Standards › ASF Health Standards Version 11 › Standard 10
Standard 10
Pain Management
Pain is assessed, treated and reassessed safely in every setting where patients have pain: hospitals, ambulatory clinics, day-care, hospice and home-based care. Opioids are managed as a distinct risk.
How to read the colours
Red: Must. Required in every setting. Criteria that protect life are always red.
Green: Medium. Required, adapted to what a humanitarian or transition setting can realistically do.
Yellow: Minimum. The lowest acceptable level in a humanitarian setting, where resources are very limited.
Each criterion is shown in three settings: Humanitarian settings, Transition and fragile, and Standard. In standard settings, every criterion is Must.
Every policy, SOP, form and course on this page is a draft to help you. Adapt it to your facility, write your own, or upload your own documents. What the assessor checks is that the standard is met and that you can show how.
10.1Opioid Prescribing Is Deliberately StewardedHumanitarian settings: MediumTransition and fragile: MediumStandard: Must
Opioid prescribing follows a written stewardship approach: appropriate starting dose and duration, consideration of non-opioid options first, and set review dates. Opioids are managed as a distinct risk, not as one more high-alert medicine.
Why it matters. Opioids relieve pain, but over-prescribing, long courses without review and missed warning signs cause harm. A written approach keeps the dose and duration to what the patient needs.
Questions the surveyor asks
- Is there a written opioid stewardship approach? It names the drugs, starting doses, review dates and non-opioid options.
- Is a physician champion or designated person responsible? Where no pharmacy function exists, one named person must own the approach.
- Are long-term and high-dose prescriptions reviewed? A review on a set date, recorded in the file.
How the surveyor verifies this criterion
Sample. The opioid policy, and a sample of 10 opioid prescriptions from the last 3 months with their review records.
1. Written approach exists
Method. Read the opioid policy for drugs, doses, review dates and non-opioid options.
Evidence to show. Opioid stewardship policy (MNP-POL-002).
Pass when. The policy covers all four elements and is signed off by the facility leadership.
2. Designated person is named
Method. Check the role assignment and the policy sign-off.
Evidence to show. Opioid prescribing review and diversion monitoring (MNP-SOP-001).
Pass when. A named person or physician champion is recorded in the policy.
3. Reviews are done and recorded
Method. Check each sampled prescription for a review record on the set date.
Evidence to show. Opioid prescribing review record (MNP-FRM-001).
Pass when. Every sampled long-term opioid prescription has a review recorded on schedule.
Good practice. A written stewardship approach, a named owner, and recorded reviews on schedule.
Immediate fail (any one means the criterion is not met). Opioids are prescribed with no written approach and no review.
Partial because. The approach exists but reviews are missing or not recorded for some prescriptions.
Staff, training and documents
Documents
- MNP-POL-002 Opioid stewardship policy
- MNP-SOP-001 Opioid prescribing review and diversion monitoring
- MNP-FRM-001 Opioid prescribing review record
E-learning
- Prescribing & Controlled Substance Management (TM-05) — content under review (Must for prescribers)
- Medication Safety: Operating SOP-MED-01 End to End (T-08) — content under review (Must for pharmacy and nursing staff)
10.2Pain Is Formally Assessed and Reassessed, Not Just Asked About OnceHumanitarian settings: MustTransition and fragile: MustStandard: Must
Pain is assessed with an agreed tool on admission and reassessed at a set interval and after any change in condition or treatment. The result is recorded and used to change the plan.
Why it matters. Pain is a vital sign that is easy to miss when it is only asked about once. Regular reassessment shows whether the treatment is working and catches new pain early.
Questions the surveyor asks
- Is an agreed pain assessment tool used? One tool for the facility, adapted for children and for patients who cannot speak.
- Is pain reassessed at a set interval? The interval is written in the plan and followed.
- Is the result used to change the plan? A score that changes nothing is not an assessment.
How the surveyor verifies this criterion
Sample. Twenty patient records from the last 3 months, including admissions and post-procedure patients.
1. Agreed tool is used
Method. Check each sampled record for the tool and its score.
Evidence to show. Pain assessment record (MNP-FRM-002).
Pass when. The agreed tool is recorded in every sampled record.
2. Reassessment is on schedule
Method. Check the reassessment entries against the set interval.
Evidence to show. Symptom assessment table (HSP-FRM-001).
Pass when. Pain is reassessed at the set interval in at least 18 of the 20 sampled records.
3. Result changes the plan
Method. Check that a change in score is followed by a change in treatment or a note.
Evidence to show. Symptom assessment and control policy (HSP-POL-001).
Pass when. A recorded change in plan follows each sampled change in score.
Good practice. Pain assessed with the agreed tool, reassessed on schedule, and the result used in the plan.
Immediate fail (any one means the criterion is not met). Pain is not assessed in the records at all.
Partial because. Pain is assessed once, or reassessments are not recorded.
Staff, training and documents
Documents
- MNP-FRM-002 Pain assessment record
- HSP-FRM-001 Symptom assessment table
- HSP-POL-001 Symptom assessment and control policy
E-learning
- No dedicated course yet; pain assessment course in development (Must for nursing staff)
10.3Pain and Symptoms Are Assessed and ControlledHumanitarian settings: MediumTransition and fragile: MustStandard: Must
Pain and other symptoms are assessed and controlled with a written plan, including a plan for breakthrough pain and an out-of-hours route for advice.
Why it matters. Uncontrolled pain and symptoms cause distress and can lead to unplanned admissions. A written plan lets any clinician on shift act safely.
Questions the surveyor asks
- Is there a written symptom plan for each patient in pain? The plan covers the first-line drug, the breakthrough dose and the review.
- Is there a plan for breakthrough pain? Staff know what to give and when to call.
- Can staff get advice out of hours? A named route, not an informal call to whoever is nearby.
How the surveyor verifies this criterion
Sample. Ten patient plans from the last 3 months, and the out-of-hours advice log.
1. Symptom plan is written
Method. Check each sampled plan for the first-line drug, breakthrough dose and review.
Evidence to show. Symptom assessment and control policy (HSP-POL-001).
Pass when. A written plan is in place for each sampled patient in pain.
2. Breakthrough plan exists
Method. Check the plan for a breakthrough dose and a call point.
Evidence to show. Symptom assessment table (HSP-FRM-001).
Pass when. Every sampled plan includes a breakthrough dose and a call point.
3. Out-of-hours advice is available
Method. Check the advice log and the out-of-hours route.
Evidence to show. Out-of-hours symptom advice (HSP-SOP-004).
Pass when. A named route is in place, and advice calls are logged.
Good practice. Written symptom plans with breakthrough cover, and a working out-of-hours advice route.
Immediate fail (any one means the criterion is not met). Patients in pain have no plan and no out-of-hours route.
Partial because. Plans are written for some patients, or the out-of-hours route is not logged.
Staff, training and documents
Documents
- HSP-POL-001 Symptom assessment and control policy
- HSP-FRM-001 Symptom assessment table
- HSP-SOP-004 Out-of-hours symptom advice
E-learning
- End-of-Life & Palliative Care (LTC-06) — content under review (Must for nursing and medical staff)
- Medication Management & Family Coordination (HC-04) — content under review (Must for care staff)
10.4Opioids and Controlled Medicines Are Managed SafelyHumanitarian settings: MustTransition and fragile: MustStandard: Must
Controlled medicines are stored securely, recorded in a register, counted at each handover with two signatures, and checked for diversion. Any discrepancy is investigated and reported.
Why it matters. Opioids are high-risk for misuse and diversion. A register and a double count are the simplest way to detect a loss.
Questions the surveyor asks
- Is there a register for all controlled medicines? Every receipt, supply and administration is recorded.
- Is each count double-signed? Two people count, and both sign.
- Are discrepancies investigated? A difference between the register and the stock is an incident.
How the surveyor verifies this criterion
Sample. The controlled drugs register and count sheets for the last 3 months, and the diversion checks.
1. Register is complete
Method. Check the register against the stock and the prescriptions.
Evidence to show. Controlled drugs register (HOS-REG-001).
Pass when. Every entry is complete, and the balance matches the stock.
2. Counts are double-signed
Method. Check the count sheets for two signatures at each handover.
Evidence to show. Opioid prescribing review and diversion monitoring (MNP-SOP-001).
Pass when. Every sampled count is signed by two people.
3. Discrepancies are investigated
Method. Check the incident log for any discrepancy.
Evidence to show. Opioid prescribing review record (MNP-FRM-001).
Pass when. Each discrepancy has a recorded investigation and outcome.
Good practice. A complete register, double-signed counts, and every discrepancy investigated.
Immediate fail (any one means the criterion is not met). A controlled medicine is missing and not reported.
Partial because. The register is kept but counts are done by one person, or discrepancies are not investigated.
Staff, training and documents
Documents
- HOS-REG-001 Controlled drugs register
- MNP-SOP-001 Opioid prescribing review and diversion monitoring
- MNP-FRM-001 Opioid prescribing review record
E-learning
- Prescribing & Controlled Substance Management (TM-05) — content under review (Must for prescribers and pharmacy staff)
- High-Alert Medication Safety (PS-03) — content under review (Must for pharmacy and nursing staff)
- Addiction Medicine & Controlled Substances (AMB-21) — content under review (Must for clinical staff with controlled medicines)
10.5Patients and Families Are Informed About Their Pain PlanHumanitarian settings: MinimumTransition and fragile: MediumStandard: Must
The patient and family are told what the pain plan is, what to expect, what side effects to watch for and whom to call. The information is given in a language they understand and recorded.
Why it matters. A patient who knows the plan takes medicines correctly, reports problems early and is less afraid of pain. Families who understand the plan can support the patient safely at home.
Questions the surveyor asks
- Is the patient told about the plan in plain language? Dose, timing, side effects and the next review.
- Is the family or carer included where the patient agrees? Carers often give the medicines at home.
- Is the information recorded? A record shows what was told and when.
How the surveyor verifies this criterion
Sample. Twenty patient records from the last 3 months, and the family information leaflets used.
1. Patient is told about the plan
Method. Check each sampled record for an information entry.
Evidence to show. Family and carer support and information (HSP-SOP-001).
Pass when. Each sampled record shows the plan was explained.
2. Family and carer are included
Method. Check the record for a family or carer entry where the patient agreed.
Evidence to show. Record of goals, values and wishes (HSP-FRM-002).
Pass when. The family or carer is included in each sampled case where the patient agreed.
3. Information is recorded
Method. Check that the information given is recorded with date and staff name.
Evidence to show. Family and carer support and information (HSP-SOP-001).
Pass when. Each sampled record has a dated information entry.
Good practice. Patients and families told about the plan in plain language, with the information recorded.
Immediate fail (any one means the criterion is not met). Patients are not told about their pain plan at all.
Partial because. Patients are told, but the information is not recorded or not in a language they understand.
Staff, training and documents
Documents
- HSP-SOP-001 Family and carer support and information
- HSP-FRM-002 Record of goals, values and wishes
E-learning
- Patient Identification, Informed Consent and Patient Rights (T-07) — content under review (Must for all clinical staff)
Who is responsible for Standard 10
Each criterion names the positions responsible for it. Every position links to its own terms of reference.
| Criterion | Responsible | Supports |
|---|---|---|
| 10.1 Opioid Prescribing Is Deliberately Stewarded | Chief pharmacist Physician (general) |
Clinical pharmacist Registered nurse |
| 10.2 Pain Is Formally Assessed and Reassessed, Not Just Asked About Once | Registered nurse | Physician (general) Palliative care nurse |
| 10.3 Pain and Symptoms Are Assessed and Controlled | Physician (general) Palliative care nurse |
Pain medicine specialist Registered nurse |
| 10.4 Opioids and Controlled Medicines Are Managed Safely | Chief pharmacist | Pharmacist (dispensing) Registered nurse |
| 10.5 Patients and Families Are Informed About Their Pain Plan | Registered nurse | Hospice / palliative care coordinator |
Role details: reporting, supervision and training
Training shown is the general recommendation. Role-specific training is set in the next improvement round.
| Role | Reports to | Supervises | Recommended training |
|---|---|---|---|
| Pain medicine specialist | Head of department (per specialty) | None | Facility induction; medicines and pain management (general recommendation) |
| Palliative care nurse | Hospice / palliative care coordinator | None | Facility induction; medicines and pain management (general recommendation) |
| Hospice / palliative care coordinator | Head of department (per specialty) | Palliative care nurse | Facility induction; medicines and pain management (general recommendation) |
| Chief pharmacist | Hospital director | Clinical pharmacists; pharmacists; pharmacy technicians | Facility induction; medicines and pain management (general recommendation) |
| Clinical pharmacist | Chief pharmacist | None | Facility induction; medicines and pain management (general recommendation) |
| Registered nurse | Head of nursing (per ward) | None | Facility induction; medicines and pain management (general recommendation) |
| Physician (general) | Head of department (per specialty) | Resident physician / house officer | Facility induction; medicines and pain management (general recommendation) |
Questions and answers
The criterion text is the authority. These answers summarise it.
Who does Standard 10 apply to?
Every setting where patients have pain: hospitals, ambulatory clinics, day-care, hospice and home-based care. Scale the criteria to the services and medicines the facility handles.
What do the colours mean for this standard?
Red (Must) is required in every setting. Green (Medium) is required, adapted to what a humanitarian or transition setting can realistically do. Yellow (Minimum) is the lowest acceptable level in a humanitarian setting. In standard settings, every criterion is Must.
Must opioid prescribing follow a written approach?
Yes. Under 10.1 the facility has a written approach that names the drugs, the starting doses, the review dates and the non-opioid options. Surveyors check that real patient files follow it.
Must pain be reassessed, not only asked once?
Yes. Under 10.2 pain is assessed with an agreed tool on admission and reassessed at a set interval and after any change. A low score does not end the assessment.
Must a patient with pain have a symptom plan?
Under 10.3 the symptoms are assessed and controlled, with a plan for breakthrough pain and an out-of-hours contact for advice.
Must controlled medicines be counted?
Yes. Under 10.4 controlled medicines are recorded in a register, counted at each handover with a double signature, and any discrepancy is investigated.
Must patients and families be told about the pain plan?
Yes. Under 10.5 the patient and family are told what the plan is, what to expect, and whom to call, and the information is recorded.
Do I have to use the documents on this page?
No. The policies, SOPs, forms and registers are drafts to help you. Adapt them to your hospital, write your own, or upload your own. What the assessor checks is that the criterion is met and that you can show how.
Guidelines for this standard
7 guidelines are held in the GMJ Guidelines Library and listed here. Each link opens the full guideline on news.gmj.ge. The complete library, grouped by standard, is at Guidelines.
- Guidelines for the pharmacological and radiotherapeutic management of cancer pain in adults and adolescents (World Health Organization)
- Guidelines on the management of chronic pain in children (World Health Organization)
- Integrating palliative care and symptom relief into primary health care (World Health Organization)
- Quality health services and palliative care: practical approaches and resources to support policy, strategy and practice (World Health Organization)
- WHO Guideline on Balanced National Controlled Medicines Policies to Ensure Medical Access and Safety (World Health Organization)
- Pain — Clinical guidelines — Diagnosis and treatment manual (Médecins Sans Frontières)
- Model List of Essential Medicines, 24th list (World Health Organization)
Also relevant to this standard:
- Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022 (Centers for Disease Control and Prevention (US))
- End of Life Care for Adults: Service Delivery (NICE NG142) (National Institute for Health and Care Excellence (UK))
References
- World Health Organization (2018). Guidelines for the pharmacological and radiotherapeutic management of cancer pain in adults and adolescents. Geneva: WHO.
- World Health Organization (2020). Guidelines on the management of chronic pain in children. Geneva: WHO.
- World Health Organization (2018). Integrating palliative care and symptom relief into primary health care. Geneva: WHO.
- World Health Organization (2017). WHO Guideline on Balanced National Controlled Medicines Policies to Ensure Medical Access and Safety. Geneva: WHO.
- Médecins Sans Frontières. Pain: Clinical guidelines, diagnosis and treatment manual. Geneva: MSF.
- Centers for Disease Control and Prevention (2022). Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022. Atlanta: CDC.