FIGURE LEGENDS
Figure 1. Biopsychosocial considerations in the assessment of pain for persons with opioid use disorder.
Pain and opioid use disorder are multidimensional entities. Biologically, ascending pain pathways carry neural signals from the spine and periphery to the corticolimbic system, which in turn, through descending pathways, modulate the actual physical and emotional experience of pain. Opioids may disrupt such pathways, increasing pain perception (hyperalgesia) and hindering modulatory input. Psychological aspects may alter these perceptions and lead to behaviors and thoughts patterns which in turn, can worsen or improve that experience. Finally, social support networks are a cornerstone of this assessment, as support can improve or worsen outcomes for both OUD and pain treatment. It is also important to acknowledge the role that healthcare disparities may play both in the perception of pain as well as on its treatment.
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Figure 2. Opioid-induced hyperalgesia, tolerance, and withdrawal as important considerations for pain assessment in opioid use disorder.
The illustrated table describes the hallmarks to differentiate opioid-related phenomena. Patients with hyperalgesia tend to experience pain symptoms that are different than their original presentation, worsening with increased opioid use. Tolerance leads to worsening pain due to desensitization, but the pain is often similar to the initial symptom and tends to improve with additional opioids. Finally, those patients experiencing withdrawal develop certain signs and symptoms otherwise described in opioid withdrawal assessment instruments, such as the Clinical Opioid Withdrawal Scale (COWS).