Opioid Prescribing and Substance Abuse, 10hr

Overdose has become the leading cause of death in the United States for those under the age of fifty, with opioids in 2016 ending the lives of more than 115 people each day (Inflexxion, 2018). This data has led president Trump and public leaders to issue a call to arms for what is being labeled a public health emergency. Some, however, argue that what is being seen relates more to a failure of the war on pain spawned in 1996 by the American Pain Society, when they acknowledged the medical systems’ serious undertreatment of pain and called for mandatory pain assessments as “the fifth vital sign (Pomeroy, 2017).

This difference creates a serious split in managing an opioid overdose epidemic. Are we dealing with a population seeking relief from poorly managed or unmanaged pain, or is there an element seeking socially unacceptable benefits that may arise from illicit or illegal use of opioids meant for pain treatment?

Should we extend treatment with kindness and gentleness, seeking to minimize and alleviate suffering, or should we make new laws to isolate offenders behind bars before they endanger themselves or others? Silly as these questions may seem to some, they are genuine. Let us look at the subject in question, opioids' benefits and use, and how this uncontrolled overuse snuck up on us. Finally, what is being done about it now and what plans are being developed to mitigate what has become a deadly addiction.

This crisis is not our first rodeo where opioids and their precursor opium formed the center of a storm. The mid-1800s saw two wars between Briton and Imperial China, where opium was the key to controlling all trade and entire regions of Asia. The Opium Wars, as they are correctly referred to, established just how powerfully the call of this drug could affect an entire populace and direct the course of nations. The power of opioids came home to North America during our American Civil War, where medics from both sides liberally used morphine as a battlefield anesthetic, and homefront households welcomed laudanum, a tincture of opium, as the treatment of choice for toothaches and soothing colicky children, to belly aches and mood swings (Board TE, 2018). Those utilizing opium-based wonder drugs faced the risk of developing tolerance and dependence, both during our previous opioid crises and now. Morphine misuse became so troubling that it was often referred to as “the army disease,” and laudanum ensnared many, such as Mary Todd Lincoln, President Lincoln’s wife, who became addicted while utilizing the tincture to aid in finding sleep (Stobbe, 2017).

As though to mirror our present crisis, pharmaceutical companies (Merck and Bayer, respectively) rapidly pushed the market cocaine and heroin, billing them to reduce the misuse and addictions laid at the feet of morphine and related opioids. When in the early 1900s, the sweet poison effects of heroin and cocaine became too great to ignore, the government lurched into motion with the 1914 Harrison Act, the first national effort to contain a drug epidemic. Effects of the Harrison legislation made codeine and heroin by physician prescription only. This change limited the quantities sold, driving up the costs of the medications, creating the beginnings of a vast underground supply and demand market system and bringing illicit and illegal opioid use into a don’t ask, don’t tell the type of existence where affected family members and addicts were to the best of society’s ability, ignored. The shadow existence of the drug addict fought and lost its opportunity for recognition and assistance competing against such happenings as the Spanish Flu, the Great Depression, and World War II, which depleted the disposable income and empathy of the nation.

A resurgence into the public eye of opioid misuse and addiction occurred in the 1960s and 70s as our nation went to war in the Orient. Combatants returning from Korea and Vietnam brought new cravings and supplied contacts, leading to a resurgence of opium, and opioid derivatives and President Richard Nixon declared in 1971 that we as a nation were at war with drugs. The 1971 War on Drugs continues today, with tough sentences on drug users and suppliers and ramped up military interdictions on illegal drug smuggling.

Though our current opioid crisis is built on the framework created by all of the previous unresolved opium epidemics, this new wave of life-destroying overuse has features that make it unique from past outbreaks. For instance, we have an “exact” start date for our crisis, the year 1995. That was the year the megalithic pharmaceutical industry brought forth the first of another set of wonder drugs to curb overuse and addiction to opioids. Most overlook the similarity to how the fight against morphine overuse brought heroin forward. Specific to our contemporary crisis is the new drug OxyContin, a long-acting form of oxycodone, one of the first of the time-released opioids. OxyContin hit the pain relief market with great promises as an end-all to pain and the risk of narcotic abuse (McCance-Katz, 2018). The assurances from Purdue Pharma, the company which aggressively marketed OxyContin, was that it was a much safer, less addictive opioid, able to be safely used for months at a time in the treatment of chronic pain (CNN, 2018).

Forceful marketing with incentives such as ‘befriending,’ then manipulating tired, overworked prescribers and lures such as weekend first-class resort training on the new medications helped pharmaceutical companies flood the market with hundreds of millions of new opioid pills and capsules (CNN, 2018). Meanwhile, pain suffers found themselves developing drug tolerance and addiction to the new products, just like the old, and those abusing themselves with prescription meds quickly found that crushing the tablets or capsule contents and snorting or injecting the powder delivers a potent ‘high’ much more powerful and quicker than swallowing a pill (Stobbe, 2017).

Substance abuse issues are a real concern in the management of pain.  Opioid misuse and abuse is a major public health problem, affecting 34.2 million Americans over 12.9. According to the Center for Disease Control, in the United States, 46 people die each day from an overdose of prescription painkillers. In 2012, healthcare providers wrote 259 million prescriptions for painkillers. Two times as many painkiller prescriptions are written in the United States as in Canada.

Misuse prevalence is variable. Of individuals over twelve, 4.6 percent reported non-medical opioid use within the last year. 12.2 percent of 12th graders reported ever abusing opioids, and 7.9 percent reported past-year use.

The number of people who sought treatment for non-heroin opioid substance abuse increased from 1.0 percent in 1995 to 8.7 percent in 2010.  Research also shows that white individuals account for 88 percent of those who reported non-heroin opioid substance abuse, and the majority of these individuals lived in a rural setting.  Those living in rural settings account for 10.6 percent of cases, and urban individuals account for 4.0 percent of non-heroin opioid abuse individuals seeking treatment.

Opioid dependence costs lost work productivity, legal costs, and psychological effects on the victims of the crimes caused by opioid abuse. In addition, opioid misuse leads to other diseases such as HIV, hepatitis, and sexually transmitted infections.

Opioids have the potential to provide analgesia and improve function. These benefits must be weighed against the potential risks, including misuse, addiction, physical dependence, tolerance, overdose, abuse by others, drug-to-drug, and drug-to-disease interactions.

A recent survey showed that individuals might go to extreme lengths to obtain certain prescription medications. Opioids were the most obtained medications, followed by sedative-hypnotics and amphetamines. Individuals seeking these medications are more likely to use more than one physician and one pharmacy. This survey showed that seventy-five patients feigned symptoms to get prescriptions, two of thirty-six used falsified MRI images, three patients paid the prescribers, and three harmed themselves to get the prescriptions (Pomeroy, 2017).

Many states have prescription drug monitoring programs. Healthcare providers must ensure that they are using these drug monitoring programs to find patients misusing prescriptions and placing themselves at risk of overdose.

The Nixon era “War on Drugs,” continued by every presidential administration since it has taught us many things about substance abuse and addiction. First, it showed us that wars on drugs do not work. Secondly, deprivation or abstinence alone from a drug of choice, including opioids, does not reduce returning to that substance when it becomes available. This situation has proved a deadly problem as the time away from opioids generally reduces a person’s metabolism's built-up tolerance. That means that with former inmates, who, on release, tend to return to using their previous dosage, the overdose rates run nearly 130 times higher than the general population (Joseph, 2018).

Caging opioid users whose offenses are centered on nonviolent opioid use as in past eras needs revisiting. New tactics need to be discussed to tame the lion of opioid overuse and to bring the crisis back from its current record highs.

It is wrong to think of the opioid crisis as a raging lion out to mangle and devour us all. It is, however, a serious issue deserving more than kneejerk election-year attention by our nation’s leaders and policymakers. The CDC estimates that each year the total national financial burden from prescription opioid use costs us, the taxpaying public, $78.5 billion each year, an amount that considers the cost of healthcare, criminal justice involvement, and addiction treatment. As we have seen in previous opium/opioid addiction epidemics, coming between a person's need for pain relief and, for some, their desire for pleasure and their drugs of choice is a tricky matter that takes consideration, planning, and a steadfast determination to see it through.

Every legislator and government agency presents a unique plan to combat the opioid epidemic. Let us look at some of the concepts that have either been already implemented or stand a good chance of being seen by healthcare professionals across the nation.

In a March 19, 2018, public address on the current opioid crisis, President Donald Trump outlined an initiative to confront the driving forces behind the opioid crisis. President Trump’s plan contains three core focus points, each with progressive actions under them (Obama Administration, 2015; President Donald J. Trump, 2018):

• Reduce opioid demand.
  • Launch a nationwide evidence-based public awareness campaign about the dangers of prescription and illicit opioids (and other narcotics).
  • Support research and development of therapies and technologies to prevent addiction and decrease the need for opioids in pain management. (e.g., non-addictive pain management options, the potential for vaccine-specific prevention of opioid addiction).
  • Reduce overall opioid prescriptions (e.g., ensure that within three years, 75 percent of opioid prescriptions reimbursed by federal dollars are issued using best practices, with 95 percent compliance within five years).
  • Ensure that the nationwide Prescription Drug Monitoring Program advocated in the Affordable Care Act is completed and operational throughout all states.
  • Stop the flood of illicit drugs across borders and within communities.
  • Secure land borders, ports of entry, and waterways against smuggling.
  • Require electronic advance documentation for 90 percent of all international goods-by-mail and consignment shipments within three years.
  • To interdict illegal shipments, use advanced screening technologies and drug-sniffing canines with all high-risk international packages.
  • Engage with opioid source countries such as China and Mexico to cooperate with stopping the movement of opioids, precursor chemicals, and other illicit drugs.
  • Expand efforts to prosecute corrupt or criminally negligent doctors, pharmacies, opioid manufacturers, and distributors.
  • Strengthen enforcement and penalties for drug traffickers.
• Save lives with proven treatments for opioid addictions and overdose.
  • Ensure first responders are supplied with naloxone to reverse an opioid overdose.
  • Improve nationwide overdose tracking to shift resources to areas of need.
  • Expand evidence-based addiction treatment in every state, focusing on medication-assisted treatment for opioid addiction.
  • Provide on-demand evidence-based addiction treatment to service members, veterans, and their families.
  • Identify and treat criminal offenders struggling with addiction. (e.g., screen every federal inmate for opioids on intake, and facilitate treatment for federal inmates while supporting state, tribal, and local drug courts to provide evidence-based treatment as an alternative or in conjunction with incarceration and supervised release.

The U.S. Department of Health and Human Services (HHS) has pushed forward with plans for a five-fold approach to containing the Opioid Crisis:

1. Nationwide improvement of treatment and recovery services.
2. Promoting the availability and use of opioid overdose-reversing medication.
3. Strengthening public health surveillance to gain a better understanding of opioid-related problems.
4. Research supports both controlling pain and minimizing addiction.
5. Advocating for the actual use of better methods of pain management.

NIH, the National Institute of Health, through a branch agency of the massive HHS system, has already been meeting with academic researchers and the big pharmaceutical companies who bear a goodly portion of the blame for the current opioid flood pushing the crisis forward. The plans NIH is busy implementing include:

• Finding and instituting safe, effective, non-addictive methods of managing chronic pain.
• Innovative new technologies and medications for the treatment of opioid use disorders.
• Methods to improve and distribute both overdose prevention and reversal interventions that save lives and work to support recovery.

The Joint Commission (JC) recognizes pain control is an important part of quality health care. They acknowledge that pain is the fifth vital sign and should be assessed with other vital signs. According to the JC, patients have the right to assess and treat pain. Additional beliefs of the JC include:

• Patients should be educated about pain.
• Providers must be competent in the assessment and treatment of pain.
• Pain should not interfere with function.
• Managing pain should be included in the plan to discharge a patient.

Say what you will about the pharmaceutical industry’s actions relating to this generation’s opioid epidemic. Some large corporations are stepping up with initiatives to slow the growth of addiction. Pharmacy chain CVS Caremark, for example, began implementing a filling restriction for new pain medication patients prescribed opioids, limiting them to a seven-day supply of medication. Other medication dispensaries are considering coming on board with this self-limitation, and some legislative plans advocate that this throttled introduction to opioids become the law of the land (Dixon, 2018).

Opioid abuse is an epidemic of our times. We can learn from previous generations’ struggles with opioid misuse and form strategies for early detection and positive interventions, like replacing opioid pain management with other interventions (i.e., physical therapy, thermal therapies, electronic pain management options, regional pain blocks, etc.). The interdiction of non-prescribed supplies of opioids and making pain management alternatives inexpensive and readily available also provide those who do need higher levels of pain management with the means of controlling their pain within the health system, allowing for treatment for dependence when needed so they are not forced into illicit and illegal methods to meet their pain control needs. Remember that detoxification does not mean much if supportive measures are not also present to help prevent relapse.

Prevention measures need to be formed at high levels of the government and the health profession, with actions and goals that we can all buy into. A uniform, united approach is the beginning of an answer to our opioid crisis, and for health professionals to contribute our best, we must stay informed regarding the changing landscape surrounding the pain of our opioid crisis.

Pain is a major problem in today’s society. Pain carries consequences across various categories, including ethical, social, economic, and legal arenas. This course will discuss pain management's ethical, social, economic, and legal implications.

Pain is a common problem seen in primary care. Chronic pain affects about one in two long-term care residents (National Clearinghouse, 2013).  Persistent pain is often associated with anxiety, depression, functional impairment, sleep disturbances, disability, and impairment in activities of daily living. Chronic pain is a pain lasting more than three months and may affect any body part.

Acute pain typically has an abrupt onset and is often described as sharp. It is usually caused by events such as a broken bone, surgery, childbirth, dental pain, or burns. Acute pain may last a short period or a few months. The pain dissipates when the underlying cause has healed. Acute pain lasts longer than 3-6 months. It is then termed chronic. Acute pain that is not appropriately treated may lead to chronic pain.

Multiple barriers to effective pain management exist. These include many individuals, families, healthcare providers, society, and political barriers.

The good news is that we have the knowledge and skills to manage most pain effectively. So what is the problem? Why is unrelieved pain still so prevalent?

Knowledge is important. Clinicians, as well as patients, need to be made knowledgeable about methods of assessing and managing pain. Knowledge alone rarely changes practice. Efforts must go beyond education alone if pain treatment is to improve. Pain needs to be made visible so it will not go unnoticed by clinicians.

Pain theories help clinicians understand the pain and help guide the treatment of pain. Pain theories have been around for many years. One of the first pain theories was the Intensive Theory, which Plato created in the fourth century BC. It defined pain as an emotion that happens when a stimulus is more intense than usual. It has been refined over the years by other scientists/philosophers. The theory suggests that repeated tactile stimulation produces pain.

The Specificity Theory of Pain suggests that certain pain receptors send signals to the brain that create pain awareness. According to the theory, pain is an independent sensation with particular peripheral sensory receptors, which act in response to damage to drive signals through the nervous system to centers in the brain.

Other theories that came to light in the 1900s include Pattern, Central Summation, Fourth Theory of Pain, and Sensory Interaction Theory.

A more recent theory is the Gate Control Theory. Pain stimulation is transmitted by small, slow fibers that go into the dorsal horn of the spinal cord. The theory states that there is a gate in the spinal cord which controls sensory information through the spinal cord. When there is more pain stimulation, gate blocking is less effective. The gates open when there is much activity in the pain fibers. Once the A-beta fibers are stimulated, which provide a stimulus for mild irritation, such as lightly touching the skin (massage), the gates may be closed. This action inhibits the perception of pain.
In addition, messages that descend from the brain – such as those in anxiety states or extreme excitement – can affect the opening or closing of the gates.

The Biopsychosocial Model of Pain suggests that pain involves physiological, psychological, and social factors. It suggests that family and culture influence pain perception and the individual’s response to pain.

Anatomy and physiology are key factors in understanding pain. Primary afferent fibers are involved in the transmission of pain. A-delta and C fibers transmit noxious stimuli from the body’s periphery to the dorsal horn of the spinal cord. The A-delta fibers have a small diameter, are lightly myelinated, and conduct slowly. They transmit rapid, sharp pain. C fibers are small and unmyelinated fibers that conduct slowly, respond to multiple stimuli, and lead to dull, achy pain. If the pain signal is strong enough, it transmits through the dorsal horn to the spinothalamic tract and the spinoreticular tract. These are the ascending tracts to the cerebral cortex, where the stimulus is recognized as pain. When the pain is identified in the cerebral cortex, it descends to the periphery.

The neurons are involved in transmitting pain by releasing substances and neurotransmitters. The excitatory substances that contribute to pain include P, glutamate, prostaglandins, and nitrous oxide. Inhibitory neurotransmitters inhibit, or partially, the transmission of pain. Common inhibitory neurotransmitters include glycine, serotonin, norepinephrine, acetylcholine, and gamma-aminobutyric acid (GABA). Medications are involved in modulating these neurotransmitters to help reduce pain.

Pain affects multiple aspects of life. Pain can lead to physiological changes and potentially to physical illness. It can lead to cognitive changes, as many patients with chronic pain suffer from depression and anxiety. Pain can change the way one thinks and acts leading to behavioral changes.

Pain has the potential to affect an individual’s social life. Chronic pain may limit the patient’s desire to interact in social settings. Social consequences of unrelieved pain may include isolation, inability or reduced desire to go to work, and overall reduced quality of life. Expression and reporting of pain can vary by culture. Some cultures have a more stoic attitude to pain, while others may express more emotion toward pain.

The political arena can strongly influence pain in society. The assessment of pain over the last 20 years has focused on eliminating and reducing pain at all costs. This attitude has contributed to the opioid epidemic and many problems for society. In recent years, politicians have been implementing laws to help assure that pain is adequately assessed and treated with extra caution in preventing medication abuse.

Multiple ethical issues surround pain and its management. Healthcare providers should attempt to minimize pain and suffering while maintaining a balance between adequate pain management and minimizing harm from pain treatment. The healthcare provider must not harm and guard against overmedicating the patient. The healthcare provider must be aware of pharmacotherapy's negative consequences, including physical dependence, tolerance, and abuse.

Some think that pain management is a human right. Medical organizations do not consider pain management an explicit duty of the prescriber, except for a part of good medical care. If pain is considered a human right, it will force the government into the middle of the patient-physician relationship.

Access to healthcare is not equitable and brings up questions of justice. Certain populations are at a disadvantage when it comes to access to pain management. Individuals who do not have insurance may lack the means to receive medical care and pain management. Individuals who are more likely to have access to care include those who are older, those who live in a suburb, and those who have insurance or a college degree or have a high income. Those with less access to care include those with financial problems and those of Hispanic ethnicity.

Ethical issues surround the end of life care. The management of pain at the end of life is a moral duty for the provider caring for a terminal patient. While opioid use may suppress respiration and may even hasten death, treating pain is an important part of care for intractable pain as death nears. The goal of giving pain management is to relieve suffering, not accelerate death. Palliative sedation may be considered to manage refractory pain at the end of life.

Diagnostic testing can help evaluate painful conditions. It is important to realize that an abnormal diagnostic test does not confirm the source of the pain. Blood tests can be useful in some conditions to determine or monitor certain causes of pain. For example, an elevated C-reactive protein or an erythrocyte sedimentation rate may be seen in those with polymyalgia rheumatica, infection, or rheumatoid arthritis (all conditions that may cause pain).

Imaging may be necessary for some situations of chronic pain. X-rays, computed tomography, and magnetic resonance imaging can help define the etiology of the pain. Caution must be utilized when imaging, as many abnormalities, may be seen in imaging tests that are not the source of the pain.

An electromyogram (EMG) or nerve condition studies are often done to assess the cause of pain. The EMG measures the electrical activity of the muscle and can help find damaged muscle, nerves, or neuromuscular abnormalities such as a herniated disc’ or myasthenia gravis. The nerve conduction study measures the ability of the nerves to send electrical signals and can help diagnose carpal tunnel syndrome or other neuropathies.

The goals of pain management are not necessarily complete pain relief. They may include a reduction in pain, improved quality of life, improved physical and psychological functioning, improved ability to work, improved ability to function in society, and reduced health care utilization.

A pain management plan is more than just a prescription for pain medication. In addition to pharmacotherapy, it should include psychological and physical modalities to manage pain. It should be modified when interventions are not effective.

The patient should be provided with education regarding the plan. It should include information about medications prescribed, other treatment options, and methods to contact the pain management team.

When developing a treatment plan, there are many considerations. The type of pain should be considered. In addition, the effect the pain has on lifestyle, including psychological, social, and biological components of life, should be considered.

Many factors affect the success of the treatment plan. Issues related to the patient, such as their ability to understand and apply the management plan, will help determine the plan's success. The patient’s willingness to implement the whole plan can profoundly affect the plan's success. If a patient is willing to take a pill but not willing to work on non-pharmacologic interventions (such as physical therapy or weight loss), the plan will lose its effectiveness.

Current treatments to manage chronic pain are not very effective, resulting in about a 30 percent reduction in pain. Clinician has the responsibility to manage pain the best that they can because proper treatment of pain can result in a significant improvement in the quality of life.

General physicians lack training in the management of chronic pain. Referral to a pain management specialist may be indicated for those with debilitating symptoms, those needing increased doses of pain medications, those who are non-responsive to treatments, or those with symptoms at multiple sites.

Caregivers' or healthcare providers' issues often affect the pain management plan. Many caregivers and healthcare providers do not accurately comprehend the patient’s pain and may hold false beliefs regarding pain management. Caregivers and healthcare providers may be inhibited by fear of side effects from medications or concerns of drug addiction so they may withhold medication from those in pain. In addition, caregivers/healthcare providers and patients may have discordant goals.

Controlled substances should be prescribed for a legitimate medical purpose, carefully considering the patient’s safety, therapy goals, and treatment efficacy. Treatment of pain should include pharmacotherapy and physical and psychological therapies.

Pain is typically classified as nociceptive, neuropathic, or other. Nociceptive pain comes from tissue damage or inflammation and may originate from the muscles, joints, skin, organs, bones, or tendons. It may include burns, tumors, muscle strain, joint pain, arthritic pain, or post-surgical pain.

Neuropathic pain comes from damage to the nervous system. It may result from anything that damages neurons. The damage may include pinching of the sciatic nerve, damage from chemotherapy, phantom limb pain, multiple sclerosis, diabetic neuropathy, postherpetic neuralgia, or post-stroke central pain. This pain is usually described as burning, tingling, stabbing, or electrical. The pain type of neuropathic pain is more likely to lead to chronic pain as nerves do not heal.

Examples of other pain that cannot classify into these two categories include fibromyalgia, complex regional pain syndrome, or nonspecific chronic low back pain.

Acute pain is defined as pain that has an abrupt onset and offers a warning of a disease process or a threat to the body (Pino & Covington, 2019). Management of acute pain may include opioids. While good pain control is important in patient care, opioids for acute pain increase the risk of long-term opioid use (Dowell, 2016). Use of caution is imperative because long-term opioid use often begins with treating acute, self-limiting afflictions. Ideally, opioids should be prescribed only when necessary, with the lowest effective dose and the shortest possible duration.

Acute painful conditions may include post-operative pain and other conditions commonly encountered in the primary care setting or emergency department. Recent guidelines have considered this and re-examined the best acute pain management.

The Center for Disease Control suggests that opioids should only be used when necessary and at the lowest effective dose. Less than three days of opioid medication is appropriate for nontraumatic nonsurgical pain (NYC Health, 2019). Immediate-release opioids are recommended for short-term use, although acute pain may require more than three days in some instances.

New York City published guidelines for the use of opioids. They recommend that most patients require three or fewer days of therapy, giving patients short-acting medication, patients should be evaluated for addiction or misuse, avoid administered benzodiazepines and opiates together, and use extreme caution with stolen, lost, or destroyed prescriptions (Brummett et al., 2017).

When too many pills are prescribed, there are “left-over pills.” These left-over pills may have use for diversion or abuse. Nonetheless, it is often difficult to predict how much acute pain each patient will have and how many pills to prescribe.

Some factors increase the risk of persistent opioid use. These risks include a history of alcohol or drug abuse, lower socioeconomic status, multiple medical comorbidities, depression, benzodiazepines or antidepressants, and preoperative pain.

Pain is a common problem in primary care, with about 20% of outpatient visits for pain issues (AMDA, 2012). Chronic pain affects about one in two long-term care residents.

Persistent pain is often associated with anxiety, depression, functional impairment, sleep disturbances, disability, and impairment in activities of daily living. Every year, chronic pain leads to more than 50 million lost workdays in the United States and costs the American taxpayer over 100 billion dollars.

Chronic pain is a pain lasting more than three months and may affect any body part. Chronic pain is most frequently caused by back pain (10%), leg/foot pain (7%), arm/hand pain (4.1%), headache (3.5%), and widespread pain (3.6%). Many individuals affected by chronic pain have more than one type of pain (APA, 2013).

The definition of chronic reads as pain that lasts beyond the usual duration of time that an insult or injury to the body needs to heal (Pino & Covington, 2019). Chronic pain can also be viewed as pain without apparent biologic value that has lasted beyond the usual tissue healing time (typically at least three months). Some define chronic pain as pain that continues for at least six months.

An expert panel concluded that chronic opioid therapy might be effective for some individuals with chronic non-cancer pain that have been thoughtfully selected (Pino & Covington, 2019). High-dose long-acting opioids are used only in specific circumstances with severe, intractable pain that has not responded to short-acting or moderate doses of long-acting opioids. No evidence exists as to who responds better between long-acting and short-acting opioids concerning pain relief and side effects (Manchikanti, 2012).

Numerous non-pharmacologic therapies are used in the management of pain. These may include a combination of physical and psychological techniques. Some methods used other than medications include: physical therapy, exercise, massage, ultrasound therapy, heat/cold application, chiropractic manipulation, psychotherapy, biofeedback, relaxation therapy, acupuncture, transcutaneous electrical nerve stimulation (TENS), music therapy, injections, neuromodulation, spinal cord stimulation, deep brain stimulation, and radiofrequency ablation of nerve tissue.

For those with pain, a  physical or occupational therapy trial can be helpful. With the help of a physical therapist, the use of exercises targeting a specific type of pathology can be helpful in the management of pain. Occupational therapists can help recommend devices that can assist in enhancing the activities of daily living.

Massage is soothing and relaxing, both physically and mentally. Massage may decrease pain by relaxing muscle tension and increasing capillary circulation, thereby improving general circulation.

A vibration is a form of electric massage. When vibration is applied lightly, it may have a soothing effect similar to massage. Vibration applied with moderate pressure may relieve pain by causing numbness, paresthesia, or anesthesia of the area stimulated.

Heat and cold therapies can assist in the management of pain. Heat reduces inflammation and promotes relaxation. It can be in hot tub baths, heating pads, or heat packs. Cold is often more effective in relieving pain than heat. The application of cold reduces muscle spasms secondary to underlying skeletal muscle spasms, joint pathology, or nerve root irritation. Cold application methods include ice massage, ice bags, and gel packs. Alternating heat and cold may be more effective than using either alone.

Multiple psychological techniques can aid in reducing pain. The basis for using these methods is that thought influences feelings, and if thought (and behaviors) can be changed, so can feelings and even sensations, such as pain. Cognitive-behavioral methods require the patient’s active participation.

Relaxation is a state of relative freedom from anxiety and skeletal muscle tension, a quieting or calming of the mind and muscles. Although relaxation is a learned technique, it can be achieved quickly in a motivated patient.

Imagery/visualization involves mentally creating a picture by using one’s imagination. This visualization may be focused on a close person, a place of enjoyment, a past event, or anything thought to bring pleasure. Since the mind is occupied, the pain is reduced in focus.

Distraction from pain is the focus of attention on stimuli other than the pain sensation. The stimuli focused upon can be auditory, visual, or tactile-kinesthetic (hearing, seeing, touching, and moving). By focusing attention and concentration on stimuli other than pain, pain is placed on the periphery of awareness. Distraction does not make the pain go away, nor does the effectiveness of the use of distraction indicate the absence of pain. Music and humor are extremely effective means of distraction.

Transcutaneous Electrical Nerve Stimulation (TENS) provides low voltage electricity to the body via electrodes placed on the skin. TENS may help with acute or chronic pain. The electrical stimulation of sensory nerves helps block pain signals going to the brain.

Biofeedback is a technique to harness the mind’s power to allow the patient to be more aware of the sensations in the body. The exact mechanism is unclear, but it promotes relaxation and helps reduce pain.

Acupuncture is a neurostimulation technique that treats pain by inserting small, solid needles into the skin at varying depths. Various theories exist to explain how acupuncture works.

Music therapy may be used to treat pain. Music therapy is the clinical and evidence-based use of music interventions to accomplish individualized goals within a therapeutic relationship by a credentialed professional. This individual has to complete an approved music therapy program. Research in music therapy supports its effectiveness in various health care and educational settings.

Music therapists use music to facilitate changes that are non-musical. Studies done with arthritic patients demonstrated that music helps relieve pain and anxiety, induce relaxation, promote healing, enhance mental function, improve communication, promote physical rehabilitation, and reduce stress, providing positive changes in mood and emotional state. Individuals doing music therapy listen to music created under the guidance of a specially educated and certified professional in music therapy.

It is believed that music, like relaxation and guided imagery, can strengthen the right side of the brain, which controls the body's healing processes. The theory of music therapy's effect on chronic pain deals with how pain signals travel through the body. When the brain senses injury to the body, pain signals begin in the somatosensory cortex and the hypothalamus and work their way through the “pain pathway,” ultimately sending pain relief signals. Some signals stimulate the release of neurotransmitters such as endorphins, dynorphins, and enkephalins. Music helps in pain reduction by activating these sensory pathways.

Different surgical interventions or procedures can be used in the pain management plan. Procedures may include injections, spinal cord stimulation, deep brain stimulation, neural ablative techniques, and surgical interventions. These are potential options for those for whom other methods have not controlled the pain.

The World Health Organization (WHO) analgesic ladder was created to manage cancer pain and published in the 1980s (WHO, 2019). Key points of the analgesic ladder include:

• Medications are given through the most comfortable route (preferably orally).
• A stepwise approach should start with non-opioid medications with or without adjuvant medications.
• Managing mild to moderate enduring or progressive pain with opioids, with or without adjuvant medications, with or without non-opioids.
• Considering the use of more potent opioids such as morphine with or without adjuvant medications with or without non-opioids for persistent pain or pain that is increasing, notwithstanding the previous step 3 above.
• Administering analgesic pain medication used for moderate to severe chronic pain on a fixed schedule (not as needed).

This approach is 80-90 percent effective.

What are adjunctive medications? Adjunctive medications enhance the analgesic effect, reduce side effects, and assist with co-existent symptoms. Different patients will respond distinctively to different treatments regarding efficacy and side effects. Trial and error are often used in the treatment of chronic pain.

When starting therapy for chronic pain, the dose should be initiated at a low dose and titrated to obtain pain control and minimize side effects. Tolerance often develops as a patient gets used to the medication.

Classes of medications include non-opioid analgesic agents, antidepressants, muscle relaxants, antiepileptic medications, topical agents, and opioids. Some get effective relief from one medication, but some get better pain relief from a combination of medications that work on different pathways. Unfortunately, research is sparse on combination medication in the management of pain.

While the patient is under treatment for the pain, the clinician should assess and document the effect on functional status, pain control, the intensity of pain, and side effects.

Analgesic agents are often given orally as this is convenient and allows a relatively steady blood concentration of the drug. Pain medication may be administered on an as-needed basis for episodic pain or given routinely for chronic pain. The use of routine, around-the-clock medication sustains a steady state in the blood and offers better pain relief for those with persistent pain.

Considering all co-morbidities is an important step in the management of pain. For example, when a patient suffers from chronic pain and depression, some medications may help effectively manage both conditions (for example, duloxetine is approved to treat chronic musculoskeletal pain, including discomfort from osteoarthritis and chronic lower back pain depression). It is also important to establish the pathophysiology of the pain syndrome, evaluate the medication list, and consider the prescribed side effects.

The clinician should distinguish between neuropathic pain and nociceptive pain. The etiology of neuropathic pain must be established, and if the etiology is reversible, manage the underlying problem. For example, if a medication (e. g., metronidazole, nitrofurantoin, isoniazid, or many cancer agents) is the etiology of the neuropathy – stop that medication.

Medications for neuropathic pain include calcium channel alpha 2-delta ligands (gabapentin and pregabalin), tricyclic antidepressants, serotonin-norepinephrine uptake inhibitors (SNRIs), the lidocaine patch, and narcotic analgesics.

Nociceptive pain is typically treated with non-narcotic and opioid analgesia. Acetaminophen is often used as a first-line agent in the management of nociceptive pain. Doses can be hepatotoxic at doses greater than three to four grams daily. Non-steroidal anti-inflammatory agents (NSAIDs), which are more effective than acetaminophen, are used as alternative options to acetaminophen and are indicated for mild to moderate pain, while some for severe pain. Like acetaminophen, they act synergistically with opioids.

In 1970, section 812 of the Controlled Substance Act was enacted, which lists controlled substances. The list describes basic or parent chemicals that may be classified as controlled substances. The Controlled Substance Act divides the drugs and other substances into five schedules, updated annually here.

Schedule I controlled substances have no accepted medical use in the United States, have a high potential for abuse, and lack safety data. Substances in this class include heroin, marijuana, 3,4-methylenedioxymethamphetamine ("Ecstasy"), and lysergic acid diethylamide (LSD).

Schedule II and IIN substances may potentially be abused and may lead to severe physical or psychological dependence. Schedule II narcotics include oxycodone (OxyContin, Percocet), hydrocodone (Vicodin, Zohydro ER), fentanyl (Sublimaze, Duragesic), methadone (Dolophine), hydromorphone (Dilaudid), morphine, opium, and codeine. Schedule IIN stimulants include methylphenidate (Ritalin) and amphetamine (Dexedrine, Adderall).

Schedule III or IIIN substances have less abuse potential than those substances that are Schedule I or II. They are at high risk for psychological dependence and low to moderate risk of physical dependence. Examples of medications in this class include buprenorphine (Suboxone) and products with less than 90 milligrams of codeine per dosage unit, such as Tylenol with Codeine. Medications considered Schedule IIIN include: anabolic steroids such as Depo-Testosterone and ketamine.

Schedule IV controlled substances have a lower potential for abuse when compared to Schedule III controlled substances. Examples of medications in this class include benzodiazepines, midazolam (Versed), modafinil (Provigil), tramadol (Ultram), and carisoprodol (Soma).

Schedule V controlled substances have a low abuse potential relative to Schedule IV substances. Examples of medications in this class include cough preparations containing less than 200 milligrams of codeine per 100 milliliters or 100 grams, such as Robitussin AC, lacosamide (Vimpat), and pregabalin (Lyrica).

The Controlled Substance Act regulates five medications: anabolic steroids, depressants, hallucinogens, narcotics, and stimulants. Each class has different properties, and substances in each class typically produce similar effects. Most controlled substances alter mood, feeling, or thought due to their effect on the central nervous system. Medications that produce euphoria are more likely to be abused, but medications may be abused to aid in sleep, reduce pain, reduce anxiety, reduce depression, and improve energy.

The Center for Disease Control (CDC) and Prevention developed guidelines for prescribing opioids for chronic pain. It offers guidance to the clinician regarding the safe and effective prescribing of opioids and assistance in managing chronic pain. This guideline focuses on patients over 18 who are seen in the primary care setting. The guideline focuses on chronic pain that does not involve end-of-life care, active cancer treatment, or palliative care.

This guideline is meant to help primary care clinicians deal with the 11 percent of adult patients that deal with daily pain (Dowell et al., 2016). It was developed because primary care clinicians reported insufficient training in opioid prescribing and concern regarding addiction. The guideline focuses on three main areas (Dowell et al., 2016):

1. Determining when to start/continue opioids for chronic pain includes looking at treatment goals, discussing the benefits/risks of therapy, and the utilization of not only opioid therapy but nonopioid therapy and nonpharmacological therapy
2. The selection, duration, dosage, follow-up, and discontinuation of opioids
3. Assessing the risk and addressing the harms of opioid use includes using methods to evaluate and reduce risks. It discusses the use of urine drug testing, the prescription drug monitoring program (PDMP), treatment of opioid use disorder, and precautions regarding co-prescriptions of benzodiazepines

1. Assessment and documentation of a comprehensive history including medical history, substance abuse history, current medications including dosages, route and time, psychiatric and psychosocial history
2. Establish a physical and psychological diagnosis and medical necessity before starting or maintaining controlled substances. Those with mental illness are at higher risk for medication abuse
3. Screening for substance abuse history because substance abusers are at increased risk of misusing controlled substances
4. Establish goals in therapy regarding pain control and functional goals
5. Using prescription monitoring programs to help determine prescription use patterns and reduce abuse of medications. These are state-run databases that track controlled substance prescriptions and help find issues with overprescribing and misuse patterns
6. Use urine drug testing to identify non-compliance or aberrant drug use
7. Consider contraindications before prescribing opioids, such as acute psychiatric instability, uncontrolled suicide risk, opioid allergy, respiratory instability, history or current abuse of substances or alcohol, current use of benzodiazepines, current use of heavy doses of other central nervous system depressants, current use of other medications that have severe drug interactions or those who practice diversion of controlled substances
8. Judicious utilization of imaging tests and other evaluations as some testing may increase fear, foster activity restriction, encourage maladaptive behaviors and encourage requests for more opioids
9. A written agreement between the prescriber and patient when controlled substances are used that reduces the risk of abuse, diversion, misuse, and overuse
10. Discuss the risks and benefits of the medications
11. Obtain informed consent before prescribing controlled substances
12. In general, start opioid therapy at low doses with short-acting medications
13. Use long-acting opioids in high doses only for severe, intractable pain that cannot be adequately managed with short-acting opioids or moderate doses of long-acting opioids
14. Use caution when titrating with long-acting opioids and considering the potential for overdose and misuse
15. Consider consultation for those who require high-dose opioid therapy
16. Ensuring only one prescriber of all opioids for a given patient
17. Monitoring for and managing constipation
18. Prescribing the lowest effective dose and the smallest quantity needed based on the expected length of the symptoms
19. Review the treatment plan regularly to include any new information about the patient, their condition, and their pain and progress toward their goals
20. Keep accurate records
21. Ensure compliance with all laws and regulations related to controlled substances
22. Individualize treatment based on the patient’s prior exposure to the controlled substance, response to treatment, and adverse events
23. Monitoring for aberrant drug-related behaviors

When non-opioid therapy is ineffective or there is severe nociceptive pain, opioid therapy may be considered. Opioid therapy is effective in managing many chronic pain conditions, including osteoarthritis, neuropathic pain, and postherpetic neuralgia.

A position paper from the American Academy of Neurology suggested that there is evidence for good short-term pain relief with opioids. However, no good evidence exists for continuing pain relief or improved function for extended periods without sustaining a serious risk of dependence, overdose, or addiction (Stinchcomb, 2018).

In chronic back pain, opioids do not improve pain scores more than non-opioid therapy. Opioid therapy is often used to manage neuropathic pain but is thought to be the second line to antidepressants and anticonvulsants.

NSAIDs present risks, and some patients are unable to tolerate NSAIDs due to side effects and co-morbid conditions. The risk associated with NSAIDs is one reason many clinicians choose an opioid to manage pain.

When opioids are used for chronic pain, treatment is typically started with short-acting medication, and the medication is titrated upwards to control pain while side effects are monitored. After determining the dose of the medication required to provide adequate pain relief with minimal side effects, the medication can be converted to a sustained release form with administration once or twice a day. When long-acting medication is in use, breakthrough medication can be given.

In recent times, opioid therapy has become more commonly used; in the past, it was only used for severe acute pain and cancer pain. It is now the most common medication in the United States.

A comprehensive medical history is the first step in the workup of an individual experiencing pain. Many healthcare providers believe pain is the fifth vital sign. A comprehensive medical history should include an evaluation of the patient’s medical and surgical history and a medication list review.

The comprehensive medical history must include a detailed description of the pain. The pneumonic: OLD CARTS has been used to evaluate pain.

• Onset:
  • When did the pain start?
  • Describe the mechanism of injury?
  • What was the causative factor?
• Location
  • Where is the pain?
• Duration
  • How long has the pain persisted?
  • Is the pain intermittent or constant?
• Characteristics
  • Describe the pain (dull, sharp, lancing, burning, throbbing, or squeezing).
• Associated symptoms
  • Are there other symptoms associated with the pain, such as spasms, reduced range of motion, edema, diaphoresis, weakness, or changes in skin, nails, or hair?
• Radiation
  • Does the pain radiate? If so, where?
• Temporal
  • What are the aggravating/causative factors?
  • What factors alleviate or diminish pain?
• Severity
  • Rate the severity of the pain?

Document the impact the pain has on the patient’s quality of life. Ask:

• Does the pain affect activities of daily living or instrumental activities of daily living?
• Does the pain limit exercise or activity?
• Does the pain affect your mood?
• Is there a reduction in your energy?
• Does the pain lead to a strain on relationships?
• Does the pain affect your sleep?
• Does the pain lead to mood alterations?
• Does the pain affect your social life?

Measuring pain intensity is often done on scales to compare the intensity of the patient’s pain at different points in time, not to compare one person’s pain to another. The use of pain scales helps the prescriber assess the effectiveness of pain treatment.

The best scales are brief, valid, require minimal training, and use both behavioral and descriptive measures of pain. A scale commonly used rates pain from 0 to 10. Another scale allows the patient to rate their pain as no, mild, moderate, severe, or unbearable. Other scales have the patient select the degree of pain on a pictorial scale with facial expressions. Pain maps are helpful in individuals who have a difficult time speaking. Pain maps have a front and rear view of the body on a piece of paper, and the patient marks the pain's location and rates the pain's severity.

Basic pain assessment is simple and must be performed regularly. Action needs to be planned based on the patient’s report of pain.

It makes no difference whether patients are in the hospital, a long-term care facility, a behavioral health facility, an outpatient clinic, or being cared for by a home care agency. No matter where patients are, the intensity of pain should be assessed and documented:

1. during the initial evaluation of the patient
2. after any known pain-producing procedure
3. with each new report of pain
4. at regular intervals when vital signs are taken
5. at suitable intervals after pharmacologic (45-60 minutes after the oral intervention; 15-30 minutes after parenteral intervention) or non-pharmacologic intervention to evaluate the current pain treatment plan.

Measuring the severity of pain is often done on scales.  Pain scales are meant to compare the intensity of the patient’s pain at different points, not to compare one person’s pain to another. The use of pain scales assists the healthcare provider in determining the effectiveness of pain treatment.

The best scales are brief, valid, require minimal training to use, and use both behavioral and descriptive measures of pain. When selecting a scale, it is important to consider which scale would work best for the individual patient.

A "0 to 10" numerical scale is the most widely used measure to assess pain intensity. When using the Numerical Rating Scale (NRS), patients are asked to rate their pain from 0 to 10, with "0" equaling no pain and "10" equals the worst possible pain they can imagine. 

Another scale allows the patient to rate their pain as “no pain, mild pain, moderate pain, severe pain, or unbearable pain." Pain maps can be used for those who have a difficult time speaking. A pain map has a front and rear view of the body on a piece of paper. The patient draws on the location of the pain and may rate the severity of the pain.

Since we have no instrument to objectively measure pain intensity in the same way that a sphygmomanometer measures blood pressure, the only valid measure of pain is the patient´s self-report (a subjective measure). Sometimes healthcare providers may believe they are the best judges of a person´s pain; however, many studies demonstrate that healthcare providers either over or underestimate a patient´s pain.

For patients who are NOT cognitively impaired but cannot respond verbally or rate their pain numerically, faces scales with happy faces representing no pain (0) and progressively sadder faces representing increasing pain intensity may be used. The patient is asked to choose the face that best depicts their feelings.

Once Current Pain Intensity is Assessed,then What?

Besides current pain intensity, the complete pain assessment includes the following:

1. Location of pain.
2. Pain intensity for the worst pain, the best pain gets, and the acceptable pain level. Satisfactory pain relief is a level of pain that may be noticeable but not bothersome.
3. Character or quality of pain. The words used by the patient to describe pain may enhance the understanding of the etiology of the pain and provide usefulness in selecting interventions to manage it. For example, somatic (musculoskeletal) pain is usually localized and described as dull, achy, and sore. Visceral pain is usually poorly localized and described as cramping or squeezing. Descriptors of burning, shooting, or knife-like Descriptors indicate neuropathic (nerve) pain. (Refer to Table 1).
4. Onset, duration, variations, and pattern (is the pain better or worse at certain times, certain hours?).
5. Alleviating factors – what makes the pain better?
6. Aggravating factors – what makes the pain worse?
7. Impact of pain on quality of life and daily functioning. How does pain affect sleeping, relationships with others, mood, emotions, or concentration.

It is also important to document pain's impact on quality of life.  Key questions to ask include:

• Does pain affect sleep?
• Does the pain lead to mood alterations?
• Does the pain lead to reduced energy?
• Does the pain reduce the patient’s ability to participate in activities and socialize?
• Does the pain affect relationships?
• Does the pain limit or affect activity or exercise?
• Can the patient participate in daily living activities such as bathing, dressing, feeding, toileting, or brushing their teeth?
• Does the pain impact instrumental activities of daily living (IADL), such as the use of the telephone, doing the laundry, handling of medications, or ability to handle the finances? The IADL is less important in the nursing home setting as many of the IADLs are impaired at baseline, which is why there was nursing home placement.

Understanding how pain was treated in the past for the patient will help the clinician treat the current pain. Reviewing past medical records will help the pain management team evaluate the condition. Reviewing all previous history, diagnostic testing, treatment options, and efficacy will help the team make an accurate diagnosis and manage pain appropriately. Certain treatment modalities, including specific medications, are often more effective in one individual when compared to another based on individual genetic variations.

Having a full understanding of all medical and surgical conditions can be very helpful in assuring proper pain management. A chronic disease may have a strong impact on the management of pain. Chronic kidney disease, for example, can affect how drugs are excreted. Using non-steroidal anti-inflammatory medications can lead to kidney failure in those with chronic kidney disease.

A mental health evaluation can help the clinician understand the best pain management. Mood or cognitive disorders can affect the way the pain is managed. Chronic pain will likely never be adequately managed if mental illness is not appropriately identified and managed. A history of drug abuse is important to ascertain, as this could profoundly affect how chronic pain is treated.

Personal characteristics may have a strong effect on pain management. Factors influencing pain include race, age, culture, religion, sex, or language.

A review of the patient’s perception of pain is important.  Why does the patient believe they have persistent pain? Does the patient feel there was adequate workup done on their condition? What does the patient expect out of treatment, and what are the patient’s goals? In addition, psychological factors that contribute to the pain should be assessed. These questions will help assess the patient’s expectations. Patients need to have realistic expectations about pain management.

A complete physical exam is an essential part of the management of pain. It is important to have a baseline examination, so subsequent evaluations will allow the health care team to determine progress in pain management and functional capacity.

The physical exam should include a detailed neurological exam, including the patient’s ambulation ability. While exams may include general observations, exams may be focused on the presenting condition. Observing hygiene, posture, dress, and appearance is essential. Those with severe pain will often have poor hygiene, unkempt dress, and appear to be in pain. Observe for any splinting, which may suggest a painful body part. Assessing skin and joints for redness, swelling, or deformities helps determine the location and etiology of pain. An abdominal exam for any tenderness or distention should be done. In addition, checking joints for their range of motion is an important part of the physical exam in chronic pain. The exam should evaluate functional capacity, strength, endurance, and any pain-related limitations.

Ongoing monitoring of the efficacy and effectiveness of the implemented plan is essential. Utilizing similar assessment tools, the healthcare provider can document the effectiveness of the pain management plan on the patient, which will include any improvement in quality of life.

When taking a patient history document, the opioid currently prescribed, its dose, frequency, and duration of use. It is essential to query the state prescription drug monitoring program to confirm the patient’s report of prescription use. Also, it is important to contact past providers to obtain medical records.

A history of illegal substance use, alcohol use, tobacco use, prescription drugs use, psychiatric history, family history of substance abuse and psychiatric disorders, history of sexual abuse, legal history, behavioral problems, employment history, marital history, social network, and cultural background should be assessed in all patients who are being considered for controlled substances. History of substance abuse does not prohibit treatment with opioids but may necessitate more intensive monitoring or referral to an addiction specialist.

Multiple tools are available to evaluate opioid risk. The Opioid Risk Tool is a tool that is used in primary care to screen adults for the risk of aberrant behaviors when prescribed opioids for chronic pain.  It is a copyrighted tool, encompasses five questions, and takes about one minute to use. It classifies a patient as having a low, moderate, or high risk of abusing opioids.  Those who are high risk have a high likelihood of aberrant drug-related behavior. The five questions include family and personal history of substance abuse (alcohol, prescription drugs or illegal drugs), age (risk is 16-45 years old), psychological disease, and history of preadolescence sexual abuse. The questions are scored with different points assigned for each question, which is variable between men and women, and a total score is tallied. The patient is placed at low, moderate, or high risk.

Since pain is a subjective experience, we measure its existence and intensity by the patient’s self-report. Unfortunately, adult patients with cognitive/expressive deficits or who are intubated, sedated, or unconscious may not be able to provide a self-report. Individuals who cannot communicate their pain remain a challenge and are at even greater risk for inadequate pain control.

When patients cannot self-report, other measures must be used to detect pain. Even if they cannot speak for themselves, these patients have the right to pain assessment and management. Valid and reliable methods to assess pain in nonverbal patients are needed. The American Society for Pain Management recommends the following multifaceted approach for detecting pain in this population.

• Use the Hierarchy of Importance of Measures of Pain Intensity for Nonverbal Patients.
  • Self-report of pain is the most reliable way to assess pain.
    • Although self-report may be possible with mild to moderate cognitive impairment, as dementia progresses, the ability to self-report decreases and eventually becomes impossible. However, even if patients cannot communicate the experience of pain, they still experience pain sensation.
    • Obtaining a report of pain from a critically ill patient may be hampered by such conditions as delirium, decreased level of consciousness, presence of an endotracheal tube, sedatives, and neuromuscular blocking agents, for example. In these situations, the patient’s ability to self-report may wax and wane; therefore, a serial assessment of the ability to self-report should be conducted.
  • Search for Potential Causes of Pain.
    • Assume pain is present and intervene with common problems or procedures known to cause pain (e.g., surgery, wound care, positioning), even without behavioral indicators of pain.
    • Rule out or treat other problems that may cause discomfort (e.g., infection, constipation, urinary retention).
    • Consider chronic pain causes that may have been present before (e.g., history of arthritis or low back pain).
  • Observe patient behaviors – a good approach only when self-report is absent. The American Geriatrics Society identifies the following six main types of pain behaviors:
    • facial expressions (e.g., grimacing)
    • verbalizations or vocalizations (e.g., moaning)
    • body movements like tense body posture
    • changes in interpersonal interactions (e.g., aggression or resisting care)
    • changes in activity patterns (e.g., refusing food or increased wandering)
    • mental status changes like crying or increased confusion
  • Encourage proxy pain rating by family members or caregivers who know the patient when patients cannot provide self-reports of pain. Inquire about behaviors that may indicate pain or whether preexisting conditions that may cause pain, such as arthritis, are present.
  • Attempt an analgesic trial with procedures or conditions likely to cause pain or when pain behaviors continue after attention to basic needs and comfort measures. Make appropriate adjustments such as increases in dose or addition of other analgesics if behaviors indicative of pain persist or additional potentially painful procedures occur.
• Establish a Procedure for Pain Assessment.
  • When patients cannot self-report pain, other, less reliable measures must be used to identify its existence. These assessment measures (described above) form a hierarchy of probable importance. Health care facilities should institute a procedure for using this hierarchy of assessment techniques as a template for the initial assessment and treatment procedure.
• Use Behavioral Pain Assessment Tools as Appropriate.
  • The number of studies addressing pain assessment in nonverbal adults who cannot provide a self-report has recently increased. Further study is required to demonstrate their reliability, validity, and usefulness in the clinical setting. When utilizing behavioral pain assessment tools, one must keep in mind the following considerations:
    • Scores obtained when utilizing behavioral pain assessment tools are NOT equivalent to self-reported intensity ratings and should never be documented. Only self-reported intensity ratings may be documented as the “5th Vital Sign.”
    • Pain behaviors may not indicate pain, but another source of distress, such as emotional distress.
    • It is best to observe a patient during care activities when pain behavior is more likely, rather than at rest.
    • Behavioral assessment tools may help identify the presence of pain. They also can be used to evaluate attempts to relieve pain by observing for a decrease in pain behaviors following an intervention.
      • At least 14 behavioral assessment tools have been developed to assess for pain in nonverbal patients with dementia. These tools are in varying stages of development and validation. When selecting a tool, choose one that has been researched for reliability and validity in a similar clinical setting. Behavioral assessment tools for the cognitively impaired are of two types: pain behavior scales and pain behavior checklists.
    • Pain behavior scales are scored by identifying the degree of observed behavior. This score is not the same as a pain intensity score. An example of a pain behavior scale is the Pain Assessment in Advanced Dementia Scale (PAINAD). It evaluates and scores five categories of behavior: breathing, negative vocalization, facial expression, body language, and consolability. Each category may receive a score ranging from 0 to 2. Any positive score may indicate that pain is present, and the score can be used to evaluate the intervention but cannot be interpreted to mean pain intensity. For a pain behavior scale to be used, the patient needs to be able to respond in all categories of behavior. For example, the PAINAD should not be used with a patient with quadriplegia since body language could not be scored.
    • Behavior checklists differ from pain behavior scales. They do not evaluate the degree of observed behavior, just its presence or absence, and do not require a patient to demonstrate all of the specified behaviors. An example of a pain behavior checklist is the Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC). This checklist evaluates 60 behaviors such as restlessness, agitation, decreased activity, and appetite changes. The total number of behaviors that a patient exhibits cannot be equated with a pain intensity score. A patient who scores 5 out of 60 behaviors does not necessarily have less pain than a patient who scores 10 out of 60. In an individual patient, though, a change in the total number of behaviors may suggest more or less pain and can be used to evaluate response to interventions.
      • Tools developed to assess pain with mechanically ventilated or unconscious patients is fewer in number. One such tool – the Adult Nonverbal Pain Scale (NVPS) – was patterned after the Faces, Legs, Activity, Cry, Consolability Observation Tool (FLACC) used to assess pain in infants and children. When tools are adapted and used in different settings, they must be tested for reliability and validity in the new patient population. The NVPS was tested in the Strong Memorial Hospital, Rochester, New York burn trauma unit. After initial testing, a further revision was made to include a respiratory component with ventilator compliance. This revised scale, which scores the categories of facial expression, activity, guarding, physiology (vital signs), and compliance with ventilator, is currently being implemented in several healthcare institutions while undergoing further testing.
    • Minimize Emphasis on Physiologic Indicators
      • Research does not support the use of vital sign changes for identifying pain. The absence of an increase in blood pressure, respiratory rate, or heart rate does not indicate the absence of pain.
    • Reassess and Document
      • Just as with patients who self-report pain, reassessment of pain with non-verbal patients must occur after the intervention and regularly over time. Reassessment should occur utilizing the same initial behavioral pain assessment tool and observing for changes in those behaviors with effective treatment.

• What are the patient’s treatment goals?
• Why does the patient think they have persistent pain?
• Does the patient feel there was enough workup done on their condition?

Assess the psychological factors that contribute to the pain. Patients need to have reasonable expectations about the pain and its management.

All patients with chronic pain should have a complete physical examination. It is important to have a baseline physical examination, so ensuing evaluations will permit the healthcare team to establish progress in the pain management plan.

Other key features assessed before treatment include:

• Current and past treatments
• History of substance abuse
• Underlying conditions

The physical examination should include:

• Hygiene, dress, and appearance - those in severe pain will often have poor hygiene and be unkempt
• A detailed neurological examination
• Assessment of skin and joints for redness, swelling or deformities, which may help determine the location and etiology of pain
• Assessing for joint range of motion
• Inspecting for any splinting
• Looking for signs of chronic liver disease
• Performing an abdominal examination for any tenderness, mass or distention
• Performing a skin examination that looks for any track marks
• Evaluating for any signs of acute intoxication, withdrawal signs, or over sedation
• Assess for infection, particularly among individuals administering by self-injection
• Looking for a productive cough, as there is a high rate of tuberculosis and community-acquired pneumonia
• Assessing for respiratory problems from smoking or snorting substances
• Evaluation for a sudden exacerbation of a previously well-controlled disease state, such as hypertension or diabetes
• Looking for unexplained weight loss
• Assessing for sleep disturbances

An important role of the practitioner is prescribing controlled substances. Establishing treatment goals is an essential aspect of opioid therapy. Goals should focus on pain relief and improvement in functioning. Prescribing controlled substances is laced with risks, and the prescriber needs to realize that a primary goal of prescribing opioids should be to maintain patient safety. A responsible prescriber should follow multiple steps to ensure their patients' safe and effective care.

Therapeutic goals should be established regarding pain control and improvement in function. Pain goals typically involve a reduction in pain, not necessarily an elimination of pain. Functional goals may include improved sleeping, increased ability to perform activities of daily living, progress in physical therapy, increased social interactions, returning to work, and improved regular exercise. In addition, goals should also include limiting side effects and minimizing adverse drug events.

Discontinuing chronic controlled substance therapy in those who repeatedly engage in aberrant drug-related behaviors, do not progress toward established goals, or experience significant side effects. Patients who have been taking the opioid for an extended time should have the medication tapered slowly. A 10% taper per week will minimize the symptoms of withdrawal. Some recommend a faster taper, such as 20 – 50% per week for those who are not addicted (VA, 2019).

Opioid overdose is a continuing public health crisis, and states have taken steps to reduce the overuse of these medications in hopes of reducing overdose and other negative outcomes. Organizations, including the CDC, have made recommendations regarding the amount or duration of opioids that should be prescribed.

The goal of pain management should be tolerable pain levels with good function. Here are some guidelines for how long medications are prescribed to those with acute pain (Brummett et al., 2017).

• Mild pain syndrome should generally be treated with acetaminophen or nonsteroidal anti-inflammatories and nonpharmacological therapy.
• For individuals who suffer from moderate pain, such as after minimally invasive surgery, simple fractures, and soft tissue surgery, a 3 to 5-day course of oxycodone may be appropriate.
• For individuals who suffer from severe pain such as a major surgical procedure, total joint replacement, or compound fracture, higher doses of opioids may be used for up to one week.
• One study looked at the number of pills prescribed after procedures for 80% of patients and showed that those after laparoscopic cholecystectomy, laparoscopic inguinal hernia repair, or an open inguinal hernia repair required 15 pills of oxycodone 5 mg. In contrast, partial mastectomy patients required five pills.
• Predicting the number of medications patients will need after discharge from their procedure can be ascertained from the number of pills the patient took the day before discharge. One study showed that patients who took 1 to 3 pills on the day before discharge from the hospital took a mean of 7.6 pills after discharge from the hospital. Individuals who took four pills on the day before discharge took 21.2 pills after being released from the hospital (Hill et al., 2018).
• Recent data suggests that over the last few years, the strength of the dosing is not decreasing, and the number of prescribed days is increasing.

While there are many opioids, morphine is considered by many as a standard comparator for other drugs. Morphine can be given orally, rectally, intravenously, subcutaneously, or intramuscularly.

Morphine is used for moderate to severe acute pain and severe chronic pain. It comes in multiple formulations. For acute pain, it is dosed at 10-30 mg every 4 hours for those who are opioid naïve. It is available as a tablet, suppository, and parenteral solution. The immediate-release tablet is dosed with 15-30 mg every 4 hours, and the oral solution is dosed with 10-20 mg every 4 hours as needed. It can also be given rectally and is often dosed 10-20 mg every 4 hours as needed. Morphine also comes in a controlled release form, a sustained-release form, and an extended-release form.

Longer-acting formulations include: Arymo ER and MorphaBond ER are extended-release tablets. The initial dose is 15 mg every 8 to 12 hours in those not opioid-tolerant or as the first opioid used. It can be titrated every 1-2 days.

Do not give Kadian for initial opioid analgesia. For non-opioid tolerant patients, 10-30 mg daily is recommended. Higher doses are indicted for opioid-tolerant patients. Titration may be done every 1- 2 days. Converting from other forms of morphine may be given once or twice a day.

MS Contin is started at 15 mg every 8-12 hours, with the dosage adjusted every 1-2 days.

The extended-release forms of morphine are not interchangeable. Changing from one medication to another should be done only by those experienced in how to do this. Extreme caution should be used when using a highly concentrated solution so overdoses do not occur.

Side effects of morphine are similar to other opioid analgesics and include dry mouth, constipation, bradycardia, hypotension, nausea, drowsiness, dizziness, mental status changes, fever, itching, weakness, hypoxia, and urinary retention.

Morphine should not be used in those with a hypersensitivity to morphine, those with toxin-mediated diarrheal disease, or those with severe/acute asthma, paralytic ileus, or severe respiratory depression. The extended-release form should not be used in those with GI obstruction.

Drug interactions commonly seen with morphine include:

• Amphetamines may increase the effect of morphine
• Anticholinergic agents may increase the side effects of morphine (constipation and urinary retention)
• Antipsychotic agents with morphine may reduce blood pressure
• Nasal azelastine (Astelin) with morphine enhances the central nervous system (CNS) depression effect
• Clopidogrel therapeutic efficacy may be reduced with morphine
• Diuretics' side effects may be increased with morphine
• Hydrocodone enhances CNS depression
• Hydroxyzine enhances CNS depression
• MAO Inhibitors enhance the side effects of morphine
• Selective serotonin reuptake inhibitors with morphine enhance the serotonergic effect and CNS depression
• Zolpidem enhances the CNS depression

Morphine is pregnancy category C. It does enter breast milk, and it is not recommended in those who are breastfeeding.

Fentanyl can be given as an injection, transdermal patch (Duragesic), an oral transmucosal lozenge (Actiq), a sublingual tablet (Abstral), a sublingual spray (Subsys), a buccal tablet (Fentora), a buccal film (Onsolis) and a nasal spray (Lazanda). The transdermal patch is used in opioid-tolerant patients with moderate to severe pain and is often started at 25 mcg per hour and changed every 72 hours.

Fentanyl can be used for multiple reasons, including premedication for surgery, general anesthesia, as an adjunct to general and regional anesthesia, and chronic pain management. The transdermal patch is for around-the-clock pain management in those with severe chronic pain. Fentanyl transmucosal and intranasal is indicated for cancer pain.

The patch form should not be exposed to external heat, as this may increase the absorption of the medication. Exercising with the patch on has the potential to increase the absorption of fentanyl. In addition, patients with a fever may also notice an increase in the absorption of the medication. The patch should only be applied to intact skin, contains aluminum and must be removed prior to an MRI.

While no official dosage adjustment is recommended in those with renal or hepatic impairment, those with mild to moderate renal or hepatic impairment should likely have the dose reduced by 50 percent with the patch, and the use is not recommended in severe renal or hepatic impairment. Transmucosal and nasal spray have no specific recommendations for dose reduction in renal or hepatic impairment.

Common side effects of fentanyl include:

• dry mouth
• edema
• bradycardia
• dehydration
• respiratory depression
• shortness of breath
• diaphoresis
• nausea/vomiting
• constipation
• application site erythema (patch)
• weakness
• muscle rigidity
• mental status changes
• headache
• sedation
• CNS depression

As with most opioids, contraindications include hypersensitivity, toxin-mediated diarrheal disease, and paralytic ileus. It should not be used for short-term pain or post-operative pain and should not be used for those who have severe respiratory disease.

Like many medications, there are multiple potential interactions. Some more common interactions include:

• Alcohol may enhance CNS depression
• Beta-agonists may decrease the serum concentration of fentanyl
• Amphetamines may enhance the effects of fentanyl
• Anticholinergic medications, along with fentanyl, increase the risk of urinary retention and constipation
• Antipsychotic agents may increase the risk of low blood pressure
• Azelastine nasal spray may enhance CNS depression
• Beta-blockers with fentanyl enhance bradycardia
• Calcium channel blockers may enhance hypotension or bradycardia
• Hydrocodone may enhance CNS depression
• Selective serotonin reuptake inhibitors with fentanyl may enhance serotonergic properties
• Zolpidem effects may be enhanced

Fentanyl is pregnancy category C. It does enter the breast milk and is not recommended in the breastfeeding mother.

Oxycodone is a schedule II controlled substance and is available in multiple forms. Immediate release (Roxicodone) is dosed 5-30 mg every 4-6 hours (lower range for opioid-naive patients). There is also an abuse-deterrent tablet (Oxceta) that comes as a 5 mg and 7.5 mg tablet.

The controlled release tablet (OxyContin) is indicated for those requiring around-the-clock pain control. It is dosed 10 mg every 12 hours to start and titrated carefully. When changing from immediate to extended-release, start the extended-release at half of the daily dose of oxycodone every 12 hours. When changing from transdermal fentanyl to extended-release oxycodone, substitute 10 mg of extended-release oxycodone every 12 hours for each 25 mcg/hour of fentanyl. The oxycodone should be started 18 hours after removing the transdermal fentanyl patch. It also comes as an oral concentrate and oral solution.

Oxycodone is often combined with other analgesic agents such as acetaminophen (e.g., Percocet, Roxicet, Tylox), aspirin (e.g., Percodan, Endodan, Oxycodan) and ibuprofen (Combunox).

Those with a creatinine clearance of less than 60 mL/min should have the dose adjusted as serum concentration of oxycodone will increase in renal insufficiency. Those with hepatic impairment should have doses reduced; with the extended-release formulation, the starting dose should be lowered one-third to one-half and slowly titrated up to affect.

Side effects include:

• Drowsiness
• Dizziness
• Itching
• Constipation
• Nausea
• Vomiting
• Less common side effects include dry mouth, headache, abnormal dreaming, blood pressure changes, diaphoresis, weakness, and fever

Oxycodone is contraindicated in those with paralytic ileus, significant respiratory depression, hypercarbia, acute or severe bronchial asthma, and GI obstruction. Caution should be used in those with biliary tract impairment, such as acute pancreatitis, as it may lead to constriction of the sphincter of Oddi. It may lead to an elevation of intracranial pressure (ICP) and should be used carefully for those with intracranial lesions, elevated ICP, or a head injury.

Extended-release tablets may be lodged into the GI tract, including the throat, in those with swallowing issues. It may also lead to intestinal obstruction or diverticulitis.

Frequent drug interactions with oxycodone:

• Alcohol may enhance CNS depression
• Amphetamines may increase the effect of oxycodone
• Anticholinergic agents may increase the side effects of oxycodone (constipation and urinary retention)
• Antipsychotic agents with oxycodone may reduce blood pressure
• Nasal azelastine (Astelin) enhances CNS depression
• Diuretics' side effects may be increased with oxycodone
• Hydrocodone enhances CNS depression
• Hydroxyzine enhances CNS depression
• MAO inhibitors enhance the side effects of oxycodone
• Mirtazapine may enhance CNS depression
• Rifampin may decrease the serum concentration of oxycodone
• Selective serotonin reuptake inhibitors with oxycodone enhance the serotonergic effect and CNS depression
• Zolpidem enhances the CNS depression

Oxycodone is pregnancy category B and D if used for an extended time or near term. It does enter the breast milk and is not recommended in those who are breastfeeding.

Hydrocodone, classified as a Schedule II Controlled Substance in October of 2014, is available as a combination pill with non-narcotic analgesic (e.g., Lorcet, Lortab, Norco, and Vicodin) and by itself in an extended-release form. The combination pill has a short-acting version of hydrocodone and is dosed with 2.5 to 10 mg of hydrocodone every 4-6 hours as needed for moderate to severe pain.

Hydrocodone extended-release (Zohydro ER) is typically dosed 10 mg every 12 hours in treatment-naive patients. It is used for severe pain requiring around-the-clock dosing of hydrocodone. The dose may be increased every 3-7 days in 10 mg increments. Those with severe hepatic impairment should start at the lowest dose and titrate up slowly while monitoring for side effects. Caution should be used with renal impairment as plasma concentration may rise.

Side effects include:

• Constipation
• Nausea
• Vomiting
• Dry mouth
• Drowsiness
• Headache
• Dizziness
• Pruritus

Contraindications to hydrocodone include paralytic ileus, severe asthma, severe respiratory depression, and hypercarbia.

Drug interactions:

• Alcohol may enhance CNS depression
• Amphetamines may increase the effect of hydrocodone
• Anticholinergic agents may increase the side effects of hydrocodone (constipation and urinary retention)
• Nasal azelastine (Astelin) enhances the CNS depression
• Diuretics' side effects may be increased with hydrocodone
• MAO inhibitors enhance the side effects of hydrocodone
• Selective serotonin reuptake inhibitors with hydrocodone enhance the serotonergic effect and CNS depression
• Zolpidem enhances the CNS depression

Hydrocodone is pregnancy category C. The extended-release form minimally enters the breast milk and should be used cautiously in breastfeeding. The combination pill has been shown to enter breast milk, and its use is not recommended.

Tramadol is a Schedule IV of the Controlled Substance Act. It is indicated for moderate-to-severe pain, and the immediate release form is dosed at 50-100 mg every 4-6 hours for a maximum of 400 mg a day.

Tramadol is also indicated for chronic moderate-to-severe pain. For those who do not need a rapid onset of pain relief or are affected by side effects, it may be dosed at 25 mg/day and titrated up every three days to 50-100 mg every 4-6 hours to a maximum of 400 mg a day.

Tramadol also comes in an extended-release form, ConZip, and Ultram ER, which is dosed 100 mg once a day and may be titrated by 100 mg every five days to a maximum dose of 300 mg a day.

When prescribing tramadol to older adults, use the lower end of the dosage range and titrate slowly. In those over 75 years old, 300 mg a day should not be exceeded and utilize extreme caution with the extended-release form.

In those with a creatinine clearance less than 30 mL/min, only the immediate release formulation should be used with doses of 25-100 mg split every 12 hours (maximum 200 mg a day). In those with severe liver impairment, the immediate release form should be given at 50 mg every 12 hours.

Side effects include:

• Flushing
• Dizziness
• Constipation
• Nausea
• Vomiting
• Dyspepsia
• Itching
• Headache
• Somnolence
• Insomnia
• Weakness
• Less common side effects include:
  • orthostatic hypotension
  • mental status changes
  • euphoria
  • rash
  • hot flashes
  • diarrhea
  • dry mouth
  • anorexia
  • joint pain
  • blurred vision
  • sweating

Patients may experience withdrawal symptoms from tramadol, including nausea, diarrhea, anxiety, pain, sweating, tremor, and rigors. Extended use of tramadol may lead to dependence, and these medications should be tapered slowly to reduce the risk of withdrawal symptoms.

Tramadol is contraindicated in those hypersensitive to the agent and those with severe liver or kidney impairment. The extended-release tablet should not be used with psychotropic drugs, opioids, hypnotics, acute intoxication with alcohol or centrally acting analgesics, and the extended-release capsule formulation should not be used in those with severe respiratory depression, severe asthma or hypercapnia.

Tramadol has been shown to increase the risk of seizures. This risk is increased in those who take serotonin reuptake inhibitors, tricyclic antidepressants, neuroleptics, other opioids, or drugs that lower the seizure threshold. The risk may also be increased in those with seizures or who are at risk for seizures, such as those with a CNS infection, cancer, history of head trauma, or while patients are going through drug or alcohol withdrawal.

Caution should be used in those with respiratory disease as those with the significant disease may be at increased risk for respiratory depression.

Drug interactions:

• Alcohol may enhance CNS depression
• Amphetamines may increase the effect of tramadol
• Anticholinergic agents may increase the side effects of tramadol (constipation and urinary retention)
• Antiemetics may reduce the effects of tramadol
• Antipsychotics and tramadol may result in reduced blood pressure, increased risk of the neuroleptic malignant syndrome and increased risk of serotonin syndrome
• Nasal azelastine (Astelin) enhances CNS depression
• Carbamazepine with tramadol may enhance CNS depression; tramadol may reduce the therapeutic effect of carbamazepine
• Cyclobenzaprine and tramadol may increase the risk of seizures or increase the risk of serotonin syndrome
• Diuretics' side effects may be enhanced with tramadol
• Hydrocodone may enhance CNS depression
• Hydroxyzine may enhance CNS depression
• MAO inhibitors with tramadol may increase the risk of seizures or increase the risk of serotonin syndrome
• Metoclopramide with tramadol may increase the side effects of metoclopramide or increase the risk of serotonin syndrome or neuroleptic malignant syndrome
• Selective serotonin reuptake inhibitors with tramadol may increase the risk of seizures or increase the risk of serotonin syndrome
• Tricyclic antidepressants with tramadol may increase the risk of seizures or increase the risk of serotonin syndrome
• Warfarin with tramadol may affect the anticoagulant effect
• Zolpidem enhances CNS depression

Tramadol is pregnancy category C. It enters breast milk and is not recommended in lactating women.

Oxymorphone, a schedule II medication, can be given intravenously, subcutaneously, intramuscularly or orally. For acute pain, the immediate-release tablet (Opana) is used at 5-20 mg every 4-6 hours as needed for opioid naïve patients. For those with chronic severe pain, the extended-release tablet (Opana® ER) is started at 5 mg every 12 hours and can be titrated up at 5-10 mg increments every 12 hours every three to seven days. Caution should be used in those with a creatinine clearance of less than 50 mL/minute, and the medication should not be used in moderate to severe hepatic impairment. Oxymorphone is pregnancy category C, and it is unclear if it is excreted in breast milk and should be used cautiously.

Hydromorphone can be given orally, rectally, subcutaneously, intramuscularly, or intravenously. The oral medication comes in standard and extended-release forms. The standard form is used for moderate to severe pain and is often dosed 2 to 4 mg every 4-6 hours. The oral liquid is typically dosed with 2.5 to 10 mg every 3 to 6 hours. Parental and oral doses are not equivalent. The parenteral dose is five times more potent than the oral dose. The long-acting form (Exalgo) is used for opioid-tolerant patients with chronic severe pain. It is dosed 8-64 mg once a day.

Hydromorphone is pregnancy category C and is excreted in breast milk. It is not recommended for lactating women.

Methadone can be given intravenously, subcutaneously, intramuscularly, or orally. The oral dose is started in the opioid-naïve patient at 2.5 every 8-12 hours. Methadone is a high-risk drug that leads to overdose. It has a half-life of up to five days and may accumulate in the body. Methadone may also prolong the QT interval leading to cardiac arrhythmias, especially at doses higher than 120 mg daily. Methadone should be used for severe pain that has not been responsive to other agents and only by clinicians with specific training in using methadone. Methadone is also used in detoxification.

Tapentadol (Nucynta, Nucynta ER) is used for acute moderate to severe pain and starts at 50-100 mg every six hours for the immediate-release formulation. The starting dose for the extended-release tablet is 50 mg every 12 hours. For chronic pain, it is typically dosed 50-250 mg two times a day as needed. The maximum dose is 500 mg a day. This medication is not recommended for those with severe liver or renal insufficiency. It is also indicated for diabetic peripheral neuropathy.

Propoxyphene has been taken off the US market as it has been linked with fatal cardiac arrhythmias.

Meperidine is not recommended as a first-line agent for chronic pain as it is associated with high central nervous system toxicity rates.

Regular follow-up is important and should occur a minimum of every three months. When assessing the pain patient, include the five A’s: analgesia, addiction, activities of daily living, adherence, and adverse effects. Part of the follow-up should be urine drug testing to detect medication adherence and illicit and non-prescription drug use. It is critical that the clinician adequately document all interactions with patients, assessments, results of testing, and treatment plans.

Written treatment agreements should be used between prescribers and patients when controlled substances are prescribed. The agreement helps guide the conversation between the patient and the prescriber. It discusses expectations, the risks, and the monitoring that will occur to limit the complications of controlled substances.

Prescription monitoring programs are available in the majority of states, including Oregon. They provide an online database that lists all prescriptions of controlled substances dispensed to each patient by pharmacies. Ideally, the prescriber should check the database before prescribing controlled substances. A patient with an undisclosed prescription for controlled substances is prescription drug misuse.

When abuse/misuse is detected, how should the clinician respond? If it is alone, minor deviation from counseling and more intensive monitoring may be all that is needed. Tapering controlled substances to reduce the risk of withdrawal is appropriate in more severe or persistent cases of misuse. When diversion is the cause of misuse, immediate prescription removal is likely the best course. A referral to an addiction specialist is recommended if a substance abuse disorder is suspected.

How should the clinician respond when abuse or misuse is detected? If it is a singular, minor deviation, then counseling and more intensive monitoring may suffice. Tapering controlled substances to reduce the risk of withdrawal is appropriate in more severe or persistent cases of misuse. When diversion is the cause of misuse, immediate prescription removal is likely the best course. If a substance abuse disorder is suspected, recommend a referral to an addiction specialist.

• Have an upper dosing threshold. The risk of accidental overdose increases with higher doses of opioids. Risk increases at 50 MME/day. Prescribers should generally avoid doses of morphine or morphine equivalents more than 90 - 200 MME/da (Horvath et al., 2018).
• Use caution with certain medications. For example, methadone should only be used by a prescriber who is extremely comfortable with the medication. Fentanyl is another medication that requires extreme caution as there is unpredictable absorption – especially with the patch.
• With opioid use, respiratory depression is more likely in the older population and those who are cachectic or debilitated. Monitor patients at high risk more closely and do not give opioids in combination with other respiratory depressants. The dose of opioids should be started at one-third to one-half of the typical starting dose in at-risk patients. Titrate opioids carefully. Constipation is likely to occur, and a bowel regime should be prescribed when opioids are used.
• The greatest risk of opioid use is respiratory arrest and death, which is greatest when the therapy is started or the dose increases. Opioid-induced respiratory depression manifests by the reduced desire to breathe and reduced respiratory rates. The patient will be breathing shallowly, and CO₂ retention can exacerbate the sedating effects of opioids. If respiratory depression is noted, the family should call 911.
• Opioids should not be used in those with respiratory depression. Titration must occur slowly, and when changing formulations, do not overestimate the converting dosage.
• Avoid combinations of opioids and benzodiazepines when these two classes are combined, particularly if there are more than 100 mg of morphine or morphine equivalents per day. The risk of accidental overdose is high.
• Pay attention to drug-to-drug and drug-to-disease interactions.

Patient education is crucial as it will reduce the risks associated with these medications and improve pain management. Patients need education in the safe use, storage, and disposal of opioid medications. Safe use of opioids requires the patient to know about adverse events and risks of abuse, misuse, and addiction.

An overdose occurs when someone takes a higher dose than the body can tolerate leading to a significant adverse effect. Respiratory depression is the primary risk. This risk is highest in those who are not tolerant to opioids, take other respiratory depressants, have multiple health conditions, or have debilitated health or impaired respiratory function.

Medications associated with a high risk of respiratory depression are schedule II opioids. Fentanyl, a synthetic opioid pain reliever, is 50 to 100 times more potent than morphine and has been implicated in many cases of overdose death. Medications that are altered for administration also increase the risk of overdose. Snorting, injecting, inhaling, chewing, or dissolving medications that should be swallowed whole (particularly extended-release opioids) increases the risk. Other methods that may lead to overdose include rapid titration of opioids and overestimating the dose when converting from one opioid to another. Medication overdoses also occur when taken by someone it was not prescribed for, especially children. Therefore, safe storage and disposal are critical.

Patient education should include information on abuse. Many patients, who end up abusing opioid medications, usually get a valid initial prescription. Most patients who abuse medications get them either by buying or stealing from an acquaintance (most typically a friend or relative) (CDC, 2016).

Patient education should also include information on misuse. Many patients will misuse medications because they seek to improve function, have uncontrolled pain, or are using them to manage stress or mental disease. Aberrant behavior may manifest in those who are undertreated for pain. In the absence of addiction, these behaviors cease when pain is adequately controlled.

The patient's teaching must include zero tolerance for drug diversion and that it will immediately terminate the prescription with referral to a substance abuse program and possible legal action.

Patients should be taught about addiction. Addiction is a chronic disease with psychological, social, genetic, and environmental factors influencing its presentation and development. Addiction presents with the drug craving, compulsive use, impaired control, and persistent use despite harm.

Drug Take-Back Programs provide a convenient way for patients to dispose of unneeded, expired, or unused controlled substances. If no program is available, the patient must use extreme caution when disposing of controlled substances. Improper disposal may lead to environmental complications or drug diversion. Controlled substances can be mixed with cat litter or coffee grounds and then sealed in a non-leaking container.

Key points in patient education include:

• Goals of treatment.
• Alternative treatment options.
• Patients should be encouraged to read their medication guide or the package insert every time they get a new prescription.
• Teach about abuse, addiction, misuse, and diversion.
• Risks of overdose or death if the dose is not taken exactly as prescribed or if someone else takes the medication.
• Pain medications may impair breathing.
• Do not give the medication to anyone else.
• If anyone else takes the medication, contact emergency services.
• Swallow whole pills that are meant to be swallowed – do not crush, snort, chew, inhale, or take any other means other than the method prescribed.
• Maintain contact with the prescriber for monitoring and titration.
• Teach about drug-to-drug interactions. Medications that should be avoided in combination with opioids include alcohol or any medication for that the patient does not have a prescription. Medications that should only be taken after a careful review and counseling by a prescriber include sedatives, hypnotics, anxiolytics, antidepressants, and antihistamines.
• Opioids may lead to cognitive impairment and affect driving ability or safety at work, especially when operating heavy equipment.
• Opioids should be stored safely and away from family members, acquaintances, and friends.
• Medications should be locked in a drawer, cabinet, or safe so no one else will get them.
• Educate patients that giving away or selling their medications to others is illegal and dangerous.
• Patients should keep track of the number of pills, capsules, etc. - so it can be determined if any are missing.
• Do not store them in a pill reminder container.
• Teach about common side effects: sedation, drowsiness, respiratory problems, dizziness, mental status changes, nausea, vomiting, constipation, anxiety, tremors, and diaphoresis.
• Monitoring will take place in the form of pill counts, urine drug screens, and the use of the prescription drug monitoring program. Unfavorable results may lead to termination of treatment or alteration in the treatment plan.

Discontinuation of opioid therapy may be considered if problematic patterns are noticed, opioid therapy is ineffective, or goals are not being achieved. The prescriber and patient must agree upon reasons to terminate therapy before initially prescribing the medications and should be part of the initial agreement.

The clinician should have a method for addressing prescription drug misuse. Minor infractions may result in patient counseling and intensifying monitoring activities. More severe behaviors may require the clinician to discontinue prescribing controlled substances. If patients are found to be diverting prescription medication, immediate cessation of the prescriptions is appropriate. In most other cases, it is appropriate to taper the controlled substances to reduce the risk of inducing a withdrawal syndrome. When stopping the medication, the patient and the prescriber must agree to stop the medication. For patients who decide to continue treatment with another prescriber, the prescriber may consider maintaining the current dose for four weeks.

When appropriate, implement a tapering schedule to avoid withdrawal. A reduction of 10% every 7 to 14 days until the patient gets to a lower dose may be made at a 5% reduction every 2-4 weeks.

Offer Individuals who have shown aberrant behavior other non-opioid options. Patients who have engaged in criminal activity (such as diverting drugs or altering prescriptions) should be referred to a substance abuse treatment program and may be discharged from the practice.

Multiple factors are associated with a risk of overdose death. Some factors include: using four or more prescribers, using four or more pharmacies and getting more than 100 morphine equivalents per day.

When we say “opioid,” we are talking about chemicals, both natural and synthetic, that, when taken correctly, mimic the pain-dampening ability of opium. The word opioid is derived from the name opium, the concentrated juice of the poppy Papaver somniferum, which can aid in sleep, pain relief, and relaxation and from which morphine, codeine, and several other alkaloids are used as or in prescription medication is taken.

Opium, and to a greater or lesser extent, all of the “opioids,” can enter the brain, stimulating chemical receptor sites conveniently known as opioid receptors located in the brain, bowels, and spinal cord. When an opioid is present, the activated receptors slow or block pain signal transmission to the brain, slow bowel function, and in general, produce a warmly euphoric feeling in both the limbic areas of the brain that house the “reward” response and the frontal cortex which helps to mediate pleasure. An increase in natural endorphins, pain-relieving chemicals produced naturally by the body, accompanies opioid use, boosting feelings of wellbeing, and further suppressing the perception of pain. The longer opioids are used, the less and fewer endorphins are manufactured by the body, leaving natural pain-fighting abilities handicapped and at a loss to function normally.

Prescription opioids are an invaluable asset for the legitimate control of moderate to severe pain.

Yes, some practices have been successful in bringing users back from their opioid misuse and keeping others from wandering into the trap of overuse and addiction. To prevent opioid misuse, for instance, encouraging clients in some safe practices and prescribers in some positive actions are useful (Freedman, 2018; Mayo Clinic, 2018).

• Encourage clients only to take the medication and amounts prescribed
• Encourage prescribers to keep a close watch on client opioid use and pull the medication while replacing it with other pain control interventions quickly when misuse is determined (i.e., physical therapy, topical lidocaine patches, hot/cold therapy, electric pulse therapy, etc.)
• Tell clients they must not accept pain medication from others nor share their pain medication with others
• Encourage clients to return unused medication to their pharmacy or another drug take-back location as soon as they no longer need it. No “saving” medications “just-in-case.”

Be alert for signs of opioid dependence, such as (Brezing & Bisaga, 2015);

• Mental changes – new or increased depression, problems sleeping, lack of interest in people or activities, suicidal thoughts, fear of not having a ready supply of opioids, and a decrease in their everyday coping skills.
• Physical changes – constricted pupils, drowsiness, slurred speech, constipation, slowed breathing, malnutrition, and even an increase in skin and other infections.

To prevent prescription drug abuse, the clinician needs to ensure:

• Patients are assessed and reassessed
• Treatment agreements are used
• Prescription monitoring occurs
• Safe prescription methods are practiced

Patients' risk should be assessed, and contraindications should be immediately identified. Contraindications to opioid treatment include those who have erratic follow-up, suffer from current untreated addiction, or have poorly controlled mental illness. When taking a patient history, document the opioid currently prescribed, its dose, frequency, and duration of use. It is important to query the state prescription drug monitoring program (PDMP) to confirm the patient’s report of prescription use. In addition, it is important to contact past providers to obtain medical records.

Before controlled substances are prescribed, history of illegal substance use, alcohol use, tobacco use, prescription drugs use, family history of substance abuse and psychiatric disorders, history of sexual abuse, legal history, behavioral problems, employment history, marital history, social network, and cultural background should be assessed. History of substance abuse does not prohibit treatment with opioids but may necessitate more intensive monitoring or referral to an addiction specialist.

Multiple tools are available to evaluate opioid risk. The Opioid Risk Tool is a tool that is used in primary care to screen adults for the risk of aberrant behaviors when they are prescribed opioids for chronic pain. It is a copyrighted tool, encompasses five questions, and takes about one minute to use. It classifies a patient as having a low, moderate, or high risk of abusing opioids. Those who are high risk have a high likelihood of aberrant drug-related behavior. It is not validated in individuals without pain. The five questions include family and personal history of substance abuse (alcohol, prescription drugs or illegal drugs), age (risk is 16-45 years old), psychological disease, and history of preadolescence sexual abuse. The questions are scored with different points assigned for each question, which is variable between men and women, and the total score is tallied. The patient is placed at low, moderate, or high risk.

Regular follow-up is important and should occur a minimum of every three months. When assessing the pain patient, the five A’s should be assessed: analgesia, addiction, activities of daily living, adherence, and adverse effects. Part of the follow-up should be urine drug testing, which can be used to detect medication adherence and illicit and non-prescription drug use. It is critical that the clinician adequately document any interactions with patients, assessments, results of testing, and treatment plans.

Written treatment agreements, which should be used between prescribers and patients when controlled substances are used, help guide the conversation between patient and prescriber. It discusses expectations, the risks, and the monitoring that will occur to limit the complications of controlled substances.

Pain is a disagreeable sensory and emotional experience connected with actual or potential tissue damage or explained in terms of such damage. Many conditions have the potential to cause pain. An understanding of these conditions, how to assess them, and how to treat them are a vital part of adequately managing the pain. In the current health care system, much pain is not even addressed. Many regulatory agencies have implemented guidelines within the health care system to help with addressing the pain epidemic.

The health care team's role is to perform a good initial pain assessment and an ongoing assessment of pain. Proper pain management requires a team approach to assessing and treating pain. Many options are available for the management of pain, including non-pharmacological options, non-opioid medications, opioid medications, and adjunctive medications. Opioid analgesics, while very good at managing pain, have led to many social and legal problems, including overuse and diversion.

The health care team is also responsible for partnering with the patient to manage the pain adequately. Each health care team member has a role in the management of pain. If health care team members perform their role, and the patient takes an active role in his/her care, the adequate treatment of pain is a very attainable goal.

• American Medical Director Association. Pain Management in the Long-term Care Setting.  American Medical Directors Association: Columbia MD. (Visit Source).  Updated 2012.  Accessed November 28, 2019.
• American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders 5th ed. Arlington, VA: American Psychiatric Publishing. 2013.
• Bajwa ZH & Ortega E. (2016). Post-herpetic neuralgia. Retrieved May 20, 2016, from: www.uptodate.com.
• Board TE. An Opioid Crisis Foretold. The New York Times. (Visit Source). Published April 21, 2018. Accessed July 15, 2018.
• Bouland DT, Fine E, Withers D, Jarvis M.  Prescription Medication Obtainment: Methods and Misuse. J Add Med, 2015;9(4):281-5. doi: 10.1097/ADM.0000000000000130.
• Brezing C, Bisaga A. Opioid Use Disorder: Update on Diagnosis and Treatment. Psychiatric Times. (Visit Source). Published April 30, 2015. Accessed July 27, 2018.
• Brummett CM, Waljee JF, Goesling J, et al. New Persistent Opioid Use After Minor and Major Surgical Procedures in US Adults. JAMA Surg. 2017;152:e170504.
• Center for Disease Control.  (2014). Opioid Painkiller Prescribing.  Retrieved May 1, 2016, from (Visit Source).
• Centers for Disease Control and Prevention “Opioid Prescribing: Where you live matters.” (Visit Source). Updated July 2017. Accessed December 8, 2019.
• Centers for Disease Control and Prevention. Opioid Overdose. (Visit Source). Published December 16, 2016. Accessed July 19, 2018.
• Davies PS & D’Arcy Y. (2013). Cancer Pain Management. Springer Publishing Company; New York.
• DeBaun MR & Vichinsky EP. (2016). Vasoocclusive pain management in sickle cell disease. Retrieved May 15, 2016, from: www.uptodate.com.
• Dias E, Correal A. What Is Narcan and How Does It Stop Opioid Overdoses? The New York Times. (Visit Source). Published April 6, 2018. Accessed August 4, 2018.
• Dixon DW. Opioid Abuse: Practice Essentials, Background, Pathophysiology. Background, Pathophysiology, Etiology. (Visit Source). Published June 21, 2018. Accessed July 13, 2018.
• Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR Recomm Rep.  2016;65(No. RR-1):1–49. DOI: (Visit Source) icon.
• Food and Drug Administration. FDA blueprint for prescriber education for extended-release and long-acting opioid analgesics. Silver Spring, MD: US Department of Health and Human Services, Food and Drug Administration; 2014.
• Freedman H. Drug Use Disorder vs. Drug Misuse - What is the Difference? The Buzz. (Visit Source). Published April 19, 2018. Accessed July 29, 2018.
• Häuser W, Wolfe F, Tölle T, Uçeyler N, & Sommer C,(2012). The role of antidepressants in the management of fibromyalgia syndrome: a systematic review and meta-analysis. CNS Drugs, 26(4), 297-307.
• Hill MV, Stucke RS, Billmeier SE, et al. Guideline for Discharge Opioid Prescriptions after Inpatient General Surgical Procedures. J Am Coll Surg. 2018;226:996.
• Inflexxion. The Opioid Crisis: A Global Problem. PainEDU. (Visit Source). Published January 3, 2018. Accessed July 6, 2018.
• Garza I. (2016).  Central neuropathic facial pain.  Retrieved May 25, 2016, from: www.uptodate.com.
• Horvath AT, Misra K, Epner AK, Cooper GM. The Diagnostic Criteria for Substance Use Disorders (Addiction). Mental Help. (Visit Source). Published April 25, 2016. Accessed July 25, 2018.
• Joseph A. A novel approach to opioid addiction: access to treatment for all inmates. STAT. (Visit Source). Published August 2, 2017. Accessed July 29, 2018.
• Kanwaljeet JS. (2016) Prevention and Treatment of Pain in the Neonate. Retrieved May 3, 2016, from  www.uptodate.com.
• Lopez G. The Growing Number of Lawsuits against Opioid Companies Explained. (Visit Source). Updated May 15, 2018. Accessed December 11, 2019.
• Lozada CJ. (2016). Osteoarthritis Treatment & Management. Retrieved June 10, 2016, from (Visit Source).
• Manchikanti L, Abdi S, Atluri S, et al. American Society of Interventional Pain Physicians (ASIPP) guidelines for responsible opioid prescribing in chronic non-cancer pain: Part 2--guidance.  Pain Physician. 2012;15(3 Suppl): S67-116.
• McCance-Katz EF. An Update on the Opioid Crisis. SAMHSA. (Visit Source). Published March 14, 2018. Accessed July 14, 2018.
• Merikangas KR & McClair VL. (2012). Epidemiology of substance use disorders. Human Genetics. 131(6), 779-89.
• National Clearinghouse Guidelines. (2013). Pain management in older adults.
• NYC Health. New York City Emergency Department Discharge Opioid Prescribing Guidelines. (Visit Source). Accessed December 14, 2019.
• Obama Administration Announces Public and Private Sector Efforts to Address Prescription Drug Abuse and Heroin Use. National Archives and Records Administration. (Visit Source). Published October 21, 2015. Accessed August 4, 2018.
• Olek MJ. (2016). Clinical features of multiple sclerosis in adults. Retrieved May 25, 2016, from: www.uptodate.com.
• Opioid Crisis Fast Facts. CNN. (Visit Source). Published June 16, 2018. Accessed July 16, 2018.Pomeroy C. The war on drugs and the war on pain. Fox News.Source. Published August 18, 2017. Accessed July 6, 2018.
• Pino CA, Covington M. Prescription opioids for acute pain in opioid naïve patients. www.uptodate.com. Updated May 14, 2019. Accessed December 17, 2019.
• President Donald J. Trump's Initiative to Stop Opioid Abuse and Reduce Drug Supply and Demand. The White House. (Visit Source). Published March 19, 2018. Accessed August 2, 2018.
• Robinson J & Kothari MJ. (2016). Treatment of cervical radiculopathy. Retrieved June 1, 2016, from: www.uptodate.com.
• Rodriguez S. Rising drug overdose deaths a testament to the failure of the War on Drugs. Orange County Register. (Visit Source). Published March 29, 2018. Accessed July 29, 2018.
• SAMHSA. (2012). Results from the 2011 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-44, HHS Publication No. (SMA) 12-4713. Rockville, MD.
• Shaffer L. Taking the Pain Out of Addiction. NovaNext. (Visit Source). Published April 19, 2017. Accessed July 29, 2018.
• Stinchcomb J. 'Dreamland' author Sam Quinones says community is antidote to opioid crisis. Port Clinton News Herald. (Visit Source). Published June 26, 2018. Accessed July 18, 2018.
• Stobbe M. A history of addiction: Opioid epidemic shares chilling similarities with the past. The Cullman Times. (Visit Source). Published October 30, 2017. Accessed July, 2018.
• Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. (2013). The TEDS Report: 2001-2011: National Admissions to Substance Abuse Treatment Services. Retrieved May 1, 2016, from (Visit Source).
• Veteran Affairs and Department of Defense. VA/DoD Clinical Practice Guidelines for Opioid Therapy for Chronic Pain. (Visit Source). Updated December 2016. Accessed December 1, 2019.
• Vincent A, Lahr BD, Wolfe F, Clauw DJ, Whipple MO, Oh TH,…St Sauver J. (2013). Prevalence of fibromyalgia: a population-based study in Olmsted County, Minnesota, utilizing the Rochester Epidemiology Project. Arthritis Care and Research.  65(5), 786-92.
• Walsh L. Buprenorphine. Veterans and Military Families | SAMHSA - Substance Abuse and Mental Health Services Administration. (Visit Source). Published June 15, 2015. Accessed August 5, 2018.
• Webster LR. Risk Factors for Opioid-Use Disorder and Overdose. Anesth Analg. 2017;125(5):1741-1748. doi: 10.1213/ANE.0000000000002496.
• Wheeler SG, Wipf JE, Staiger TO, & Deyo RA. (2016). Evaluation of low back pain. Retrieved May 24, 2016, from: www.uptodate.com.
• World Health Organization. WHO's pain ladder. (Visit Source). Updated 2019. Accessed December 1, 2019.