Clinicians treating pain have dual obligations which requires a balanced approach: effective pain management and limiting controlled substance-related problems in patients and in their communities. They face two crises: 18,893 opioid-associated overdose deaths in 2014 (14%↑ from 2013) as well as 100 million Americans with chronic pain, itself harmful including risk for death such as related to suicidality. Opioid addiction is seen in 8-12% of those prescribed opioids. Substance abuse indicators, mental health issues, and benzodiazepines have been found in up to 95%, 57%, and 49% respectively of those with an opioid overdose death.
A nonsystematic review of the literature, available guidelines, and the practical experience of clinicians collaborating through the North Colorado Health Alliance has resulted in this document. It is not intended to be a guide for pain management (treatment selection, etc.), opioid prescribing (selection, dosing, metabolism, interactions, etc.), nor for non-prescribing clinicians. Rather, it is a non-comprehensive checklist to educate and remind prescribers how to risk manage opioids.
Evidence-based research, while critical, does not address all the personalized needs of patients in front of the medical provider with decision-making responsibilities. Although there is limited evidence about best practices, there is broad support for certain principles and processes which embrace the chronic care model:
Clinician Training
• Clinicians treating pain should receive training to ensure that they are:
- Person-centered, family-inclusive, trauma-informed, and recovery-oriented
- Knowledgeable about the spectrum of treatments available and the means to address barriers to care
- Knowledgeable about using medications and non-medication approaches
- Knowledgeable about controlled substances laws and regulations, which vary state-by-state
- Comfortable with identifying/addressing prescription drug adverse events, including substance use problems
- Comfortable working in a multi-disciplinary team and able to identify her/ his own skills and limitations
• Clinicians should build an integrated multidisciplinary team: the entire office staff, pharmacists, modality practitioners, pain specialists in medication management and procedures, surgeons, behavioral health (psychiatrists/psychologists), addiction specialists, peer coaches, social work, care management. Referral should take place when there is diagnostic or therapeutic uncertainty.
• Clinicians or the clinical team should establish its own guidelines and step-based protocols for the treatment of chronic pain and risk managing opioids.
• Clinicians should always treat persons with pain, including those with addiction, in an individualized, respectful, non-judgmental style that employs motivational interviewing techniques.
Patient Assessment
The process of managing chronic pain begins with a stepwise patient assessment to determine:
- Character and severity of pain / function: Pain scales, Brief Pain Inventory, Quallity of Life scale, PEG-3
- Pain generator(s) with a thorough history, exam, diagnostic studies, and consultation
- A differential diagnosis and as specific a diagnosis as possible
- Previous efforts to address pain and their levels of success
- Comorbid conditions, notably DM, respiratory, behavioral health, trauma, memory, substance abuse
Pain Treatment
Treat to resolve the pain generator(s) and consequently the pain whenever possible
If the pain generator(s) cannot be resolved, treat pain by this general approach:
• Establish realistic treatment goals for both pain and activity, as analgesia is only one means to improve function
• Formalize the plan with a written agreement sensitive to the literacy level of and reviewed/signed by the patient
• Treatment should be multi-modal and multidisciplinary, addressing the diverse bio-psycho-social nature of pain:
- Non-pharmacologic-co-located when possible: modalities (PT, OT, acupuncture, chiropractic, therapeutic exercise, mindfulness meditation , etc.), procedures (injections, surgery, etc.), and pain behavior therapy
- Non-controlled medications – which also have risks that need to be appropriately managed
- Controlled medications such as opioids, which may or may not be necessary
- Rational polypharmacy: coordinate medications for efficacy and to minimize drug-drug interactions
• Build on past successful treatment approaches as long as they remain safe and effective
• Use the minimal dose of any treatment necessary to improve function, wary of drug interactions
• Have a plan to address acute, sometimes urgent exacerbations of chronic pain
• Take into account the assessed comorbid conditions: behavioral health, substance abuse, respiratory, memory
• Assist access to necessary care, addressing patient’s financial and other resources
• Build a treatment team specific to the patient’s needs
• Actively communicate and coordinate care with treatment team members (team meetings if possible) following established rules for Protected Health Information: HIPAA, 42 C.F.R. Part 2, and state regulations
• Educate the patient and her/his family about the multiple avenues for treating pain and informed consent of the treatments provided, providing educational tools when useful
• Patients should be active in their own care: self-health practices (diet, activity, service work, spiritual practice, etc.) and pain self-management (ice, activity pacing, stress reduction, yoga, mindfulness meditation, etc.)
• Continuously track and respond to adverse reactions as well as both pain and function
• If function has not improved, switch to an alternative treatment
• Track and respond to treatment-related aberrancies: behavioral aberrancies, the online prescription database (Prescription Drug Monitoring Program), body fluid (typically urine) drug testing, and other processes
• Continue pain workup to reduce diagnostic and therapeutic uncertainties while pain treatment is underway
• Continue therapeutic trials of the potentially safest and most effective options for pain whenever possible
• Make every effort to keep the patient connected with their medical home medical home, discharging from a practice only as the last resort and performed with respect and according to accepted practice
Document Patient Care
• Use the standard SOAP-like format and other elements of standard medical charting
• Record both pain and risk management data
• If templates are used, ensure that adjustments are made specific to the current patient contact
• Record not only what is done, but also concerns and medical decision-making considerations
2016 North Colorado Health Alliance
Steven Wright, MD
