A Systematic Approach to the Use of Opioids in the Treatment of Chronic Pain

Many clinicians may have reluctance to prescribe opioids for patients in pain outside of the most controlled of situations (i.e., when the patient is a hospital inpatient). This phenomenon is fairly well accepted by clinicians and patients, and is often the result of some combination of a variety of factors:

  • – Clinicians who are not experts in the field of pain management may have had little training in the area of pain management beyond treatment of the short-term management of acute pain and have a low level of comfort with using chronic opioid therapy
  • – Patients may have fears about becoming addicted or dependent on opioids, and have questions about these issues that go unanswered and further propagate those fears and concerns
  • – Negative media coverage about high profile opioid overdoses continues to fuel additional public uncertainty at both the prescriber and patient level
  • – Clinicians have fear of regulatory scrutiny and investigation if they prescribe these medications on a regular basis

The path of least resistance for all but the expert clinician might seem to be to avoid the use of opioids when treating chronic pain altogether, and utilize alternative measures that exclude their use. In reality, that solution is likely an unrealistic and untenable solution in many cases, as the incidence of chronic pain is seemingly rising on an annual basis, and opioids still often remain the hallmark, if not an important component of a chronic pain treatment plan when other therapeutic measures have failed. In fact, there is an outcry by some for more effective management of chronic pain than we currently achieve today, including a patient’s right to demand it. On the other hand, the “opioid pendulum” has clearly moved towards a more restrictive approach to opioid prescribing, and many to question the long-term efficacy of chronic opioid therapy based on their assessment of available scientific evidence to justify it.

Despite concerns about opioid prescribing, primary healthcare providers remain the frontline practitioners faced with treating the most common kinds of chronic pain, such as back pain, arthritis pain, headache pain, and other common types of musculoskeletal pain. Beyond education directed towards primary healthcare providers about the pathophysiology of these common types of pain, and its appropriate treatment, there have been many valuable contributions made by experts about the issue surrounding the responsible, safe and effective use of opioids when appropriate.

Experts in the field of pain management have suggested using common medical approaches and paradigms, similar those used as part of routine clinical practices for other medical conditions. This can help allay some fears and concerns on both sides of the “opiophobic fence.” It also has the potential to improve the confidence level for clinicians to use opioids when they are the appropriate choice for the treatment of patients in chronic pain.

The term “universal precautions” originated from an infectious disease model that addressed an approach to patients when there was a deficiency of significant risk assessment information. Past behavior or practices were not reliable indicators of safe and reasonable approaches, especially with at-risk patients. In 2005, Gourlay, Heit, et al., proposed a “universal precautions”1 approach to the use of opioids in the pain patient. The intention of the authors was to offer a structured rational approach to pain patients and serve “as a guide to start a discussion within the pain management and addictions communities. They are not proposed as complete but rather as a good starting point for those treating chronic pain. As with universal precautions in infectious diseases, by applying the following recommendations, patient care is improved, stigma is reduced, and overall risk is contained.”

These universal precautions for opioid use include the following 10 steps:

  1. 1. Make a Diagnosis with Appropriate Differential – Along with other steps to arrive at a diagnosis for the cause of the patient’s pain, address any comorbid conditions, including probable substance use disorders and other psychiatric illness.
  2. 2. Psychological Assessment Including Risk of Addictive Disorders – A complete inquiry into past personal and family history of substance misuse is essential to adequately assess any patient. A sensitive and respectful assessment of risk should be done with available tools, and should not be seen in any way as diminishing a patient’s complaint of pain or reliability. Patient-centered urine drug testing (UDT) should be discussed with all patients regardless of what medications they are currently taking. Those found to be using illicit or un-prescribed licit drugs should be offered further assessment for possible substance use disorders. Those refusing such assessment should be considered unsuitable for pain management using controlled substances.
  3. 3. Informed Consent – The health care professional needs to educate the patient about the proposed treatment plan with opioids including anticipated benefits, foreseeable risks, and concerns at a level appropriate to the individual patient.
  4. 4. Treatment Agreement – The expectations and obligations of both the patient and the treating practitioner need to be clearly understood. The format of this agreement can be verbal or written. Along with the informed consent should clearly identify responsibilities of both the clinician and the patient, monitoring for compliance plans, and any other important information that needs to be discussed.
  5. 5. Pre- and Post-Intervention Assessment of Pain Level and Function – Initiation of opioid therapy for patients in this setting should be considered a “trial” of therapy by both the clinician and patient. Without prior assessment of pain level and function, it would be impossible to measure progress.
  6. 6. Appropriate Trial of Opioid Therapy +/- Adjunctive Medication – Opioids may or may not be the first treatment of choice, and will most likely be used with other adjunctive medications. At this point, it is important to monitor the success or failure of the therapeutic trial with opioids.
  7. 7. Reassessment of Pain Score and Level of Function – Regular reassessment of the patient is critical to support continuation or discontinuation of the therapy.
  8. 8. Regularly Assess the Four A’s of Pain Medicine2 – Routine assessment of Analgesia, Activity, Adverse effects, and Aberrant behavior will help to direct therapy and support pharmacologic options taken.
  9. 9. Periodically Review Pain Diagnosis and Comorbid Conditions, Including Addictive Disorders – It is important to assess for changes in the patient’s condition, or behavior time. These need to be considered dynamically.
  10. 10. Documentation – Careful and complete documenting of the initial evaluation and each follow-up is both medico-legally indicated, and in the best interest of patients and clinicians. Thorough documentation can reduce medico-legal exposure and risk of regulatory sanction. A rule of thumb to remember is: if you do not document it, it did not happen.

Utilizing an approach like universal precautions for all patients who are appropriate candidates for chronic opioid therapy has the potential to unify treatment plans, allow for unbiased application of treatment standards and monitoring, and can potentially reduce the under-treatment of pain when opioids are part of the indicated solution. Although it has been nine years since this approach was recommended, to many it continues to provide a systematic, reproducible method for safe and appropriate use of chronic opioid therapy today in 2014.

References

  1. 1. Gourlay DL, Heit HA, Almahrezi A. Universal precautions in pain medicine: a rational approach to the treatment of chronic pain. Pain Med. 2005 Mar-Apr;6(2):107-12.
  2. 2. Passik SD, Weinreb HJ. Managing chronic nonmalignant pain: Overcoming obstacles to the use of opioids. Adv Ther. 2000;17(2):70-83.