para>Patients on chronic opioid therapy must agree to monitoring. Clinicians should use universal precautions and systems-based practice, including written agreements, random urine drug screens, pill/patch counts, and other measures (see "Ongoing Care") (4,5)[B].
SURGERY/OTHER PROCEDURES
Consider interventional procedures, including joint injections, nerve blocks, spinal cord stimulation, and intrathecal medication among others, as needed.
COMPLEMENTARY & ALTERNATIVE MEDICINE
- Acupuncture: efficacy in chronic neck and back pain and fibromyalgia
- Exercise: efficacy in low back pain and fibromyalgia
- Improved mood and coping skills, decreased disability with CBT
- Mind-body interventions: yoga, tai chi, hypnosis, progressive muscle relaxation, meditation
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Patient Monitoring
- It can be difficult to identify appropriate pain relief-seeking behavior from inappropriate drug-seeking, but consistent patient-clinician relationships over time can often discern the difference.
- Always maintain a risk-benefit stance and avoid judging a patient.
- Assess and document benefits, pain levels, functioning, and quality of life. In general, patients successfully taking opioids for pain become more engaged (better relationships and productive work).
- At each visit, assess and document harm, using universal precautions approach. This system-based practice includes the following:
- Informed consent for opioid therapy
- Written or electronic agreement between patient and clinician
- One prescribing clinician (or designee) and one pharmacy
- No after-hours prescriptions or early refills
- Mandatory police reports for medication thefts
- Random urine drug tests, pill/patch counts
- Requirements for patient to continue with physical therapy, counseling, psychiatric medications, or other necessary treatments
- Participate in state's prescription drug monitoring program: See www.pmpalliance.org.
- Taper and discontinue medications (10% dose reduction per week) if patient does not benefit, if side effects outweigh benefits, or if medications are abused or diverted. If addiction is suspected, always offer treatment for substance abuse (4,5)[B].
PATIENT EDUCATION
American Chronic Pain Association: http://theacpa.org/
COMPLICATIONS
- Rate of addiction in chronic pain patients is unclear (3-19% in published literature), but it may reflect rate in the general population.
- Definitions
- Addiction: chronic biopsychologic disease characterized by impaired control over drug use, compulsive use, and continued use despite harm
- Physical dependence: withdrawal syndrome produced by abrupt cessation or rapid dose reduction; is not addiction but a physiologic phenomenon
- Tolerance: state of adaptation when a drug induces changes that diminish its effects over time
- Diversion: selling drugs or giving them to persons other than for whom they are prescribed
ALERT
Caution: From 1999 to 2007, the rate of unintentional overdose death increased by 124%, largely due to prescription opioid overdoses (especially methadone). In 2011, prescription narcotic overdose was the leading cause of accidental death in the United States (http://www.cdc.gov/drugoverdose/index.html) (6)[B].
REFERENCES
11 Institute of Medicine, Committee on Advancing Pain Research, Care, and Education. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education and Research. Washington, DC: The National Academies Press; 2011.22 Alford DP, Krebs EE, Chen IA, et al. Update in pain medicine. J Gen Intern Med. 2010;25(11):1222-1226.33 Dobscha SK, Corson K, Perrin NA, et al. Collaborative care for chronic pain in primary care: a cluster randomized trial. JAMA. 2009;301(12):1242-1252.44 American Society of Anesthesiologists Task Force on Chronic Pain Management. Practice guidelines for chronic pain management: an updated report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine. Anesthesiology. 2010;112(4):810-833.55 Manchikanti L, Abdi S, Atluri S, et al. American Society of Interventional Pain Physicians (ASIPP) guidelines for responsible opiod prescribing in chronic non-cancer pain: Part 2—Ξidance. Pain Physician. 2012;15(3 Suppl):S67-S116.66 Bohnert AS, Valenstein M, Bair MJ, et al. Association between opioid prescribing patterns and opioid overdose-related deaths. JAMA. 2011;305(13):1315-1321.
ADDITIONAL READING
- Federation of State Medical Boards of the United States, Inc. Model policy for the use of controlled substances for the treatment of pain www.painpolicy.wisc.edu/sites/www.painpolicy.wisc.edu/files/model04.pdf.
- Washington State Agency Medical Director's Group. Interagency guideline on opioid dosing for chronic non-cancer pain: an educational aid to improve care and safety with opioid therapy. www.agencymeddirectors.wa.gov.
CODES
ICD10
- G89.29 Other chronic pain
- G89.21 Chronic pain due to trauma
- G89.28 Other chronic postprocedural pain
ICD9
- 338.29 Other chronic pain
- 338.21 Chronic pain due to trauma
- 338.28 Other chronic postoperative pain
SNOMED
- 82423001 Chronic pain (finding)
- 431481001 chronic pain due to injury (finding)
- 279047007 Persistent pain following procedure (finding)
- 373621006 chronic pain syndrome (disorder)
CLINICAL PEARLS
- Start with the presumption that the patient's pain is real, even if pathophysiologic evidence for it cannot be found.
- Emphasize that being pain-free may not be possible but that better function and quality of life can be shared goals.
- Use a multidisciplinary approach with nonpharmacologic therapies, exercise, patient self-management strategies and thoughtful medication use with clear goals, expectations, and documentation of care plan.
- Use universal precautions and systems-based practice to safely and effectively prescribe opioids for chronic pain.