Pain Management Tools

The HUSKY Health program is committed to providing support to CMAP providers. Please utilize the following tools to assist with the assessment and treatment of patients with chronic pain conditions.


Pain Assessment Tool

There are a number of pain assessment tools that can be used to evaluate a patient’s pain and current level of function. HUSKY Health recommends the use of the following pain assessment tool:

Opioid Risk Assessment Tools

There are various standardized opioid risk assessment tools that can be used to evaluate a patient’s risk of aberrant drug-related behavior. HUSKY Health recommends the use of the following risk assessment tools, some of which require registration to access:

  • Opioid Risk Tool (ORT): The ORT is a brief, self-report screening tool designed for use with adults in the primary care setting to assess for risk of future opioid abuse among individuals prescribed opioids for the treatment of chronic pain.
  • Diagnosis, Intractability, Risk and Efficacy (DIRE) Score Tool: The DIRE Score Tool, developed by Miles Belgrade, MD, is designed to assess the probability of success or risk of opioid analgesia in patients with chronic pain conditions.

Patient Agreement Form

Opioid Agreements are documents negotiated between patients and their healthcare providers. The agreements specify patient obligations and responsibilities, along with prescriber policies, such as those concerning prescription refills and urine drug monitoring.

  • Sample Patient Agreement Forms: This resource includes two sample patient agreement forms that can be used with patients who are beginning long-term treatment with opioid analgesics or other controlled substances.

Sample Informed Consent Form

Sample Informed Consent Form: This sample informed consent form is for use with patients who are beginning long-term therapy with opioid analgesics to help ensure they understand the side effects, risks, conditions, and purpose of their treatment.

Pain Diary

Daily Pain Diary

Sample Notification of Discontinuation of Opioid Treatment Form

  • Sample Notification of Discontinuation of Opioid Treatment Form: A critical component of treatment is recognizing when to taper and/or transition a patient off of opioid-based medications. Providing this sample letter to your patient allows you to document why opioid treatment can no longer be provided and gives you the opportunity to provide the patient with information about addiction treatment services.

This portion of the HUSKY Health website is managed by Community Health Network of Connecticut, Inc., the State of Connecticut’s Medical Administrative Services Organization for the HUSKY Health Program. For the general HUSKY website gateway, please visit www.ct.gov/husky. HUSKY Health includes Medicaid and the Children’s Health Insurance Program, and is administered by the Connecticut Department of Social Services.