosocial, and environmental factors influencing its development and manifestations. 

It is characterized by behaviors that include one or more of the following: impaired 

control over drug use, compulsive use, continued use despite harm, and craving.” 

The statement also defined “pseudoaddiction” as “patient behaviors that may occur when 

pain is undertreated,” including a focus on obtaining medications, illicit drug use and 

deception and other behaviors that may lead clinicians to label them as being "drug 

seeking." It also said “a patient who is physically dependent on opioids may sometimes 

VA-ESP April 2008 29
Assessment and Management of Pain in Inpatients 

continue to use them despite resolution of pain only to avoid withdrawal. Such use does 

not necessarily reflect addiction.” 

These definitions are not universally agreed upon, and work to harmonize terminology 

continues. 106 However, these definitions are consistent with the basic concepts that 1) 

tolerance and physical dependence are normal responses to opioid therapy, but addiction 

is not; 2) addictive use of medications is associated with aberrant, destructive behaviors 

such as “persistent sedation or intoxication due to overuse; increasing functional 

impairment and other medical complications; psychological manifestations such as 

irritability, apathy, anxiety, or depression; or adverse legal, economic or social 

consequences 3) addiction is a multidimensional disease with neurobiological and 

psychological dimensions. Many guidelines say that a history of addiction to opioids or 

to alcohol is a relative contraindication for prescribing chronic opioids for nonmalignant 

pain. Guidance on how a history of addiction should influence inpatient management of 

acute pain is unclear. 

105 The prevalence of addiction among chronic opioid users was unknown. Most studies 

of the prevalence of addiction among patients with chronic pain have used simplistic or 

outdated criteria for diagnosing addiction, or did not describe their criteria at all.107 Not 

surprisingly, estimates of the prevalence of addiction varied wildly, from 0.2% to 50%, 

depending on the investigators’ definition. The apparent prevalence was much lower in 

studies that used stricter criteria for addiction based on behaviors that are thought to 

distinguish it from tolerance and physical dependence, and higher in studies that 

classified patients as addicted if they exhibited “drug-seeking” behavior. While, as a 

group, the prevalence studies are weak, they do suggest strongly that when a patient on 

chronic opioid therapy presents with pain, clinicians should not presume that the patient 

is addicted, and should never diagnose addiction unless there is reason to belief pain 

control is adequate. 

In the literature, there are several lists of signs and symptoms that may be indicators of 

addiction (as opposed to tolerance and physical dependence.) We found no studies of 

whether, in acute care settings, clinicians can distinguish addiction from physical 

dependence or pseudoaddiction. We also found no studies of the discriminant ability of 

the individual signs and symptoms of addiction, that is, their ability to identify distinct 

groups of patients for whom different assessment and treatment strategies are most 

effective. 

On the other hand, several instruments intended to screen chronic opioid users for 

addiction may be helpful in assessing whether relevant signs, symptoms, and behaviors 

are present. The Pain Medicine Questionnaire and the SOAPP questionnaire have good 

psychometric properties.107 The CAGE-AID is a modified CAGE which adapts questions 

about alcohol to drug use (eg “Have you felt you ought to cut down your drinking or 

drug use?” “Have you felt bad or guilty about your drinking or drug use?” etc.) It has 

not been tested extensively. None of these instruments has been shown to improve longterm outcomes of chronic nonmalignant pain management, and none has been evaluated 

in the setting of acute pain in inpatients.

VA-ESP April 2008 30
Assessment and Management of Pain in Inpatients 

VA-ESP April 2008 31

Guidelines for managing post-operative pain specify that initial dosing should be adjusted 

for patients who take opioids for chronic nonmalignant pain. For the most part, these 

guidelines for initial dosing have been generalized to patients who have acute pain from 

other causes, but we did not find any evidence about effectiveness or safety in the target 

population for this report. 

CONCLUSIONS 

The results of the systematic evidence review, including the type and quality of evidence 

for each key question, are summarized in Table 5 below. 
Assessment and Management of Pain in Inpatients 

Table 5. Summary of Systematic Evidence Review, Key Question 1. How do differences in timiof assessment, severity of pain, and follow-up of pain affect choice of treatment, clinical outcom

KQ# Key question Type of Evidence Grade of Evidence Comments 

1a In medical inpatients with GRADE Very Low = Any 

acute pain, does routine assessment of pain affect choice of treatment, clinical outcomes, and safety? 

None We found no evidence that directly linke

or choice of measure for assessment with or safety of treatment specifically in medstudies demonstrated that observational nurse or physician is inaccurate. 

estimate of effect is very uncertain. 

GRADE Low = Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. 

1b Does the choice of 

assessment measure affect choice of treatment, clinical outcomes, and safety? 

1 descriptive study in 

cancer patients 

Within a program of routine assessment studies of how the choice of assessment choice of treatment, clinical outcomes, ofocus on the psychometric qualities and each method. In cancer patients, there is fair evidence study that opioid-related oversedation anincreased substantially after implementaon a numerical scale routinely with othe

1c Do protocols for Very Low 

assessing pain improve outcomes? 

None In most cases, these protocols are part of 

strategies to improve pain management. evaluations that could isolate the effect o

orders, clinical pathways, or other protocthe target population. 

GRADE Moderate = Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. 

3 chart review studies in the ED setting fquality that remain after institution of sylower-priority triage score, older age, awere factors associated with delay or loreceiving analgesia. In a study of patie

in an ED with direct access to on-call suless severe pain, and daytime admissionanalgesia, despite the elimination of refe

1d Are there gaps in quality 

even when pain is assessed routinely? 

5 descriptive studies 

in the ED 

GRADE High = Further research is very unlikely to change our confidence on the estimate of effect. 

1e Specific condition: 

nonsurgical abdominal pain 

1 systematic review 

and meta-analysis of 

randomized trials 

and 1 additional trial 

Opioid administration has a negligible imanagement of acute abdominal pain. 

VA-ESP April 2008 
Assessment and Management of Pain in Inpatients 

Summary of Key Question 2. How do the timing and route of administration of pain interventioneffectiveness, adverse effects, and safety in inpatient care settings? 

Grade of Evidence KQ# Key question Type of Evidence Comments 

Moderate 1 uncontrolled collaborative VHA/IHI 

wide strategies showed measurable imprevalence of severe pain, frequency odocumentation of plan of care, and preducation on pain management. A comultifaceted intervention achieved incpain but did not alter pain intensity or 

1 uncontrolled 

systemwide 

intervention and 1 

controlled trial 

2a Do acute pain management 

teams and other institutional initiatives improve effectiveness, adverse effects, and safety in medical inpatients? 

Low Most primary studies in these reviews 

or cancer pain, and were uncontrolledmanagement teams and other system-improved the timeliness and frequencthe findings were mixed for improvemIn controlled studies, Acute Pain Servintensity and improved functional abilmagnitude of these effects was not alwimportant. 

2 systematic 

reviews of beforeafter or 

uncontrolled studies 

2b Do acute pain management 

teams and other institutional initiatives improve effectiveness, adverse effects, and safety in other settings? 

Very Low We found no evidence about the value 

with the patient’s primary care physic

2c How does coordination with 

the patient’s primary care physician affect outcomes? 

None 

Very Low We found no evidence on the compara

different agents and methods of admininpatients. 

2d How does the choice of None 

treatment modality affect effectiveness, adverse effects, and safety in inpatient care settings? 

Low There is almost no information on the 

in a medical ward setting. Most of the adverse effects of PCA was derived frpatients with postoperative or chronic 

2e Effectiveness and safety of 

patient-controlled analgesia (PCA) 

3 controlled trials 

and 1 cohort study 

VA-ESP April 2008 
Assessment and Management of Pain in Inpatients 

Moderate (1) NSAIDs provide effective analgesi

and act more quickly through the IV r2) Opioids provide analgesia that is ebut result in a higher incidence of vomadverse events, particularly pethidine provided superior pain relief and led admissions compared with meperidine studies excluded patients who had neginvestigations for biliary stone or renalimit the applicability of findings to alwith pain from these suspected causes

Specific conditions: renal colic and biliary stone pain 

Renal colic studies: 

3 RCTs comparing 

route of NSAID 

administration; 1 

systematic review 

of NSAIDS vs. 

opioids; 

1 RCT of 

hydromorphone; 

1 study of 

hydromorphone in 

biliary pain 

2g Specific conditions: Low 

phantom limb pain 

1 systematic review 

of controlled trials 

Overall there is a paucity of evidence specific treatment of phantom limb papreemptive epidurals, early regional nmechanical vibratory stimulation provsupport for these treatments. Single sevidence of the effectiveness of variou(calcitonin, morphine, ketamine, gabadiscrimination training), and perioperketamine and epidural analgesia showof phantom limb pain, but these studiesmall sample size. 

VA-ESP April 2008 
Assessment and Management of Pain in Inpatients 

VA-ESP April 2008 Summary of Key Questions 3 and 4. 

KQ# Key question Type of Evidence Grade of Evidence Comments 

3 For inpatients with impaired 

self-report due to any of several factors, including delirium or confusion, preexisting severe dementia, closed head injury, stroke, and psychosis, how do differences in assessment and management of acute pain affect clinical outcomes or safety? 

3 systematic 

reviews of 

descriptive and 

cross-sectional 

evaluations of 

assessment 

instruments; 

no study 

designs were 

excluded 

Low Most studies were conducted in nursing homes in patients with 

assessment. Delirium is a more common cause of cognitive iminpatient setting, and we identified no studies of pain assessmepatients with delirium. All 3 reviews concluded that among thnonverbal behavioral pain indicators in use, none are more reliand none are convincingly appropriate for use in this populatiototal of 13 scales, and the PACSLAC and PAINAD appear to h

properties. The value of these measures in decision-making is cutoff values for these scales have not been established. We f

directly linked differences in assessment and management with safety in this subgroup of patients. 

4a For inpatients with 

dependencies on tobacco, alcohol, stimulant, marijuana, or opioids, how do differences in assessment and management of acute pain affect clinical outcomes or safety? 

Case reports, 

retrospective 

studies, and 

expert 

opinions 

identified by a 

systematic 

search 

Low Guidelines for managing acute pain in opioid-tolerant patients 

substance abuse disorder are based on case reports, retrospecopinion were compiled in a good-quality systematic review. Trecommendations are based is weak, however, being derived frretrospective studies and expert opinion 

4b How do the assessment and 

management of acute pain differ between patients on preexisting opioid therapy and patients with opiate addiction? 

None Very Low Definitions for tolerance, physical dependence, and addiction, 

not universally agreed upon, and estimates of the prevalence of chronic pain varied widely, from 0.2% to 50%. We found no scare settings, clinicians can distinguish addiction from physicapseudoaddiction. We also found no studies of the discriminant and symptoms of addiction to identify distinct groups of patienassessment and treatment strategies are most effective. Guideloperative pain specify that initial dosing should be adjusted fofor chronic nonmalignant pain, and while these guidelines for generalized to patients who have acute pain from other causesevidence about effectiveness or safety in the target population. 
Assessment and Management of Pain in Inpatients 

Recommendations for future research 

Pain is a prevalent problem for medical inpatients, and research has not addressed this 

setting effectively. The lack of evidence suggests that the VA should characterize current 

practice, avoid overly prescriptive standards, and emphasize a robust research agenda. 

Given that pain intensity is used widely, and that outpatient research raises some 

questions about the accuracy and relevance of single item screening for pain to improved 

patient outcomes, veterans might benefit from clinical research that: 

1) Tests use of pain intensity along with other approaches (automated nurse / 

physician alerts, expanded screening items / paradigms, patient direct-triggered 

nurse / physician alerts) to better link screening to intervention. Psychometric 

evaluation is needed as one aspect of this research. 

2) Draws upon quality improvement research to evaluate the efficacy of key 

intervention components. 

3) Evaluates different initial treatment intensities including the clinical 

effectiveness and safety of PCA, but not excluding high intensity oral regimes 

(which are used in lieu of PCA in places such as Australia). These studies 

should stress the evaluation of alternative follow-up strategies and ascertain the 

risk / benefit and ceiling effects of alternative approaches to medical pain 

management. 

4) Specifically addresses basic clinical science of pain in delirium, severe mental 

illness (such as schizophrenia which you highlight) and dementia (such as 

identifying a ‘gold standard’ for validity – e.g., fMRI vs. observation), and 

clinical studies that address 1-3 should not exclude veterans with substance 

abuse disorder. Furthermore, studies that examine treatment in those 

populations and that include outcomes relevant to prior abuse such as triggering 

of recurrent abuse, dysphoria, etc., are needed. 

5) Evaluates performance measures that go beyond assessment to include prompt 

treatment and successful alleviation of pain in the medical inpatient setting (see 

Table 6). 

Additional recommendations pertinent to VA care can be found in Buffum et al.97

VA-ESP April 2008 36
Assessment and Management of Pain in Inpatients 

Table 6. Examples of indicators for measuring aspects of pain 

management 

Performance 

measure 

Developed for 

population/setting Numerator Denominator 

Assessment and diagnosis

Percentage of patients 

with documented 

assessment for pain 

using standardized tool 

on admission

Long-term care 

setting 

Number with documented 

admission assessment for 

pain using standardized tool 

All patients 

108

Percentage of patients 

with documented care 

plan for acute or 

chronic pain

Long-term care 

setting 

Number with documented 

care plan for acute or 

chronic pain 

All patients with reported 

pain 

108

Percentage of patients 

receiving physical 

exam to assess for 

causes of pain

Long-term care 

setting 

Number receiving physical 

exam to assess for causes of 

pain 

All patients with reported 

pain 

108

Percentage with 

cognitive and language 

problems receiving 

targeted pain 

assessment

Long-term care 

setting 

Number with cognitive and 

language problems receiving 

targeted pain assessment 

Patients with diagnosed 

cognitive and/or language 

deficit 

108

Percentage with 

periodic documented 

assessment by nursing 

staff of effectiveness 

of pain management

Long-term care 

setting 

Number with periodic 

documented assessment by 

nursing staff of effectiveness 

of pain management 

Patients with reported 

pain 

108

Percentage with 

periodic documented 

assessment of 

effectiveness of pain 

management by 

medical doctor 

(MD)

Long-term care 

setting 

Number with periodic 

documented assessment of 

effectiveness of pain 

management by medical 

doctor (MD) 

Patients with reported 

pain 

108

Percentage with 

documented complete 

assessment of pain 

covering all pertinent 

components of pain

Long-term care 

setting 

Number with documented 

complete assessment of pain 

covering all pertinent 

components of pain 

All patients with reported 

pain 

108

Screening for pain109 Vulnerable elders 

(aged 65+) 

Number of patients screened 

for chronic pain in initial 

evaluation 

All vulnerable elders 

Screening for 

depression

Vulnerable elders 

(aged 65+) 

Number of patients screened 

for depression 

Vulnerable elders with 

presenting with chronic 

pain 

109

Treatment/ management

Percentage with 

documented absence 

of pain symptoms after 

treatment

Long-term care 

setting 

Number with documented 

absence of pain symptoms 

after treatment 

All patients with reported 

pain who received 

treatment 108

Percentage with 

documented reduction 

of pain symptoms

Long-term care 

setting 

Number of patients with 

documented reduction of 

pain symptoms 

All patients with reported 

pains 108

Percentage of patients Long-term care Number of patients with All patients receiving 

VA-ESP April 2008 37
Assessment and Management of Pain in Inpatients 

with orders for not 

recommended drugs

setting orders for not recommended 

drugs 

medications to treat pain 108

Percentage of patients 

with appropriate 

treatment for pain

Long-term care 

setting 

Number of patients with 

appropriate treatment for 

pain 

All patients with reported 

pain 108

Percentage of patients 

prescribed narcotics 

for pain with 

appropriate bowel 

management program 

in place

Long-term care 

setting 

Number of patients 

prescribed narcotics with 

appropriate bowel 

management in place 

All patients receiving 

narcotics to treat pain 

108

Percentage with 

adverse drug reactions 

(ADRs) to pain 

medications

Long-term care 

setting 

Number of patients with 

adverse drug reactions 

(ADRs) related to pain 

medications 

All patients receiving pain 

medication 

108 

Percentage with 

controlled adverse 

drug reactions (ADRs) 

to pain medications

Long-term care 

setting 

Number with controlled 

adverse drug reactions 

(ADRs) to pain medications 

All patients with reported 

pain receiving pain 

medication who had an 

adverse drug reaction 

(ADR) 

108 

Addressing risks of 

NSAIDs

Vulnerable elders 

(aged 65+) 

Number of patients whose 

medical record indicates 

whether s/he has a history of 

peptic ulcer disease, and if a 

history is present, 

documentation of 

justification of NSAID use 

All vulnerable elders who 

have been prescribed a 

cyclooxygenase 

nonselective NSAID for 

the treatment of chronic 

pain 

109

Constipation with 

opioid use

Vulnerable elders 

(aged 65+) 

Number of vulnerable elders 

offered a bowel regimen, or 

whose medical record 

documents the potential for 

constipation or explains why 

bowel treatment is not 

needed. 

All vulnerable elders 

treated with opioids for 

chronic pain 

109

Meperidine not used109 Vulnerable elders 

(aged 65+) 

Number of patients requiring 

analgesia who were not 

given meperidine 

All vulnerable elders who 

require analgesia 

Percentage who 

reported how often 

their pain was 

controlled

Adult inpatients The number of respondents 

from the denominator who 

indicated "Always," 

"Usually", "Sometimes," or 

"Never" on the two 

questions regarding their 

experiences with control of 

their pain 

Hospital inpatients with 

an admission during the 

reporting period who 

answered the "Pain 

Management" questions 

on the CAHPS Hospital 

Survey 

110

VA-ESP April 2008 38
Assessment and Management of Pain in Inpatients 

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