This is the first article in a series of eight articles by Ilene Robeck, M.D. regarding difficult conversations a primary care provider may have when dealing with patients with chronic pain. This series is meant to be a guide for primary care providers facing these situations.
- Difficult situation #1: The patient’s complaints about pain are increasing with requests for dose increases as their activity decreases. There is Increasing pain complaints and requests for dose increases while decreasing activity. There is no indication that the opioid is helpful.
- Advice: It is always helpful in this setting to make sure that the problem related to increasing pain and decreasing activity is not related to worsening structural problems. For example in a patient with chronic back pain who is deteriorating in terms of function it may be necessary to repeat X-rays, MRIs or lab work, to make sure that there is no evidence of new pathology, worsening old pathology, infection or underlying medical problems that may exacerbate pain, such as vitamin D deficiency, thyroid disease, diabetes, liver disease and/or kidney disease.
This is a good opportunity to review an opiate agreement and to reinforce what opiates can and cannot do alone in regard to chronic pain. In addition, the opiate agreement must let the patient know that lack of improvement on opiates is a situation that may result in tapering and discontinuing opiate therapy. Once the patient understands and signs an opiate agreement, check a urine drug screen to make sure that there are no unprescribed drugs or medications worsening the patient’s pain and/or need for escalation in opiate dosing.
A structured physical therapy assessment and options for non-pharmacologic and non-opiate pharmacologic therapy needs to be reviewed with the patient. Patient education about the role of medication and non-pharmacologic options should be emphasized and can be accomplished through booklets, online resources such as the painaction.com website, and/or practice- or institution-run pain schools.
Part of the patient education process is that we now know that there are doses of opiates that will result in higher morbidity and mortality, and that unchecked escalation of opiate dose is no longer considered safe. Most patients respond well to this information and will begin to work with you to lower and possibly discontinue opiates if there is no significant improvement on safer doses. The role of opiate hyperalgesia also needs to be discussed, and there are many patients whose pain actually improves when the opiate dose is lowered and the patient becomes more active.
Dr. Robeck was a chronic pain consultant for primary care for 25 years prior to joining the Veterans Health Administration. She works at the Bay Pines VA Healthcare System in Bay Pines, Florida. Because of her experience with chronic pain management, her primary care practice has increased to include consulting to other VA primary care providers. To put this article in context please read Dr. Robeck’s introductory article, “It’s Never Too Late to Start All Over Again“.