Chronic Pain Management: An Evidence-Based Approach

Jennifer Reidy, MD, MS, FAAHPM

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].