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Opioid Prescribing and Substance Abuse, 10hr

10 Contact Hours including 10 Pharmacology Hours
Illinois ARNP Requirement
This course is applicable for the following professions:
Advanced Registered Nurse Practitioner (ARNP), Certified Registered Nurse Anesthetist (CRNA), Clinical Nurse Specialist (CNS), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Nursing Student, Registered Nurse (RN)
This course will be updated or discontinued on or before Wednesday, April 20, 2022
Course Description
Participants will learn how to prescribe opioids and manage pain safely and competently.
CEUFast Inc. did not endorse any product, or receive any commercial support or sponsorship for this course. The Planning Committee and Authors do not have any conflict of interest.

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To earn of certificate of completion you have one of two options:
  1. Take test and pass with a score of at least 80%
  2. Reflect on practice impact by completing self-reflection, self-assessment and course evaluation.
    (NOTE: Some approval agencies and organizations require you to take a test and self reflection is NOT an option.)
Authors:    Raymond Lengel (MSN, FNP-BC, RN) , David Tilton (RN, BSN) , Julia Tortorice (RN, MBA, MSN, NEA-BC, CPHQ)

Outcomes

≥90% of participants will know how to prescribe opioids safely.

Objectives

After completing this course, the student will be able to:

  1. Describe the circumstances which brought about the current opioid crisis.
  2. Explain what opioid tolerance looks like and what it means to the person affected.
  3. Compare and contrast acute versus chronic pain
  4. Discuss the Center for Disease Control and Prevention’s guideline for prescribing opiates
  5. Discuss recommendations on limitations on dosages and the length of prescriptions for opiates
  6. List five risk factors for opiate abuse and misuse
  7. Discuss treatment options for chronic pain including opioids, nonopioids, and nonpharmacologic therapy options
  8. Discuss the implications of pain on the patient
  9. Define acute, chronic, nociceptive and visceral pain
  10. Discuss the assessment and measurement of pain
  11. Compare and contrast pharmacological and non-pharmacological methods to manage pain
  12. Compare and contrast the assessment and management of pain in special populations

Opioid Crisis

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.1,2 This 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 during 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 sign3.”

This creates a serious split on how to manage 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 the treatment of pain? 

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 take a look at the subject in question, opioids: their benefits and their use, and how this situation of uncontrolled overuse snuck up on us. And finally, what is being done about it now and plans that are being developed for moving forward to mitigate what has become a deadly addiction.
 

Prelude to the Opioid Crisis

This 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 the control of 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 home front households welcomed laudanum, a tincture of opium as the treatment of choice for toothaches and soothing colicky children, to belly aches and mood swings.4 Those utilizing opium-based wonder drugs faced the risk of developing tolerance and dependence, both during our previous opioid crises and now. Morphine misuse, in fact, 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.5    

As though to mirror our present crisis, pharmaceutical companies (Merck and Bayer respectively) rapidly pushed to the market cocaine and heroin billing them as a means of reducing the misuse and addictions laid at the feet of morphine and related opioids.6 When in the early 1900’s the sweet poison effects of heroin and cocaine became too great to ignore, the government lurched into motion with the 1914 Harrison Act, the very first national effort to contain a drug epidemic. Effects from the Harrison legislation made codeine and heroin by physician prescription only. This limited the quantities sold, driving up the costs of the medications, and creating the beginnings of a vast underground supply and demand market system and brought illicit and illegal opioid use into a don’t ask don’t tell 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.

The Controlled Substances Act7

In 1970 The Controlled Substances Act became law. The new law creates schedules (groupings) on medications based on their potential for abuse. Heroin is included in Schedule I, the highest risk for abuse. Schedule II drugs include morphine, oxycodone, and fentanyl, among other opioids.

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 with them new cravings and supply contacts leading to a resurgence of opium and opioid derivatives and bringing President Richard Nixon to declare in 1971 that we as a nation were at war with drugs. The 1971 War on Drugs still continues today, with tough sentences on drug users and suppliers, and ramped up military level interdictions on illegal drug smuggling. 

Time Periscope: Then and Now 4,7

1900 – Heroin and Cocaine are legal OTC’s (over the counter) and popular.

  • 1 in 300 Americans faced drug addiction.

1970 – Heroin epidemic rages in U.S. cities.

  • 3000 overdose deaths.

1988 – The crack epidemic is at its height nationwide.

  • 5000 overdose deaths.

2016 – The most recent year with complete numbers available.

  • All opioids are either tightly controlled or illegal. 
  • 1 in 133 Americans faces drug addiction.
  • 42,000 overdose deaths, according to the CDC (Centers for Disease Control and Prevention).

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 that 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 both pain and the risk of narcotic abuse.8 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.7

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.7 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, delivering a potent ‘high’ much more powerful and quicker than swallowing a pill.5
 

Prevalence

Substance abuse issues are a real concern in the management of pain.  Opioid misuse and abuse is a major public health problem, and it affects 34.2 million Americans over the age of 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.10 Two times as many painkiller prescriptions are written in the United States as in Canada.

Misuse prevalence is variable. Of individuals over the age of 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.11

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 2010.12  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 who live in rural settings account for 10.6 percent of cases and urban individuals accounting for 4.0 percent of non-heroin opioid abuse individuals who sought treatment.12

Opioid dependence costs lost work productivity, legal costs, and psychological effects of 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 the sedative-hypnotics and amphetamines.  Individuals who seek these medications are more likely to use more than one physician and more than 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.13

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

War on Drugs

The Nixon era “War on Drugs,” continued by every presidential administration since it has taught us many things about substance abuse and addiction. First of all, it showed us that wars on drugs do not work. Secondly, that deprivation or abstinence alone from a drug of choice, including opioids, does not reduce returning to that substance when it again becomes available. This has proved a deadly problem as the time away from opioids generally reduces the built-up tolerance a person’s metabolism has. That means 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.15

Costs of The War on Drugs 3,14,15

The war on drugs has been being waged since 1971. Some of its costs include;

  • More than $1 trillion spent
  • Millions of people arrested and imprisoned
  • Over half of those currently in federal prison are incarcerated on drug-related charges
  • Increases in prescription drug costs
  • Increases in illegal, illicit drug use

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 current 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 which takes into account the cost of healthcare, criminal justice involvement, and addiction treatment.2 As we have seen in previous opium/opioid addiction epidemics, coming between a persons 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 seems to be presenting their own unique plan on how to combat the opioid epidemic. Let us take a 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.

President Trump’s Plan

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 them16,17:

  • Reduce opioid demand.
    • Launch a nationwide evidence-based public awareness campaign about the dangers of prescription and illicit opioids (and other narcotics) use.
    • 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 a vaccine-specific in the 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 be 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 shipments and consignment shipments within three years.
    • Utilize advanced screening technologies and drug-sniffing canines with all high-risk international packages to interdict illegal shipments.
    • 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, 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.

U.S. Department of Health and Human Services Plan

The U.S. Department of Health and Human Services (HHS) has pushed forward with plans for a five-fold approach to containing the Opioid Crisis2:

  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 support on 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.2 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 that pain control is an important part of quality health care.  They acknowledge that pain is considered the fifth vital sign and should be assessed with other vital signs.   According to the JC, patients have the right to assessment and treatment of 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 for the discharge of a patient.

Say what you will about the pharmaceutical industry’s actions relating to this generation’s opioid epidemic, some of the 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 are advocating this throttled down introduction to opioids become the law of the land.18

Working Together to End the Opioid Crisis

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 providing 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 really 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 in order for health professionals to contribute our best, we must stay informed regarding the changing landscape surrounding the pain of our opioid crisis.

Multidimensional Nature of Pain

Pain is a major problem in today’s society. Pain carries with it consequences across a broad range of categories, including ethical, social, economic, and legal arenas. This course will discuss the ethical, social, economic, and legal implications of pain and pain management.

Pain is a common problem seen in primary care. Chronic pain affects about one in two long-term care residents.19 Persistent pain is often associated with anxiety, depression, functional impairment, sleep disturbances, disability, and impairment in activities of daily living. Chronic pain is defined as pain lasting more than three months and may affect any part of the body.

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 of time or may last for a few months. The pain dissipates when the underlying cause has healed. When acute pain lasts longer than 3-6 months, it is then termed chronic. It is possible that 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

Pain theories help clinicians understand pain and help in the guidance of the treatment of pain. Pain theories have been around for many years. One of the first pain theories was the Intensive Theory, which was created by Plato 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 out signals to the brain that creates the awareness of pain. 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 the Pattern Theory, Central Summation Theory, the Fourth Theory of Pain, and the 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, the gate blocking is less effective. When there is a lot of activity in the pain fibers, the gates open. Once there is stimulation of the A-beta fibers, which provide a stimulus for mild irritation such as lightly touching the skin (massage), the gates may be closed. This 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 not just physiological factors but also psychological and social factors. It suggests that family and culture influence the perception of pain and the individual’s response to pain.

Pain Anatomy and Physiology

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 and are lightly myelinated and conduct slowly. They transmit rapid, sharp pain. C fibers are small and unmyelinated fibers that conduct slowly and 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 back to the periphery.

The neurons are involved in the transmission of pain through the release of substances and neurotransmitters. The excitatory substances that contribute to pain include substance 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.

The Impact of Pain

Pain affects multiple aspects of life. Pain can lead to physiological changes and potentially to physical illness. It has the potential to 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 to 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 being placed on the prevention of medication abuse.

Ethics and Pain

Pain and its management are surrounded by multiple ethical issues. Healthcare providers should attempt to minimize pain and suffering while maintaining a balance between adequate pain management and minimizing harm from the treatment of pain. The healthcare provider has to do no harm and must guard against overmedicating the patient. The healthcare provider has to be aware of the negative consequences of pharmacotherapy, 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 in 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 receiving 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, 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, the treatment of 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. The use of palliative sedation may be considered to manage refractory pain at the end of life.

Diagnostic tests

Diagnostic testing can be helpful in evaluating 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 (which are 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 using 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.

Case Study

Ms. L is a 52-year-old female with a history of bilateral knee osteoarthritis; she currently rates the pain as a 7/10 in her right knee and 6/10 in her left knee. She takes celecoxib 200 mg twice a day and uses 1000 mg of acetaminophen for breakthrough pain about three times a day. She has been stable with these medications for the past six months, but over the last month, she has not been getting adequate relief from her pain and has been progressively disabled and has stopped exercising because of pain in her knees.
In addition to osteoarthritis, she has a past medical history of hypertension, dyslipidemia, depression, and obesity. She has a past surgical history of an appendectomy as a child. She is currently on atorvastatin, lisinopril, celecoxib, and acetaminophen. She has no known allergies.

She has no history of alcohol, drug, or substance abuse. She has a strong family network, including a supportive husband of 25 years and two sons who live within twenty miles of her home. She has a past history of depression but is currently not depressed.
The physical exam shows significant crepitus in both knees and obesity (BMI of 34). She is unable to fully extend the right knee due to pain.

An x-ray demonstrates moderate arthritic changes in both knees. The patient is unwilling to consider the surgery of her knees.

The prescriber offers tramadol immediate-release 25 mg in the morning, which is titrated every three days in 25 mg increments as distinct doses to 100 mg/day (25 mg four times a day). Pain control was still not adequate, and the dose was then increased by 25 mg every three days to 50 mg every 6 hours.

Pain control was significantly improved, and then the patient was given tramadol SR 200 mg once a day. The patient was able to function and exercise. Her quality of life was much improved.

Goals of Pain Management

The goals of pain management are not necessarily complete pain relief. They may include a reduction in the amount of pain, improved quality of life, improved physical and psychological functioning, improved ability to work, improved ability to function in society, and a reduction in 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 success of the plan. The patient’s willingness to implement the whole plan can have a profound effect on the success of the plan. If a patient is willing to take a pill but is not willing to work on non-pharmacologic interventions (such as physical therapy or weight loss), then 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. The 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 who have debilitating symptoms, those that need 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 have an accurate comprehension of 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 giving medication to those who are in pain. In addition, caregivers/healthcare providers and patients may have discordant goals.

Controlled substances should be prescribed for a legitimate medical purpose with careful consideration of the patient’s safety, goals of therapy, and efficacy of the treatment. Treatment of pain should include not only pharmacotherapy but also physical and psychological therapies.

Pain Descriptions and Definitions

Pain typically classifies 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 usually describes 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 as well.

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

Definitions

  • Pain – An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage
  • Acute pain – Pain that has an abrupt onset and offers a warning of a disease process or a threat to the body
  • Chronic pain – Pain that lasts beyond the usual duration of time that an insult or injury to the body needs to heal (typically at least three months). Chronic pain is without apparent biologic value. Some define chronic pain as pain that continues for at least six months
  • Maladaptive pain – Pain that is not useful and is out of proportion to tissue damage. This type of pain tends to last long after tissue healing and is often due to changes in the central nervous system
  • Adaptive pain – Pain that protects the individual from injury and aids with healing after an injury
  • Allodynia — Pain from a stimulus that typically does not cause pain
  • Hyperesthesia – Increased sensitivity to stimulation
  • Paresthesia — An unusual sensation that is often described as burning or prickling and commonly affects the extremities
  • Visceral pain – Pain from the viscera mediated by stretch receptors. This pain is commonly described as deep, dull, poorly localized, and cramping
  • Nociceptive pain – Pain from threatened or real tissue damage to non-neural tissue that is caused by the activation of nociceptors
  • Neuropathic pain – Pain from an abnormal neural activity from an injury, disease process, or dysfunction of the nervous system
  • Mononeuropathy – A Neuropathy affecting one nerve
  • Polyneuropathy – A Neuropathy affecting several nerves

Acute 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.20" Management of acute pain may include opioids. While good pain control is important in patient care, the use of opioids for acute pain increases the risk of long-term opioid use.21 Use of caution is imperative because long-term opioid use often begins with the treatment of acute, self-limiting afflictions. Ideally, opioids should be prescribed only when necessary, with the lowest effective dose and for the shortest duration possible.

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 have re-examined the best way to manage acute pain.

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.22 Immediate-release opioids are recommended for short term use, although in some instances of acute pain may require more than three days.

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.23

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 the history of alcohol or drug abuse, lower socioeconomic status, multiple medical comorbidities, depression, use of benzodiazepines or antidepressants, and preoperative pain.

Chronic Pain

Pain is a common problem seen in primary care, with about 20% of outpatient visits being for pain issues.24 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 defined as pain lasting more than three months and may affect any part of the body. 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.25

The definition of chronic reads, “Pain that lasts beyond the usual duration of time that an insult or injury to the body needs to heal.20” 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.20 The use of 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.26

Pain in Special Populations

Pediatrics

Many narcotics are available in liquid form for pediatric use. Acetaminophen with hydrocodone is available as an elixir. Acetaminophen with oxycodone and oxycodone alone is also available in liquid form. The dose is based on the oxycodone and is dosed at 0.05 to 0.15 mg/kg/dose every 4-6 hours to a maximum of 5 mg per dose. Morphine is available as an immediate-release formulation and is dosed at 0.2 to 0.5 mg/kg every 4-6 hours to a maximum of 30 mg per dose. Hydromorphone is dosed at 0.05 mg/kg every 4-6 hours to a maximum of 5 mg per dose.

Pain in children is similar to adults. The source of the pain, along with its location and severity, should be ascertained. In older children, self-reporting is a reasonable technique to assess pain. For those too young to understand self-reporting the use of scales such as the facial expression scale can be used. With the help of a caregiver, observing the child for verbal responses, motor responses, or facial expressions will help the clinician determine the degree of pain in a non-verbal child.

Pain management in children should work to control, lower, or prevent the pain. Pain management techniques are based on the severity, type, duration, and source of pain. Non-pharmacological measures to control pain include physical/occupational therapy and cognitive/behavioral therapy.

Pharmacological agents may also be considered. Mild pain can be managed with NSAIDs or acetaminophen. When pain is not responsive to these medications, the use of stronger medications, including opioids, are considered. Regular assessment of pain control during treatment will help assure proper pain management. When pain is moderate to severe, providing pain medication around the clock is a reasonable option. Adjunctive therapy can be used in children, including medications, to manage co-morbid depression and anxiety. The use of anticonvulsants for neuropathic pain may also be considered.

Neonates feel pain like any other patient. Untreated or pain not treated appropriately may lead to long-term effects, including altered sensitivity to pain.27

It is important to have a standard method to assess pain in neonates. It is difficult to assess pain in neonates and infants because they have limited ability to communicate. In this population, assessment is based on physiological and behavioral factors. Factors that suggest pain in the neonate and infant include vital signs, oxygen saturation, skin color, crying pattern, facial expressions, muscle tone, and consolability.

Scales for pain in neonates used in the neonatal intensive care unit include Neonatal Facial Coding System, Neonatal Infant Pain Scale, and the Neonatal Pain Agitation and Sedation Scale. No tools are universally accepted to assess pain in infants and children. In neonates, pain assessment tools have a difficult time detecting pain in those with very low birth weight, on paralytic medications, or those that have prolonged pain.27 Due to the difficulty in finding and quantifying pain in the neonate and young child, pain management should include an attempt to reduce or prevent pain in the face of potentially painful situations. It is important to limit the number of painful procedures performed on young children.

Older Adults

Age does not cause pain, but many conditions that cause pain are more common in older adults. In general, older adults are undertreated in regard to their pain partly because they have problems communicating pain. Those with reduced vision reduced hearing or impairments in cognition present a bigger challenge in the assessment of pain.

In individuals who are cognitively intact, self-report of pain is the most reliable method to assess pain. For those who have a cognitive impairment, simple questions, and basic screening tools can often reliably identify pain. Long-term care residents are often afflicted with some degree of cognitive impairment. Residents of long-term care facilities may present with behavioral changes or some physical changes as the presentation of pain.

Older adults may not report pain as readily as younger adults. Some older adults believe that pain is part of aging; therefore, do not bother to discuss it with the health care team. When assessing the older adult, it is important to determine their perception of pain. Some patients perceive severe pain as a sign of a serious illness or loss of independence, or they may believe this is just a consequence of aging.
When evaluating the older adult, it is important to have an accurate medication history, including herbal medicines and dietary supplements. Patients should also be asked about alcohol use, drug use, and tobacco use.

It is also important to determine the patient’s coping techniques. This will help the nurse understand how the patient functions and to help them deal with the pain in the most effective way. Many older adults use prayer and hope to assist in coping with pain.
Goals should be set for the patient to determine an acceptable level of pain to allow the patients to have a satisfactory quality of life. Closely monitoring for adverse drug reactions is an important part of the management of chronic pain, as many medications have many side effects. A balance should be sought between the quality of life and side effects/risks of the treatment.

Older adults have some physiological changes that affect the way medications are used. There is slowing of the gastrointestinal transit time, which may extend the effects of continuous release medications. Changes in gastric pH may affect the absorption of some medications. Chronic liver changes may lead to changes in drug metabolism. Chronic renal insufficiency is common in older adults and may lead to reduced clearance of medications.

Pain in Pregnancy and Labor

Pregnancy is associated with many changes that have the potential to cause pain, such as changing body shape, increasing weight, hormonal shifts, and joint laxity. Acetaminophen is thought to be a safe option for pain control throughout pregnancy. NSAIDs should not be used in late pregnancy. NSAIDs have the potential to lead to premature closing of the ductus arteriosus if used in the third trimester.

Many different pain syndromes are commonly seen in pregnancy. Mechanical back pain due to weight distribution changes is one of the most common types of pain. Pain in the pubic symphysis is common and can be managed with position changes and the use of pelvic support devices. Leg cramps may be prevented and treated with calf stretching. Carpal tunnel syndrome is often seen during pregnancy and is likely related to fluid retention, which causes compression on the nerves in the carpal tunnel. Symptoms of carpal tunnel syndrome most commonly come on in the third trimester and resolve after pregnancy, but might be prolonged by breastfeeding.

Labor is a painful period, and treatment may involve a variety of techniques. The most reliable method to manage pain is with epidural and spinal analgesic techniques. The use of opioids induces sedation and thereby contributes to pain control. Unfortunately, opioids act systemically, and some effects may be transferred to the fetus leading to respiratory depression in the neonate.

Pain in the Psychiatric Patient

Psychiatric disorders are up to three times higher in those with chronic pain when compared to the general population. Depression, anxiety, and post-traumatic stress disorder are the most prevalent psychiatric disorders in patients with chronic pain. The patient with pain and psychiatric disease typically reports more intense pain than the patient without co-morbid mental illness.

Chronic pain management has multiple challenges in psychiatric patients. Optimizing treatment of the underlying psychiatric illness is an important step in order to achieve an optimal reduction in pain. It is also important to screen and treat for any substance abuse or substance-induced disorder. This will help assure appropriate and adequate treatment of pain. Medications with abuse potential should be used cautiously, as there is a high prevalence of drug use disorders in psychiatric patients. The use of exercise and cognitive behavioral therapy is an important step in the management of pain in psychiatric patients. In addition, monitoring for compliance is an important part of the management of the psychiatric patient who suffers from chronic pain.

Specific Pain Syndromes

Visceral Pain

Many conditions lead to visceral pain. Visceral pain occurs when there is a stimulation of nociceptors of the organs in the abdomen, pelvis, or chest. Visceral pain is diffuse, hard to pinpoint, and often referred to as a remote structure. Visceral structures are aggravated by ischemia, inflammation, and stretch.

Chest pain can occur from many different etiologies. There are a few life-threatening situations that must be considered, including myocardial infarction, pulmonary embolism, aortic dissection, tension pneumothorax, and esophageal rupture. The majority of chest pain is not life-threatening, and selected causes include chest wall pain (costochondritis, muscle strain), panic attacks, pneumonia, pleurisy, myocarditis, gastroesophageal reflux disease, and pericarditis.

Abdominal pain is a common problem, and most cases are not life-threatening. Like chest pain, it is important to rule out serious causes of abdominal pain immediately. Serious causes of abdominal pain are suggested by unstable vital signs, high fever, an inability to pass gas or have a bowel movement, vomiting blood, or having dark/tarry stools. Common diagnoses that are potentially life-threatening include acute bowel obstruction, acute mesenteric ischemia, bowel perforation, ulcer, acute myocardial infarction, and ectopic pregnancy. Other causes of abdominal pain include appendicitis, gallbladder disease, diverticulitis, constipation, kidney stones, lactose intolerance, and inflammatory bowel disease.

Many patients have chronic abdominal pain, and many of these cases are benign – functional dyspepsia or irritable bowel syndrome. If no organic disease is found, then that patient should be treated symptomatically. Those individuals over the age of 50 are more likely to have a more serious cause of chronic abdominal pain, and functional abdominal pain should be made only after more serious causes have been ruled out.

Pelvic pain is a common problem in women and may represent a urologic, gynecologic, gastrointestinal, musculoskeletal, metabolic, or vascular issue. Acute pelvic pain may be of visceral or somatic origin. In all women who have the possibility of being pregnant, a pregnancy test should be done. Other testing to rule out other causes of pelvic pain includes a complete blood count, sedimentation rate, chlamydia/gonorrhea testing, a serum hCG level, and a urinalysis.

Diagnostic testing may include a pelvic ultrasound to rule out a mass or ectopic pregnancy, or a laparoscopy can help determine if endometriosis is present. Features that suggest a serious cause of pelvic pain include peritoneal signs, brisk vaginal bleeding, high fever, or unstable vital signs.

There are many potential causes of chronic pelvic pain. Diagnosing and treating chronic pelvic pain can be challenging. Determining the exact cause of the abdominal pain may include the use of extensive laboratory evaluation, imaging modalities, and at times exploratory surgery. For those with chronic pelvic pain, the examination may use a pain map and identify tender areas to see if physical exam tender areas match the pain map. Ideally, the clinician should attempt to treat the underlying cause of the pelvic pain, but the use of a non-specific treatment may be considered when there is no specific diagnosis.

Sickle Cell Disease

Sickle cell crisis is a vaso-occlusive phenomenon leading to pain associated with blood cell destruction and subsequent anemia. While not the only feature of sickle cell disease, pain is a major component of the condition. Acute sickle cell disease pain is secondary to vaso-occlusion, and the consequent tissue ischemia and inflammation. Over time chronic pain may result. Assessment of pain is challenging in sickle cell crisis as there are no objective findings that definitively confirm a crisis or the degree of pain.

An acute painful episode can be precipitated by multiple events such as stress, infection, weather conditions, dehydration, or alcohol consumption. Pain can affect many parts of the body, such as the chest, back, extremities, or abdomen. Many times the pain is associated with fever, elevated breathing rate, hypertension, nausea, and vomiting.

Treatment of pain in chronic disease can be challenging to manage. If mild pain is present, and the patient is not on chronic opioid therapy, pain management should be started with non-opioid therapy moving to opioids when the pain becomes more severe. Individuals who are on chronic opioids will require additional opioids for breakthrough pain. When treated in the emergency room, the use of intravenous morphine, hydromorphone, or fentanyl can be used. If pain cannot be relieved with two doses, then admitting the patient to the hospital for pain management may be necessary. Many patients with sickle cell disease have chronic pain that is managed with long-acting opioids.28

Headache

Headaches are a frequent cause of recurrent pain and one of the most common diagnoses seen in health care. There are multiple types of headaches, including migraine, tension, and cluster headache. Tension headache is the most common. It is important for the healthcare provider to have an understanding of red flags that suggest a serious cause of a headache. When a serious cause of a headache is suspected, urgent evaluation is necessary and may include the use of brain imaging to rule out an underlying secondary cause of a headache.

Signs/symptoms that suggest a more serious cause of headache include:

  • New-onset headache, especially in those over age 40
  • Worst headache of your life
  • A headache with an accompanied neurologic sign or symptom – e.g., confusion, stiff neck, seizure, focal neurologic sign (e.g., one-sided weakness), impaired alertness
  • Headaches that awaken the patient from sleep
  • Fever and stiff neck
  • Pregnancy – may suggest pre-Eclampsia
  • History of cancer
  • History of HIV or immune compromise
  • Headache made worse by cough, exertion or the Valsalva maneuver
  • History of recent head trauma
  • Illicit drug use
  • Progressive headache

Tension headaches may occur every day and have a variable presentation. Typically there are described as pressure, tightness, or aching. They may feel like a band around the head, and they may be bifrontal or bitemporal or generalized. Tension headaches can be intermittent with a variable duration or constant.

Migraine headaches are classically one-sided (but may generalize), are pounding or throbbing. Patients with migraines often have co-existent nausea/vomiting and/or photophobia.

An acute migraine can be managed with multiple agents. The use of acetaminophen or NSAIDs may be considered. When simple analgesics are not effective in the management of the pain, the use of migraine-specific agents (triptans or dihydroergotamine) may be considered. These agents are available in oral, rectal, and injectable formulations. Oral agents are preferred by many patients, but for those with severe nausea that accompanies a migraine, a non-oral route is the best option. First-line prophylactic agents for migraines include propranolol, amitriptyline, topiramate, and valproic acid.

Neuropathic Pain Conditions

Many conditions lead to neuropathic pain, including multiple sclerosis, post-stroke pain, spinal cord injury, traumatic brain injury, syringomyelia, trigeminal neuralgia, peripheral neuropathy, and post-herpetic neuralgia.

Multiple sclerosis (MS) is commonly associated with pain. It is estimated that 43 percent of MS patients have at least one painful symptom.29 Common painful symptoms include: dysesthetic pain, back pain, spasms, Lhermitte sign, visceral pain, and trigeminal neuralgia.

Central post-stroke pain is experienced as unilateral head/facial pain that starts within six months of a stroke. It affects up to 8 percent of stroke victims.30 The pain is typically persistent but may come and go. The severity of the pain may be variable, and stress often exacerbates the pain.

Treatment of central post-stroke pain includes benzodiazepines; anticonvulsants such as gabapentin, pregabalin, lamotrigine, or carbamazepine; baclofen; antidepressants such as amitriptyline or an SSRIs; and clonidine. When pain is resistant to pharmacotherapy, the use of neuromodulation (deep brain stimulation) and surgery may be considered.

Spinal cord injury (SCI) patients often develop chronic pain after spinal cord injury that affects the quality of life. Pain is often poorly localized and neuropathic in nature (e.g., burning, stabbing). The pain can be evoked or spontaneous. Pain can be at-level pain (pain at the level of the SCI) that is caused by injury to the nerve roots and dorsal gray matter, causing pain at the level of the injury. Pain can also be below the level of the SCI, which is thought to be caused by injury to the spinothalamic tracts and/or thalamic deafferentation.

Pain may be managed with antidepressants (e.g., tricyclic antidepressants), antiepileptics (e.g., gabapentin, lamotrigine, or valproate), and standard analgesic medications (opiates). When medications are not effective, the use of invasive treatments is considered. These may include deep brain stimulation, cordotomy, or motor cortex stimulation.

Syringomyelia is a delayed progressive intramedullary cystic degeneration that affects a small number of patients after spinal cord injury. It is thought to occur from scarring and subsequent obstruction of cerebral spinal fluid flow and altered tissue compliance leading to an extension of the central canal, which presses on the nearby cord tissue.31 In syringomyelia, the patient will present with progressive pain that may include sensory, motor, or bowel problems. Treatment of the condition is mainly surgical.

Post-concussion syndrome can occur days or even weeks after a traumatic brain injury (TBI). This can occur with any degree of head injury from mild to severe. It is characterized by dizziness, vertigo, headache, reduced concentration, apathy, depression, sleep disturbance, confusion, irritability, and anxiety. Headache after TBI typically occurs within seven days of the injury and is typical of the tension-type or migraine type of headache. In those with TBI, many other headache syndromes may be seen.

While the post-concussive syndrome is often reported in athletes, it is more common in older adults. MRIs may be performed for patients who have symptoms that persist in ruling out other problems and provide reassurance.

Treatment options for post-concussive headaches can be variable. Not a lot of research is available on the use of medications in the management of post-concussive headaches. Management involves the treatment of the symptoms, which include analgesics, migraine-specific medication (e.g., tricyclic antidepressants, propranolol), psychotropic medications, and counseling to manage psychosocial symptoms. Most patients have a quick recovery (within weeks), but some patients may have prolonged symptoms.

Trigeminal neuralgia results in head/facial pain coming from one or more of the branches of the trigeminal nerve. Classically the pain is unilateral, brief, stabbing, and/or lancinating that is sudden in onset.

Imaging, typically with an MRI, is sometimes done to distinguish primary from secondary trigeminal neuralgia. The primary disease has no identifiable lesion causing the symptoms. Secondary causes of trigeminal neuralgia include acoustic neuromas, multiple sclerosis, cerebral aneurysms, and trigeminal neuromas. A secondary disease is more common if there is bilateral involvement; it occurs at a younger age; or if there is associated sensory loss.

Conditions that may mimic trigeminal neuralgia include dental pain, multiple sclerosis, herpes zoster, or atypical headaches.

Treatment for the pain of trigeminal neuralgia includes carbamazepine and oxcarbazepine. For those who are intolerant or non-responsive to these agents, baclofen or lamotrigine can be used. Surgical options are sometimes tried for refractory cases.

Peripheral neuropathy can come from many etiologies, including diabetes, cancer, alcohol, and HIV. Peripheral neuropathy typically presents with distal sensory loss, weakness, numbness, and/or burning. The presentation may be variable. Neuropathy due to diabetes is one of the more common types of neuropathies.

Many forms of diabetic neuropathy exist, including symmetric polyneuropathy, radiculopathies, autonomic neuropathy, and mononeuropathies. They typically result in symptoms that begin in the lower extremities. Sensory symptoms are seen first, followed by motor symptoms. Patients complain of a gradual sensory loss, numbness, a burning sensation and pain in the feet, and mild gait abnormalities. Overtime weakness may develop, and a "stocking and glove" distribution of sensory loss may occur. Physical exam findings depend on which nerve fibers are involved.

Diagnostic tests that help define a neuropathy include conduction studies such as electromyogram and/or nerve condition studies. Treatment of neuropathies includes treating the underlying disease (e.g., control blood sugar in diabetes) and medications to treat the symptoms. Medications used to manage the pain of neuropathy include tricyclic antidepressants, duloxetine, gabapentin, pregabalin, carbamazepine, topiramate, tramadol, and NSAIDs.

Post-herpetic neuralgia is pain that presents after a herpes zoster infection, which is caused by the varicella-zoster virus. Certain groups are at higher risk of developing pain after a herpes zoster infection. These include older individuals, those who had higher levels of acute pain during the acute infection and those with a more severe rash.31

Herpes zoster is an infection that starts with a sharp, burning, stabbing pain that follows a dermatome. A rash will be seen a few days later along the same dermatome. Commonly affected dermatomes include the thoracic, cervical, and trigeminal nerves. After the rash abates, some individuals develop pain along the same dermatome that persists longer than four months. Pain may persist for years or even throughout life. Allodynia is often seen in those with post-herpetic neuralgia.

Post-herpetic neuralgia is commonly treated with tricyclic antidepressants, pregabalin, and gabapentin. Topical capsaicin or lidocaine can be used. Opioids are sometimes used but should be used cautiously. They are considered second or third-line options and are sometimes used while the TCAs, pregabalin, gabapentin take effect, then tapered. If all other options are not effective, the use of intrathecal glucocorticoids may be considered.

Back Pain

Most cases of back pain are non-specific and will improve within a few weeks with conservative treatment, but some people develop chronic pain. Those more likely to develop chronic back pain include those with functional impairment, poor health, comorbid psychiatric conditions, maladaptive pain-coping behaviors and non-organic signs – such as pain in the low back when pressing directly on top of the head.32 Less than one percent of patients with back pain have a serious cause of back pain, and less than ten percent have specific etiologies.32 When back pain is present, it is important to rule out any serious pathologies. Serious pathologies are suggested by certain red flags.

A complete history and physical exam is an important part of the exam to rule out serious causes of back pain and help identify the cause of the back pain. Certain conditions that are more urgent require immediate imaging with an MRI and referral, including those who have any red flags. Those who have not improved after 4-6 weeks of conservative therapy may be considered for imaging. Patients who have conditions that may benefit from surgery or epidural injections should have imaging. Other conditions that are helped by imaging include osteoarthritis and ankylosing spondylitis.

Back pain should not be treated with bed rest, but modifying activity slightly to account for the pain is appropriate. Oral analgesics should be used short-term to provide pain control. Re-evaluation should occur at four weeks to assure improvement, evaluate for any needed testing, and reevaluate the need for pain medications.

Initial oral agents should include NSAIDs for 2-4 weeks. Those with an allergy or contraindication to NSAIDs may consider acetaminophen. When pain is not controlled with NSAIDs, the use of a muscle relaxant may be considered. For those who cannot take a muscle relaxant, the combination of an NSAID and acetaminophen is an option. The use of opioids and tramadol should be used very judiciously in acute low back pain and only in those who are not getting pain control from other agents or contraindications to those other agents.

Physical therapy can be used for acute low back pain but is more often used for chronic low back pain. One of the most important aspects in the management of back pain is education. Patients should be educated on the causes of back pain, the expected course of back pain, its encouraging prognosis, the value of diagnostic testing, treatment options, and when to contact their healthcare provider.

Back Pain Red Flags
  • New bowel or bladder incontinence
  • Saddle anesthesia – loss of sensation in the perineum, buttocks, and inner thighs
  • Severe neurological deficits
  • Weight loss
  • New-onset over age 50 years old or under 18 years-old
  • Progressive motor deficit
  • Night pain or rest pain
  • Fever – concern for infection – recent urinary tract infection or history of intravenous drug use
  • Current or recent cancer diagnosis or major risk factor for cancer
  • Pain persists beyond 6 weeks
  • Suspected vertebral fracture

Acute disc herniation with radiculopathy in the lower back (lumbosacral spine) is a common diagnosis. The five lumbar vertebral bodies are movable, while the five sacral vertebrae are fused. Below each vertebra, a pair of neural foramina (spinal nerve roots) exits that have the same number as the vertebra body. For example, the L5 nerve root exits between the L5 and S1 vertebral bodies.

The most common cause of lumbosacral radiculopathy is a herniated disc or degenerative arthritis leading to stenosis of the neural foramina. Other causes of radiculopathy include congenital abnormalities, infection, and cancer. Radiculopathy can occur at any nerve root, but L5 or S1 impairment is the most common. L5 radiculopathy is associated with back pain that radiates down the lateral aspect of the leg into the foot. The exam shows reduced dorsiflexion, foot inversion and eversion, and reduced toe extension. The reflexes are typically normal in L5 radiculopathy.

S1 radiculopathy presents with back pain that radiates down the posterior aspect of the leg into the foot. The exam shows reduced strength in leg extension and plantar flexion. There is a reduced sensation on the lateral foot and the posterior part of the leg. The ankle reflex is reduced or absent.

It is typically not necessary to perform an emergent MRI on patients with suspected lumbar or sacral radiculopathy as long as the clinician does not suspect a serious underlying cause (e.g., cauda equina syndrome, cancer, epidural abscess) of the radiculopathy. If symptoms persist, worsen, do not respond to conservative therapy, or procedures are considered, the use of imaging with an MRI may be considered. For those with severe or unrelenting findings that have imaging results, not suggestive of an underlying cause should undergo electromyography and nerve conduction studies. In some cases, a lumbar puncture is done.

Case Study

Chris is a 44-year-old secretary who presents to her primary care provider with back pain for the last three weeks. The pain started after she lifted a heavy box at work. Her self-management regime included bed rest and taking acetaminophen alternating with ibuprofen for the last three weeks. She reports that the pain is not getting any better. The pain is described as aching and diffuse along her lower back. She reports that the pain is worse with walking and prolonged standing or sitting and is relieved when lying down. She reports that the pain radiates into her right buttock, but not down the leg.
Chris is generally healthy. The only medication that she takes on a regular basis is sertraline for depression. She has never had any surgeries and has no allergies to medications.

On physical exam, her vitals are stable, and she appears comfortable. She walks with a slight limp. The exam shows diffuse tenderness across her lumbar spine. There is no deformity, the straight leg raise is normal, the sensation is intact to the lower extremities, and the remaining aspects of her exam show no focal neurological finding. Recent labs demonstrated a normal blood count and normal liver and renal function. Her primary care physician recommends that she goes to physical therapy and prescribes diclofenac 50 mg three times a day for three weeks and encourages her to use acetaminophen for breakthrough pain.

At the three week follow-up, Chris is doing better. Her primary care physician recommends continued home exercises as recommended by the physical therapist and use of as-needed acetaminophen for pain; the NSAID is stopped at this time as it is likely limited if any inflammation contributing to the pain.

This case is typical of back pain; it essentially resolved within six weeks. The pain was caused by an acute injury with muscle spasms causing the referral of pain into the buttock. Radicular pain was not present. Radicular pain would be present if there was inflammation, compression, or injury to a spinal nerve root.

The use of imaging is not indicated in this case because there were no red flags. Typically this type of back pain responds to the use of simple analgesics; the use of opioids is not necessary. Acetaminophen is preferred for analgesia because of its relatively safe profile. The use of an NSAID may be needed because of its anti-inflammatory effect. At times, the short-term use of a muscle relaxer may be helpful for muscle spasm that often contributes to this type of acute pain. Tramadol is often used in cases of mild acute pain, but due to its potential abuse should be relegated to a second or third-line option. In this case, Chris is also on sertraline, and there is a potential interaction between tramadol and sertraline.

The goal, in this case, is to minimize disability and return Chris to her baseline function as soon as possible. Relative rest at first may be appropriate, but prolonged bed rest will contribute to deconditioning and stiffness and will prolong recovery. The patient with acute low back pain should have exercises to strengthen the low back, stomach, and other core muscles as well as stretching the low back and legs.

Appropriate health care of back pain will get patients back to normal functioning quickly while minimizing the risk of dangerous treatment options.

Chris is a 44-year-old secretary who presents to her primary care provider with back pain for the last three weeks. The pain started after she lifted a heavy box at work. Her self-management regime included bed rest and taking acetaminophen alternating with ibuprofen for the last three weeks. She reports that the pain is not getting any better. The pain is described as aching and diffuse along her lower back. She reports that the pain is worse with walking and prolonged standing or sitting and is relieved when lying down. She reports that the pain radiates into her right buttock, but not down the leg.
Chris is generally healthy. The only medication that she takes on a regular basis is sertraline for depression. She has never had any surgeries and has no allergies to medications.

On physical exam, her vitals are stable, and she appears comfortable. She walks with a slight limp. The exam shows diffuse tenderness across her lumbar spine. There is no deformity, the straight leg raise is normal, the sensation is intact to the lower extremities, and the remaining aspects of her exam show no focal neurological finding. Recent labs demonstrated a normal blood count and normal liver and renal function. Her primary care physician recommends that she goes to physical therapy and prescribes diclofenac 50 mg three times a day for three weeks and encourages her to use acetaminophen for breakthrough pain.

At the three week follow-up, Chris is doing better. Her primary care physician recommends continued home exercises as recommended by the physical therapist and use of as-needed acetaminophen for pain; the NSAID is stopped at this time as it is likely limited if any inflammation contributing to the pain.

This case is typical of back pain; it essentially resolved within six weeks. The pain was caused by an acute injury with muscle spasms causing the referral of pain into the buttock. Radicular pain was not present. Radicular pain would be present if there was inflammation, compression, or injury to a spinal nerve root.

The use of imaging is not indicated in this case because there were no red flags. Typically this type of back pain responds to the use of simple analgesics; the use of opioids is not necessary. Acetaminophen is preferred for analgesia because of its relatively safe profile. The use of an NSAID may be needed because of its anti-inflammatory effect. At times, the short-term use of a muscle relaxer may be helpful for muscle spasm that often contributes to this type of acute pain. Tramadol is often used in cases of mild acute pain, but due to its potential abuse should be relegated to a second or third-line option. In this case, Chris is also on sertraline, and there is a potential interaction between tramadol and sertraline.

The goal, in this case, is to minimize disability and return Chris to her baseline function as soon as possible. Relative rest at first may be appropriate, but prolonged bed rest will contribute to deconditioning and stiffness and will prolong recovery. The patient with acute low back pain should have exercises to strengthen the low back, stomach, and other core muscles as well as stretching the low back and legs.

Appropriate health care of back pain will get patients back to normal functioning quickly while minimizing the risk of dangerous treatment options.

Neck Pain

Neck pain can occur from multiple pathologies, including trauma, muscle strain, or disc pain. The majority of cases of neck pain will resolve within three weeks. Initial treatments are conservative, including oral analgesics (acetaminophen or NSAIDs for mild or moderate pain; short-term opioids for severe pain), posture modification, and exercise.

Chronic neck pain has multiple treatment options. The use of a long-term cervical collar is not recommended. The use of a cervical collar to manage severe pain for less than three hours a day for at a maximum of 2 weeks may be considered. Physical therapy and home exercises should be used.

Pharmacological options for chronic pain include: acetaminophen; NSAIDs; a low-dose antidepressant, especially in those who have pain that interrupts sleep; a muscle relaxant may be considered for those with muscle spasm; and rarely opioids. Other options for pain management include trigger point injections, cervical medial branch blocks, TENS units, and radiofrequency neurotomy. Surgical evaluation may be considered in those with myelopathy or neurological symptoms associated with radiculopathy.

Cervical radiculopathy often resolves on its own. The initial treatment in those who have obvious signs/symptoms of cervical radiculopathy includes pain control, often with non-steroidal anti-inflammatory medications. At times, the use of oral corticosteroids to reduced inflammation is considered. When the pain is reasonably controlled, physical therapy is initiated.

After conservative treatment, some patients may have recurrent symptoms even if there is an initial improvement. At this point, conservative treatment should again be initiated except in the cause of significant motor deficit or myelopathy.

Confirmed cervical radiculopathy with severe symptoms that have not responded to conservative therapy can be managed with epidural steroid injections under fluoroscopic guidance unless there is a progressive neurological deficit.

No firm evidence exists that surgery for cervical radiculopathy provides significant benefit. Some individuals will derive benefit from surgery, while others will not. Certain individuals should have surgical evaluation including those with cervical nerve root compression on imaging, persistent radicular pain after 6-12 weeks of conservative treatment, signs/symptoms of cervical radiculopathy, or progressive motor weakness that impairs function.33

Complex Regional Pain Syndrome

Complex region pain syndrome (CRPS) is broken down into type I and II. It is a disorder of the extremities illustrated by regional pain that is inconsistent in degree or time to the expected pain. The pain is localized around a certain territory. The primary clinical manifestation is pain that is typically described as stinging, burning, or tearing and is exacerbated by movement, temperature variation, stress, or any contact. In addition, some individuals have allodynia or hyperalgesia. The patient may also notice differences in skin color or temperature. The affected side may be more edematous or sweat more when compared to the other side. Limb movement is typically impaired by pain, edema, or contractures. The patient with CRPS may also have unilateral variations in hair or nail growth along with skin atrophy.
The progression of the condition is variable over time. The underlying pathology is not well understood but may include inflammation and changes in pain perception in the central nervous system.

CRPS I is the more common type and is diagnosed when the typical symptoms are present, and there is no evidence of a peripheral nerve injury. CRPS II is less common and is present when there is evidence of a peripheral nerve injury. CRPS is more commonly seen in women. It is often associated with some acute event that starts the syndrome. This may include some sort of trauma, such as a broken bone or a crush injury. The diagnosis is made on clinical exam after other conditions are ruled out.

Treatment of CPRS should involve a multidisciplinary approach, including physical and occupational therapy, physiological interventions, and pharmacotherapy. Pharmacologic options include NSAIDs, tricyclic antidepressants, gabapentin, or topical treatments (lidocaine or capsaicin). Other less common options include calcitonin, glucocorticoids, alpha-adrenergic agonists/antagonist (e.g., prazosin, clonidine), ketamine, and opioids. Multiple interventional approaches may be considered, including regional sympathetic nerve blocks, trigger/tender point injections, and spinal cord stimulation.

Phantom Limb Pain

Phantom limb pain is aching, burning, or shock-like pain where an amputated limb used to be. It is important to rule out other causes of the symptoms, such as infection or wound on the stump, ischemia, or neuroma, before diagnosing phantom limb pain. The incidence of this condition is variable, and it is hypothesized that not controlling pain before and after the surgery increase the risk of phantom limb pain. Multiple agents are helpful in the management of phantom limb pain, including acetaminophen, NSAIDs, TCAs, and gabapentin. In addition to medication, non-pharmacologic methods to manage pain include TENS units, mirror therapy (which helps resolve the visual-proprioceptive disconnect), biofeedback, and occasionally surgical interventions.

Cancer Pain

Pain is very prevalent in cancer. It is present in up to one-half of patients when first diagnosed with cancer and, according to some estimates, up to 100 percent of people with advanced cancer.34

Pain in cancer can be acute or chronic. Acute pain is seen during interventions such as surgery, tissue injury, or radiation therapy. Acute pain can also be felt secondary to cancer itself, such as an obstructed bowel, a perforated bile duct, bleeding from liver cancer, or a pathological fracture. Chronic pain during cancer is typically related to the tumor itself or as a complication of treatment.

Neuropathic pain is also seen in cancer patients. Neuropathic pain in cancer can arise from the tumor pressing on a nerve or nerve plexus. In addition, neuropathic pain can be a result of the treatment, as many chemotherapeutic agents or radiation therapy have the potential to cause nerve injury. Many conditions that result in neuropathic pain, such as herpes zoster and post-herpetic neuralgia, are relatively common in cancer patients.

Management of cancer pain is typically aggressive. The use of opioids is common in chronic cancer pain, and doses should be titrated to find effective pain control. Agents commonly used include hydromorphone, morphine, oxycodone, and hydromorphone. These agents are preferably given orally or transdermally. Dosing is commonly started with short-acting agents, but for those with chronic pain switching over to a long-acting formulation is preferred with the continued use of short-acting agents for break-through pain. The dose for breakthrough pain is typically about 10 percent of the basal daily opioid dose. Individuals who need rapid titration do well with the use of opioids given via infusion by the IV or SC route.

While morphine is traditionally a common agent that is used, other agents have a good effect in certain situations. For those with swallowing difficulty or poor ability to absorb from the GI tract, the use of fentanyl can be used. Hydromorphone or fentanyl is recommended for those with renal insufficiency.

Irritable bowel syndrome

Irritable bowel syndrome (IBS) has multiple presentations. The most common symptoms include abdominal pain and altered bowel habits (constipation, diarrhea or alternating constipation and diarrhea). The abdominal pain of IBS improves with bowel movements, and the onset of pain is associated with a change in stool frequency and a change in the form of the stool.

To diagnose the condition, the criteria of recurrent abdominal pain occurring at least one day a week for the last three months associated two of the following three:

  • Change in the form of the stool
  • Change in the frequency of stool
  • Pain related to the bowel movement.

IBS is not associated with weight loss, anemia, rectal bleeding, and does not wake the person from sleep. As long as no alarm features are present, endoscopic evaluation is not necessary.

Alarming Features in IBS
  • Rectal bleeding
  • Weight loss
  • Nocturnal symptoms
  • Family history of colorectal cancer, celiac sprue or inflammatory bowel disease
  • Unexplained iron deficiency anemia

For individuals with mild and intermittent symptoms, lifestyle and dietary modification may be used, such as avoiding irritating foods, including beans, cabbage, and onions. Other dietary changes that may be helpful include avoiding large meals, avoiding caffeine, eating on a regular basis, and limiting fat intake.

In patients with mild to moderate symptoms that do not respond to lifestyle changes or those with severe symptoms, the use of pharmacotherapy can be considered in addition to lifestyle changes. Pharmacotherapy should focus on the treatment of predominant symptoms. Medication trials should be re-evaluated at two to four weeks. When constipation is the predominant symptom, the use of psyllium or polyethylene glycol should be tried. The next line options for constipation-predominant IBS include linaclotide and lubiprostone.

For patients with abdominal pain, the use of antispasmodics (e.g., dicyclomine, hyoscyamine) may be used. Antidepressants can be added when abdominal pain persists when using antispasmodics. Antidepressants are helpful in those with IBS and depression.

When IBS presents with diarrhea, the use of antidiarrheal agents can be used. If these are not effective, bile acid sequestrants are added. In select cases, rifaximin is considered.

Fibromyalgia

Fibromyalgia (FMS) is a condition characterized by chronic widespread musculoskeletal pain. Patients also complain of fatigue, sleep disturbances, psychiatric symptoms, cognitive disturbances, and multiple other somatic complaints. The etiology and pathophysiology are unclear.

In FMS, pain is typically diffuse and persistent. It is often described as stiffness, deep aching, soreness, burning, or throbbing. Patients typically report that pain is persistently present, but the intensity may vary. Poor sleep, excessive stress, and/or exposure to cold may exacerbate the pain. Generally, pain is worse in the morning and improves throughout the day. Pain commonly affects the neck, shoulders, back, arms, legs, and chest wall.

The patient looks well, and no objective findings characterize the disease on the exam. In addition, laboratory and radiological exams are normal in fibromyalgia.

Some have suggested that fibromyalgia is a form of central sensitization. Likely there is a genetic predisposition to the condition. It is thought that certain stressors such as sleep disturbance, infections, or trauma (emotional and physical) may lead to fibromyalgia.

Fibromyalgia is more common in women and has been shown to be six times more common when compared to men. The prevalence is about 2-3 percent in the United States. It is the most common cause of generalized musculoskeletal pain in females aged 20 to 55.35

Signs and Symptoms include:

  • Widespread musculoskeletal pain that affects both sides of the body
  • Fatigue which often occurs when waking up and in the mid-afternoon
  • Poor sleep (non-refreshed/non-restorative sleep and/or difficulty falling or staying asleep)
  • Numbness/tingling often seen in the extremities
  • Headache which may include migraine or tension headache
  • Cognitive disturbances such as problems with attention
  • Psychiatric disturbances including depression, anxiety, and posttraumatic stress disorder

Other conditions and symptoms associated with FMS include restless leg syndrome, obstructive sleep apnea, bladder irritability, chronic fatigue syndrome (CFS), Raynaud phenomenon, symptoms of autonomic dysfunction (e.g., orthostatic tachycardia), vulvodynia, temporomandibular syndrome, chest wall pain, irritable bowel symptoms (abdominal pain, diarrhea, constipation), dry eye, night sweats, shortness of breath and palpitations.

  • Soft tissue tenderness may be variable. When palpating a tender point, pressure should be equal to the amount of pressure to whiten the nail bed.
  • The exam should rule out any other causes of pain - synovitis or joint tenderness may suggest another disease.
  • Mild sensory or motor problems may be noted in fibromyalgia.
  • No visible inflammation is seen, but the patient often complains that their joints are swollen.

In 1990, the American College of Rheumatology (ACR) developed classification criteria. It identified nine pairs or 18 tender points and said that 11 of 18 of the points should be positive to diagnose FMS.

In 2010, a new criterion for diagnosed FMS was published. It did not recommend using the tender point examination to diagnose FMS as they are difficult to obtain, and many clinicians have not been trained in their use. It uses a widespread pain index (WPI) and a symptom severity (SS) scale in the diagnosis of FMS. The WPI assesses the number of painful body regions from a list of 19 areas. The SS score assesses the amount of fatigue, cognitive symptoms, the degree of waking up feeling unrefreshed, and the number of general somatic symptoms.

Patients with FMS often complain of hurting all over or feeling as though they have the flu. It is diagnosed in those with chronic pain and no hint of muscle inflammation.
Differential diagnosis of FMS includes osteoarthritis, autoimmune disease, rheumatoid arthritis, systemic lupus erythematosus, hypothyroidism, inflammatory myopathy, systemic inflammatory arthropathies, spondyloarthritis, Ankylosing spondylitis, myositis, and polymyalgia rheumatic.

The laboratory evaluation rules out other conditions and should include a complete blood count (CBC), an erythrocyte sedimentation rate (ESR) and/or C-reactive protein (CRP). Other tests may be ordered on an individual basis, such as a thyroid-stimulating hormone test (if hypothyroidism is suspected) or a creatine kinase (if inflammatory myopathy is suspected). Testing for other rheumatologic diseases (an antinuclear antibody test and rheumatoid factor) should be done if clinically indicated only.

Treatment of FMS is challenging at best. It typically includes a combination of non-pharmacological and pharmacological treatments implemented by a multidisciplinary team. The treatment approach must be individualized. The goals of treatment are to reduce pain and other symptoms of the disease.

Education is a critical step in the treatment of FMS. The condition must be explained to the patient, including treatment approaches. Key aspects of patient education include:

  • Sleep hygiene
  • Symptoms will vary over time – fatigue and pain typically persist.
  • It is a benign disease, and this should be taught to the patient. The patient must understand that the disease will not deform the patient, lead to a cosmetic issue, or become life-threatening.
  • Emotional or physical stress may increase symptoms. The patient should be taught stress-reduction and relaxation techniques to help in the management of the condition.
  • While infection may be a precipitating factor, it is not a persistent infection that causes the symptoms.
  • Neurohormonal abnormalities may account for fatigue, pain, mood disturbance, and sleep disturbance.
  • Exercise should be encouraged but may increase pain – especially early in an exercise program.

Other non-pharmacological methods to manage FMS include supervised physical therapy, cognitive behavioral therapy, biofeedback, tai chi, or yoga.

Medications are often used in the management of FMS. Typically non-pharmacological methods are used first, and when they are not effective, the addition of medication is considered. Commonly used medications include low dose tricyclic antidepressants, selective serotonin reuptake inhibitors, pregabalin, duloxetine, cyclobenzaprine, and milnacipran. When utilizing medications, the dose should be started low and built up gradually.

Amitriptyline, milnacipran, and duloxetine are fist line agents for fibromyalgia, but most patients do not find significant improvement (some improvement was noted with sleep and pain, but fatigue and quality of life were only minimally improved) on these medications and many have significant side effects.36

When first-line agents do not work, a combination of medications can be tried. For example, the use of duloxetine in the morning and a tricyclic antidepressant before bed is one such combination. Combinations of medications work through different mechanisms of action and focus on different symptoms.

At times the addition of analgesics or anti-inflammatory medication can be tried. The use of acetaminophen, NSAIDs, or tramadol may be considered to target pain when more traditional FMS agents do not work. Generally, opioids should be avoided in FMS.

Rheumatoid Arthritis

Rheumatoid arthritis (RA), a chronic destructive, sometimes deforming disease, attacks the collagen in the body, especially in the joints. Rheumatoid arthritis is associated with widespread symptoms such as fatigue, fever, poor appetite, nerve damage, and increased size of the spleen and lymph nodes. RA can irreversibly damage joints; therefore, early diagnosis and treatment to control inflammation can improve the outcomes of the disease.

Treatment options include psychosocial care, patient education, therapy, and pharmacologic treatment. A rheumatologist should be involved in the care of patients with RA as disease-modifying antirheumatic drugs (DMARD) are complex to use. If therapy is started soon, the patient will experience better outcomes. DMARD therapy is complex and requires a lot of monitoring and beyond the scope of this article.
The use of NSAIDs and glucocorticoids are also used in the management of RA. They can be used as bridging therapy to get quick control of inflammation until the DMARDs take effect and can be used for pain control.

Osteoarthritis

Osteoarthritis (OA) is the most common cause of disability in the older population. Arthritis affects twenty percent of adults and costs more than $128 billion annually in the United States. As the population ages, the burden of OA will increase. Managing arthritis improves mobility, decreases falls, decreases death rates, and improves the quality of life.

Osteoarthritis is defined as a joint disease with the deterioration of the joint and abnormal bone formation. OA is present when the endings of the bones - called cartilage, which normally cushion the bones - no longer do their jobs. The ends of the bones rub together, and the cartilage wears away.

Treatment of osteoarthritis focuses on pain control and maintaining function. In the near future, there may be treatments available to reverse or even cure the disease process, but at present, symptom control is the only option. Treatment focuses on medications, and non-medication means to control the pain and minimize disability.

Non-drug treatment is first-line management as it bypasses the negative effects drugs have on the body. Non-drug treatments include exercise, nutrition, physical and occupational therapy, heat and cold treatments, ultrasound, weight loss, magnets, and patient education.

When non-drug methods do not provide adequate relief, medications are used to treat OA. Due to its lack of negative side effects (when compared to non-steroidal anti-inflammatory medications), Acetaminophen is recommended as a first-line treatment for OA. Acetaminophen is more likely to be beneficial if the arthritis is not inflammatory. The American Academy of Orthopaedic Surgeons does not recommend for or against the use of acetaminophen. Their position paper reports that acetaminophen has no benefit over placebo, so they do not recommend this treatment. They do acknowledge that the side effect profile of acetaminophen is less toxic than non-steroidal anti-inflammatory agents (NSAIDs). NSAIDs are considered more effective in providing relief from hip and knee pain in osteoarthritis. Like acetaminophen, they act synergistically with opioids.

NSAIDs, such as ibuprofen (Motrin, Advil), naproxen sodium (Aleve, Naprosyn), choline and magnesium salicylates (Trilisate), diclofenac sodium (Voltaren, Voltaren XR), celecoxib (Celebrex), meloxicam (Mobic), and nabumetone (Relafen), are recommended by the American Academy of Orthopaedic Surgeons. These medications have more side effects than acetaminophen.

Another option for those with risk for gastric ulceration is the use of celecoxib. Celecoxib is the only available selective inhibitor of cyclooxygenase (COX) -2. COX-2 inhibitors are less likely to lead to gastric irritation. In those at very high risk for gastrointestinal bleeding, a COX-2 agent along with a proton pump inhibitor can be used. Monitoring for and eradication of Helicobacter pylori reduces the risk of NSAID-induced gastrointestinal injury.

Generally, NSAIDs are equally effective, but if one agent is ineffective, another NSAID may be effective as there is individual variation in response to different NSAIDs.
Topical NSAIDs may be used, especially if the disease is localized to one area. Topical agents are associated with a significantly less adverse event profile than systemic agents. In the United States, diclofenac sodium topical gel and diclofenac sodium topical solutions are available for the management of osteoarthritis.

Other topical agents can provide significant relief for patients with OA. Capsaicin (Zostrix) decreases the neurotransmitter called substance P, which is involved in the transmission of pain. Capsaicin is applied three to four times a day. It takes Capsaicin a few weeks before it provides significant pain relief. Hands should be washed after contact with the substance.

Another topical agent sometimes used for the treatment of localized pain is the lidoderm patch. This is not approved by the food and drug administration for use in OA but is often used. It is a small patch applied to the skin around the painful joint wore for no more than 12 hours a day.

Other options include tramadol, codeine, hydrocodone, hydromorphone, oxycodone, fentanyl, and morphine.

Intra-articular steroid injections can be used for painful joints. This involves placing a needle directly into the arthritic joint and injecting a steroid along with a numbing agent. Prior to the administration of the medication, aspiration of synovial fluid may occur. These are very effective treatments, but their length of effect is variable from weeks to months. Reduction in pain may be seen as soon as one week after the injection. Corticosteroid injections have the potential to damage cartilage, and no more than three injections per year should be given.37

Intra-articular hyaluronic acid is sometimes used to mimic the joint lubricant – which is often reduced in those with OA - that naturally occurs in the knee. It is classified as a medical device and not a drug. Products include Hyalgan, Supartz, Orthovisc, and Euflexxa, and Synvisc. The American Academy of Orthopaedic Surgeons does not recommend treatment. Side effects include discomfort, swelling, and pain at the injections site.

When medical treatment fails, surgery is the next option. Surgical options include arthroscopy, osteotomy, total joint arthroplasty, or joint fusion.

Myofascial Pain Syndrome

Myofascial pain syndrome is a group of conditions that involve muscle, tendon, ligament, fascia, bursa, and/or subcutaneous tissue. Diagnoses commonly seen in myofascial pain syndrome include tendinitis, bursitis, enthesitis, fasciitis, and regional myofascial pain disorder. Some are self-limiting, while others are more chronic. Tendonitis commonly occurs due to overuse and presents with local discomfort and inflammation. Bursitis is inflammation of the bursa, which are small pads that are filled with fluid. It is caused by infection, systemic disease, or repetitive injury. Enthesitis is when there is inflammation where the tendon inserts on the bone. Common diagnoses in this condition include plantar fasciitis and Achilles tendonitis.

Regional myofascial pain presents with taut bands in the skeletal muscle or in the fascia. These bands are indurated and hurt when pressed on. They result from acute trauma, minor microtrauma, or chronic strain.

Myofascial pain syndrome is a wide range of conditions that are typically treated symptomatically. Many of these conditions are caused by inflammation and are best treated with anti-inflammatory agents to treat not only the pain but also the inflammation.

Non-pharmacological therapy

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 trial of physical therapy and/or occupational therapy 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 be helpful in recommending 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.

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, and/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 the form of 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 spasm, joint pathology, or nerve root irritation. Methods of cold application include ice massage, ice bags, and gel packs. Alternating heat and cold may be more effective than the use of either one alone.

Multiple psychological techniques can aid in reducing pain. The basis for the use of 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 both 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 may be a focus on a close person, a place of enjoyment, a past event, or anything that is 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 an 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 that it works is unclear, but it promotes relaxation and helps reduce pain.

Acupuncture is a neurostimulation technique that treats pain by the insertion of small, solid needles into the skin at varying depths. Various theories exist to offer an explanation of 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 a wide variety of health care and educational settings.

Music therapists use music to facilitate changes that are non-musical in nature. Studies done with arthritic patients demonstrated that music helps to relieve pain and anxiety, induce relaxation, promote healing, enhance mental function, improve communication, promote physical rehabilitation, and reduce stress providing positive changes in both 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 signals that provide pain relief. There are also signals that 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 in whom other methods have not controlled the pain.

Pharmacologic Interventions

The World Health Organization (WHO) analgesic ladder was created for the management of cancer pain and published in the 1980s.39 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 are medications used to 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 it may be 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 in addition to depression). It is also important to establish the pathophysiology of the pain syndrome, evaluate the medication list, and consider the side effects of the medications prescribed.

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 used in the treatment of 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 a day. 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.

Schedules of Controlled Substances

In 1970, section 812 of the Controlled Substance Act was enacted, which lists substances that are controlled. 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, which is updated annuallyhere.

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. Examples of 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 that have less than 90 milligrams of codeine per dosage unit, such as Tylenol with Codeine. Medications that are 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 that contain less than 200 milligrams of codeine per 100 milliliters or per 100 grams such as Robitussin AC, lacosamide (Vimpat), and pregabalin (Lyrica).

The Controlled Substance Act regulates five classes of 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 likely to 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.

U.S. Centers for Disease Control and Prevention Guideline for Prescribing Opioids

The Center for Disease Control (CDC) and Prevention developed guidelines for prescribing opioids in chronic pain. It offers guidance to the clinician regarding safe and effective prescribing of opioids and assistance in the management of chronic pain. This guideline focuses on patients over the age of 18 who 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.40 It was developed because primary care clinicians reported insufficient training in opioid prescribing and concern regarding addiction. The guideline focuses on three main areas40:

  1. Determining when to start/continue opioids for chronic pain and includes looking at treatment goals, discussing 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, which includes the use of methods to evaluate risks and reduce risk. 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

Recommendation 1

The first recommendation suggests that chronic pain should be managed primarily with nonpharmacologic therapies and nonopioid pharmacologic therapies. Opioid therapy should be considered only when consideration given to both the potential benefit in pain control and functional improvement versus the risks. When opiates are used, they should be combined with nonopioid and nonpharmacological therapy.

Appropriate non-pharmacological therapies include weight loss, physical therapy, exercise, psychological therapies, and selected intervention procedures (joint injections). Nonopioid pharmacotherapy may include NSAIDs, acetaminophen, cyclo-oxygenase (COX)-2 Inhibitors, some anticonvulsants, and some antidepressants. The use of nonopioid pharmacotherapy is associated with a significantly reduced risk of overdose.

Recommendation 2

The second recommendation suggests that before initiating opioid therapy in chronic pain patients, it is important to establish realistic goals for pain and function. Also, patient education given that opioid therapy would discontinue if risks of therapy deemed greater than the benefits. Opioid prescriptions should only continue when there is a meaningful improvement in function and pain, and the benefit outweighs the risk to patient safety.

Research suggests that long-term use of opioids is associated with serious risks, and that risk is dose-dependent. Research shows weak evidence that opioid therapy beyond six months results in clinically significant pain relief or clinically significant improvements in quality of life. Many patients who use long-term opiate therapy discontinue therapy due to adverse effects or inadequate pain control. Because of these facts, it is hard to predict which patient will have benefits greater than harm when receiving chronic opiate therapy.

When opioid therapy initiated, the prescriber should determine the assessment protocol of the effectiveness of therapy. Also, treatment goals should be established with the patient before starting therapy. Goals should include relief in both pain and improvement in function. Conditions that lead to progressive functional impairment or injuries such as spinal cord trauma may have a primary goal of pain relief as opposed to improvements in physical function. In addition, the consideration of the social and emotional well-being of patients should impact that assessment as well.

Functional goals may include returning to work, attending specific recreational activities, walking around the block, or taking the dog for a walk. Assessing for depression and anxiety as well as other psychological conditions is an important aspect of managing the whole patient. Generally, if pain and function are not improved on opioid therapy, tapering or discontinuing the opioid should be strongly considered.

A written agreement should also be used that discusses how opioids will be prescribed and monitored and how they will be tapered or discontinued. Situations, where opioids should be tapered or discontinued, including when opioids are not needed, side effects become too severe, or treatment goals not being met.

Recommendation 3

The third recommendation suggests that providers should discuss the risks and benefits of opioid therapy both before and during treatment. Also, the responsibilities of both patient and clinician merit mandatory discussion before and during therapy.

Key teaching points:

  • Functionally improvement is the main goal, even if pain still is present.
  • The use of opioids generally does not improve pain and function in the long-term, but opioids may reduce pain in the short-term.
  • Discuss common side effects include nausea, vomiting, mental status changes, constipation, dry mouth, drowsiness, tolerance, physical and psychologic dependence, and withdrawal symptoms upon ceasing opioids.
  • Discuss potentially fatal respiratory depression, especially with higher doses or when used with other depressants such as benzodiazepines.
  • Chronic opioid use may lead to a lifelong opioid use disorder.
  • Increase fluid intake and fiber to reduce the risk of constipation.
  • Opioids reduce the ability to operate motor vehicles safely.
  • Discuss that the need for periodic review with consideration given to reducing or discontinuing the opioid.
  • Discuss the importance of not sharing prescriptions among family or friends.
  • Discuss safe storage, such as in a locked location.
  • Discuss the safe disposal of controlled substances.
  • Discuss monitoring that will include the use of urine drug testing and the use of the prescription drug monitoring program.
  • Consider discussing the use of naloxone.

Recommendation 4

Recommendation number 4 suggests that when starting opiates for chronic pain, immediate-release opioids are recommended over longer-acting medications. Longer-acting opioids are associated with a higher risk of overdose when compared to immediate acting opioids.

The Food and Drug Administration (FDA) reported in 2014 that extended-release or long-acting opioid pain medications should be used when pain is severe enough to necessitate daily, around the clock long-term opiate treatment when other options are not effective, not tolerated or would not offer adequate pain management. They should not have used on an as-needed basis.

Other key points under this recommendation include:

  • Certain medications are only appropriate for opioid-tolerant patients. An opioid-tolerant patient is defined as someone who has taken 60 mg daily of oral morphine, 30 mg daily of oral oxycodone, or equianalgesic dosages of other opioids for at minimum one week.41
  • There is not enough evidence to determine if taking immediate-release opioids for breakthrough pain when using ER/LA opioids is safe outside of palliative care, end of life care, and active cancer.40
  • The use of abuse-deterrent technologies makes it more difficult and less rewarding to manipulate the opioids. While they still can be abused, it is more difficult to do so. The abuse-deterrent technology does not prevent unintentional overdose, and the document from the Center for Disease Control does not make recommendations regarding abuse-deterrent formulations.
  • Research suggests Methadone having the highest number of overdose deaths when compared to other opioids when prescribed for chronic pain. Methadone also has cardiac complications such as QT prolongation and cardiac arrhythmias. In addition, methadone has a variable and long half-life, which can complicate when peak respiratory depression occurs. There is more interindividual variability in the pharmacodynamics of methadone when compared to other opioids. Methadone should only be used by prescribers that are very familiar with the unique pharmacodynamics and are willing to monitor patients on it closely.
  • The pharmacodynamics of transdermal fentanyl is also complex. A gradual increase in serum concentration can occur over the first 72 hours. Absorption can be variable based on factors such as external heat.
  • Initiation of Opioid treatment should not occur with ER/LA dosing, and this type of medication should not be used for intermittent use. They should be considered only in those who have severe pain and have used intermediate release opioids daily for at least seven days.

Recommendation 5

Recommendation five suggests that when starting opiates, the lowest effective dosage should take precedence. Extreme caution should be used when prescribing opiates. The risks versus benefits should be reevaluated with dosages above 50 morphine milligram equivalents (MME)/day used. If dosages above 90 MME/day used careful documentation of its justification should be accomplished.

Benefits of high dose opioids are not well established, and higher doses are associated with more harm, such as opioid use disorder, overdose, and motor vehicle accidents.
While lower doses of opiates reduce the risk, there is no dose threshold eliminating the risk of overdose. Dosage above 90 MME/day is linked to a high risk of overdose with lower dosages associated with less risk. According to the CDC document, when dosages pushed to over 50 MME/day, the risk of overdose increases without improving pain control or functional benefit.

When increasing the dosages of opioids, the increase should occur in the smallest amount possible to reduce the risk of overdose. There is no firm evidence on how long to wait before increasing dosages, but waiting for at least five half-lives before increasing the dosage has been recommended. In addition, extreme caution should be used in individuals over the age of 65 or those with kidney or liver insufficiency.

When dosages are increased above 50 MME/day, the prescriber should:

  • Assess if the opiate is helping to meet the treatment goals
  • Increase the frequency of follow-ups
  • Consider providing naloxone
  • Provide overdose education

Even patients who have been on high doses for many years; the offer to wean their dosage should occur. The patient should have education regarding recent clinical evidence suggesting that patients on high doses of opiates are at higher risk for overdose, and the provider should offer the patient an opportunity to wean dosage slowly if indicated.

Recommendation 6

Recommendation 6 suggests that when using an opioid for acute pain, the provider should use the lowest dose of immediate-release opioids and provide a quantity that is no more than the expected duration that the patient needs. Three days or less is often enough, and more than seven days rarely indicated.

Some research suggests that for back pain managed in a primary care setting, the use of opioid medications results in a large reduction in pain until the fourth day of treatment, and after that, smaller pain reductions are noted. Opioids should not be prescribed “just in case.40

Recommendation 7

Recommendation number 7 suggests that patients using opioids for chronic pain should have the benefits and harms evaluated within one to four weeks of beginning therapy or when there is a dose increase. After that, the benefits and harms should be evaluated at least every three months. If benefits do not outweigh the harms, the provider should consider tapering opioids to a lower dosage or discontinuing opioids.

Individuals who continue opioid therapy for three months or more are at increased risk of developing opioid use disorder.40 Therefore, frequent follow-up in the first three months may help reduce the risk of opioid use disorder. Another argument for close follow-up is that the risk of overdose is high during the first two weeks of treatment with ER/LA opioid use. The risk is especially high with methadone or fentanyl.

Research suggests that individuals who do not have pain relief from opioids at one month will likely not have pain relief at six months. Therefore, assessment within the first month is important to determine who will likely benefit from opioid therapy. Frequent assessments should reduce the risk of complications of long-term opioid use such as overdose, opioid use disorder, and other injuries.

Certain individuals are at higher risk for opioid use disorder or overdose, and this includes individuals with a history of a substance use disorder, individuals with depression or another mental health condition, patients taking greater than 50 MME/day, those with a history of overdose, and those taking other central nervous system depressant medications. These individuals should be evaluated more frequently. If found to be without benefit from the opiate, strong consideration should occur in reducing the dose or discontinuing the opiate.

When tapering opioids, the dose should be reduced weekly by 10-50%. In individuals who had a severe adverse event, such as an overdose, rapid discontinuation of 2-3 weeks could be utilized.40 For individuals who have utilized opioids for extended periods reducing dosages slowly may be appropriate. Reducing as slowly as 10% a month may be utilized in individuals who have been taking opioids for years. A slow reduction in opioid doses reduces the signs of opioid withdrawal such as anxiety, nausea, vomiting, diarrhea, tremor, increased heart rate, insomnia, drug craving, and abdominal pain.

Recommendation 8

Recommendation number 8 suggests that risk factors for opioid-related harms should be assessed before starting therapy and during opioid therapy. In addition, clinicians should implement strategies to reduce risk in individuals at high risk. The strategies would include individuals on greater than 50 MME per day, those with a history of an overdose, a history of a substance use disorder, or those on concurrent benzodiazepines.

One strategy to reduce the risk of overdose death includes prescribing naloxone. Naloxone can reverse the opioid when there is severe respiratory depression. Naloxone has the potential to bring on acute withdrawal symptoms in patients who are physically dependent on opioids.

Other factors that place patients at high risk for overdose including those with sleep-related breathing disorders such as sleep apnea or congestive heart failure, pregnancy, mental health issues, those with renal or liver insufficiency, and those greater than age 65.

Pregnancy puts both mother and fetus at risk because it can increase the risk of poor fetal growth, congenital disabilities, stillbirth, and preterm delivery. It can also lead to neonatal opioid withdrawal. When prescribing opioids for anyone of childbearing age, it is important to discuss a possible consequence of opioids during pregnancy.

Prescribing medication, including opioids, can be challenging in older adults. Some of the concerns include reduced renal or hepatic function, higher risk of respiratory depression, increased risk of side effects including cognitive impairment, more comorbid medical problems, polypharmacy, higher risk of falls, and constipation.

Extra caution should be utilized in individuals with mental health problems when prescribing opioids. This group of individuals is at higher risk for opioid use disorder and increased risk for drug overdose (especially in those with depression). For individuals with significant psychiatric instability or high suicide risk, opioid therapy should not be initiated. Also, individuals who have been prescribed benzodiazepines should very cautiously be prescribed opiates, if at all.

The Patient should be asked about drug and alcohol use. In addition, the prescriber should use the prescription drug monitoring program (PDMP) database before prescribing. For individuals with a substance use disorder obtaining outside consultation with a substance use disorder specialist or pain specialist regarding the management of pain is recommended.

Recommendation 9

Recommendation number 9 suggests that the clinician should review the PDMP database to determine previous/current opioid prescriptions as well as other medications that may interact and place the patient at higher risk for overdose. The clinician should review this data at a minimum of every three months, but as often as every prescription is written.

Research is limited on the benefits of PDMPs, but evidence suggests that individuals who received opioid prescriptions from multiple prescribers and at high doses are at the highest risk for overdose. The PDMP can help detect these situations.

Providers should not dismiss patients from their practice based on data received from these databases. Doing so has the potential to have negative health outcomes. The PDMP provides the provider and opportunity to intervene to reduce the risk of overdose by providing interventions as providing education, considering alternative therapies, or prescribing naloxone.

Recommendation 10

Recommendation number 10 suggests that when prescribing opioids for chronic pain, the use of urine drug testing should be used before the start of therapy, and at least once a year. The use of urine drug testing will ensure the patient is taking the medications as prescribed and that there are no illicit drugs in the patient’s system. The use of other controlled substances increases the risk of overdose. Urine drug testing has the potential to identify these patients and reduce risk. Urine drug testing also can determine when patients are not utilizing prescriptions as prescribed, which may point to diversion or side effects that limit compliance.

While urine drug testing should be done before starting opioid therapy, there is disagreement with how frequently testing should be done during long-term therapy. It should be done at least once a year. In high-risk individuals, more frequent testing should ensue.

Patients should have educated regarding the purpose of drug testing; to improve patient safety. Before testing, the provider should ask about the use of other drugs or other medications, and if there might be any unexpected results. The clinician should be prepared for any unanticipated results and should have a plan for dealing with them. Unexpected results should be discussed with the patient to determine if there is a logical explanation. If the unexpected results (for example, negative for a prescribed drug or positive for an unexpected drug) are not explained, then confirmatory testing should occur.

Confirmed unexpected results can lead to one of the following outcomes:

  • Modification of the pain management strategy
  • More frequent evaluations
  • Tapering/stopping the opioids. When testing for expected medications is repeatedly negative, then abrupt discontinuation is appropriate (as the patient is not taking the medication).
  • More frequent re-evaluation
  • Giving naloxone
  • Referral for substance use disorder treatment
  • Clinicians should not remove the patient from care due to an unexpected urine drug test. The abrupt removal from treatment is a safety measure as the patient could have withdrawal or obtain medication from another source or even start heroin. It could also be construed as patient abandonment. Lastly, it may miss a chance to get the patient into treatment for substance abuse disorder.

Recommendation 11

Recommendation 11 suggests avoiding prescribing an opioid and benzodiazepine together. This combination reduces respiratory drive and significantly increases the risk of overdose. The recommendation is not an ultimatum to never prescribe these two agents together but should be done rarely and with extreme consideration. For example, a patient who has been on a long-term, low dose benzodiazepine and develops severe acute pain may be a candidate for a low dose opiate medication. Other medications that suppress the central nervous system should be avoided in those on opiates. These may include sedatives, hypnotics, muscle relaxants, some antidepressants, and sedating antihistamines.

Recommendation 12

Recommendation number 12 recommends using an evidence-based treatment in those with opioid use disorder, which may include medication-assisted treatment (MAT) with behavioral therapy.

Points discussed under this recommendation include:

  • Opioid dependence is estimated to be present in between 3-26 percent of primary care patients on opioids for chronic pain. The use of MAT is effective in preventing relapse in those with opioid use disorder.40
  • MAT can occur with buprenorphine or methadone and, in some cases, naltrexone. Naltrexone blocks opioids effects and can be given as daily oral therapy or as monthly injections.
  • Providers should be aware of community resources available to help patients get treatment for opioid use disorder.
  • The use of MAT in pregnant women with opioid use disorder improves maternal outcomes. Treatment should be with buprenorphine or methadone, not naltrexone.

The CDC guideline aims to enhance the communication between patient and provider regarding the risks and benefits of opioid treatment in chronic pain. It also looks to reduce the risks of long-term opioid therapy and improve effectiveness and safety.

Steps in Prescribing Controlled Substance42:

  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. Establishing a physical and psychological diagnosis and establish 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 misuse controlled substances
  4. Establish goals in therapy regarding pain control and functional goals
  5. Using prescription monitoring programs to help determine patterns of prescription use and reducing 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 noncompliance 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 reduce 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

Management of Acute and Chronic Pain with Opioids

When non-opioid therapy is ineffective, or there is severe nociceptive pain, opioid therapy may be considered. Opioid therapy is effective in the management of 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 the continuation of pain relief or improved function for extended periods without sustaining serious risk of dependence, overdose, or addiction.51

In chronic back pain, opioids do not improve pain scores any 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 with 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 titrated upwards to control pain while side effects monitored. After determining the dose of the medication required to provide adequate pain relief with minimal side effects, the medication can then be converted to a sustained release form with administration once or twice a day. When long-acting medication 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 class of medications prescribed 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 review of the medication list.

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 any 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 is having 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 the intensity of pain 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 to use, and use both behavioral and descriptive measures of pain.25 A scale commonly used rates pain from 0 to 10. Another scale allows the patient to rate their pain as no pain, mild pain, moderate pain, severe pain, or unbearable pain. 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 location of the pain and rates the severity of the pain.

Pain Assessment and Measurement

Basic pain assessment is simple and must be performed regularly. Action needs to be planned on the basis of 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 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 in time, not to compare one person’s pain to another.  The use of pain scales assists the healthcare provider to determine the effectiveness of pain treatment.

The best scales are those that 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 type of 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.  In a pain map, there is 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, for example, the only valid measure of pain is the patient´s self-report (a subjective measure). Sometimes healthcare providers may believe that 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.

Pain Scale

For patients who are NOT cognitively impaired but who cannot respond verbally and/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 how they are feeling. 

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 level of pain. 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 are indicative of 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
Table 1: Types of Pain
Pain TypeDescriptionEtiologyTreatment
Neuropathic
  • Burning
  • Shooting
  • Tingling
  • Numbness
  • Radiating
  • Nerve involvement
  • Tumor
  • Postherpetic neuralgia
  • Diabetic neuropathy
  • Post-stroke pain
  • Antidepressants
  • Anticonvulsants
  • Local anesthetics
  • Opioids
Nociceptive Visceral (Poorly Localized)
  • Squeezing
  • Cramping
  • Pressure
  • distention
  • deep
  • Tumors occupying the liver, pancreas, and spleen
  • abdominal or thoracic surgery
  • ascites
  • Non-opioids
  • Acetaminophen
  • NSAIDs
Nociceptive Somatic (well-localized)
  • Dull
  • Achy
  • Throbbing
  • Sore
  • Bone metastases
  • Musculoskeletal injury
  • mucositis
  • Skin lesions
  • Opioids
  • Coanalgesics
  • Corticosteroids
  • local anesthetics
  • Bisphosphonates
  • Radioisotopes

It is also important to document the impact pain has 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 socializing?
  • Does the pain affect relationships?
  • Does the pain limit or affect activity or exercise?
  • Is the patient able to participate in activities of daily living 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?  This is less important in the nursing home setting as many of the IADL are impaired at baseline, which is the reason there was nursing home placement.    

Understanding how pain was treated in the past for the patient will help the clinician treat the current pain.  A review of past medical records will help the pain management team evaluate the condition. Reviewing all previous history, diagnostic testing, treatment options, and the efficacy of those treatment options 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 the way that drugs are excreted.  The use of 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 way to manage pain.   Mood or cognitive disorders can affect the way the pain is managed.  If mental illness is not appropriately identified and managed, chronic pain will likely never be adequately managed.   A history of drug abuse is an important factor to ascertain, as this could profoundly affect how chronic pain is treated.  

Personal characteristics may have a strong effect on pain management.  Factors that influence pain include race, age, culture, religion, sex, and/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.  This will help assess the patient’s expectations.  It is vital for patients 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 ability to ambulate.  While exams may include general observations, exams may be focused according to 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 part of the body.  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 include an evaluation of 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, the frequency of use, and the 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 substances 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 low, moderate, or high risk to abuse opioids.  Those who are high risk have a high likelihood of aberrant drug-related behavior.  The five questions include asking about 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 in low, moderate, or high risk.  

Nonverbal Patients’ Pain Assessment

Since pain is a subjective experience, we measure the existence and intensity of it by the patient’s self-report. Unfortunately, adult patients who have cognitive/expressive deficits or who are intubated, sedated, and/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 need to 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 clearly needed. The American Society for Pain Management recommends the following multifaceted approach for consideration in 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, 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 in the absence of 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 valid approach only when self-report is absent. The American Geriatrics Society identifies the following six main types of pain behaviors:
    1. facial expressions (e.g., grimacing)
    2. verbalizations or vocalizations (e.g., moaning)
    3. body movements like tense body posture
    4. changes in interpersonal interactions (e.g., aggression or resisting care)
    5. changes in activity patterns (e.g., refusing food or increased wandering)
    6. mental status changes like crying or increased confusion.
    • Encourage proxy pain rating by family members or caregivers who know the patient when patients are unable to 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 that are 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 are unable to self-report pain, other, less reliable measures must be used to identify its existence. These assessment measures (described above) form a hierarchy, arranged in order of probable importance. Health care facilities should institute a procedure for the use of 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 the assessment of pain in nonverbal adults who cannot provide a self-report has increased recently. Further study is required, though, 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 as such. 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 be helpful in identifying 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 who is a quadriplegic, since body language could not be scored.
      • Behavior checklists differ from pain behavior scales. They do not evaluate the degree of observed behavior, but just its presence or absence, and do not require a patient to demonstrate all of the behaviors specified. 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 and/or unconscious patients are 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 need to be tested for reliability and validity in the new patient population. The NVPS was tested in the burn trauma unit at Strong Memorial Hospital, Rochester, New York. After initial testing, 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 health-care 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’ needs to 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.

Patient’s Perception of the Pain

  • What is 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

Goals of Treatment

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 it is important for the prescriber to realize that a primary goal of prescribing opioids should be to maintain patient safety. A responsible prescriber should follow multiple steps to ensure the safe and effective care of their patients.

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.

Recommendations on Limitations of the Length of Prescriptions

Discontinuing chronic controlled substance therapy in those who repeatedly engage in aberrant drug-related behaviors, do not progress toward established goals or those who 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.42

Opioid overdose is a continuing public health crisis, and states have taken steps attempting 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 that opioids 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.23

  • Mild pain syndrome should generally be treated with acetaminophen and/or nonsteroidal anti-inflammatories along with nonpharmacological therapy.
  • 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 those from a major surgical procedure, total joint replacement, 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.69
  • 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 a mean of 21.2 pills after being released from the hospital.43

Recent data suggests that over the last few years, the strength of the dosing is not decreasing, and the number of days of prescribing is increasing.

Side Effects

Opioid medications are associated with multiple side effects, including constipation, nausea, vomiting, pruritus, abdominal cramping, sedation, and mental status changes. Multiple interventions are available to reduce side effects.

Constipation is a frequent issue in those who use opioids. Risk factors for constipation include older age, those with intra-abdominal pathology, and those who eat a low-fiber diet. Those on opiates should be encouraged to increase fiber intake, drink plenty of fluids, and be encouraged to exercise. Stool softeners (e.g., docusate sodium) and stimulants (e.g., bisacodyl) may be needed to manage constipation. An osmotic laxative such as polyethylene glycol or lactulose may also be considered, which may be added to stools softeners/stimulants for resistant constipation. Antiemetic medication can help treat nausea. Antihistamines can treat pruritus.

Opioids are associated with somnolence and other mental status changes. Patients do develop tolerance to these symptoms over weeks. Reducing the dose may lessen the mental status changes. An adjunctive medication may be added to the lower dose of opioid to help manage the pain. Rarely, the use of a stimulant can be used to manage sedation due to opioid use.

Respiratory depression may occur, but it is uncommon when the medication is used carefully. Starting low and slowly titrating the dose will reduce the risk of respiratory depression. Problems arise with rapid titration, the addition of another drug that may suppress the respiratory drive (benzodiazepine, alcohol, or a barbiturate) or the patient overdoses. Sedation precedes respiratory depression, so when starting a patient on opioid therapy, encourage them to take the first dose in the office to be monitored or in the presence of a responsible adult who can help monitor the patient. The level of consciousness should be assessed 30-60 minutes after the opioid is given. The next dose should be held, and the prescriber should be contacted immediately in the following circumstances: if the patient has a reduced level of consciousness, has hypoxia or has a respiratory rate less than 10 per minute.44

Opioids

Natural Opiates

Synthetic Opiates

  • Morphine
  • Codeine
  • Heroin
  • Thebaine
  • Oripavine
  • Demerol
  • Fentanyl
  • Dilaudid
  • Norco
  • Lortab
  • Atarax
  • Methadone
  • Buprenorphine
  • Pentazocine
  • Propoxyphene
  • Tramadol

Semisynthetic Opiates

  • Oxymorphone (contains Thebaine)
  • Hydrocodone (contains Codeine)
  • Oxycodone (contains Thebaine)
  • Hydromorphone (contains Morphine)

Semisynthetic opiates are molecules which contain some natural opiates and a mix of synthetic chemicals.

Morphine

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, solution, suppository, and parenteral solution. The immediate-release tablet is dosed 15-30 mg every 4 hours as needed, and the oral solution is dosed 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 who are 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 once a day is recommended. Higher doses are indicted for opioid-tolerant patients. Titration may be done every 1- 2 days. When converting from other forms of morphine, it 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, 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 enhances 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

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 indicated for around the clock pain management in those with chronic severe 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, and it 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, 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.

Fentanyl45, 52

Fentanyl and its street produced analogs (acetylfentanyl, furanylfentanyl, and carfentanil, among others) are synthetic opioids meant to mimic the effects of opium. Pharmaceutical grade fentanyl is fifty times more potent than heroin, and 100 times more potent than the same amount of morphine. Medicinal use fentanyl is a very useful tool in managing severe pain, such as in cancer treatment or palliative, end-of-life care. Black market fentanyl sometimes referred to as IMF (illicitly manufactured fentanyl), varies in strength and purity, yet remains incredibly potent. Street drug dealers often mix IMF into cocaine or heroin in order to up the drug’s effects.

Carfentanil, a fentanyl knock-off, is roughly 10,000 times more powerful than morphine and requires specialized toxicology to detect.
The seriousness of synthetic opioids, such as fentanyl and its close mimics, is reinforced by a study published in the May 2018 Journal of the American Medical Association that found in the year 2016, 46 percent of opioid deaths were attributed to a synthetic opioid. That’s up from the 14 percent synthetic opioid death rate in 2010.

Oxycodone

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 who require around the clock pain control. It is dosed 10 mg every 12 hours to start and titrated carefully. When changing from immediate release 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 the removal of 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 less than 60 mL/min should have the dose adjusted down 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 period of time or near term. It does enter breast milk and is not recommended in those who are breastfeeding

Hydrocodone

Hydrocodone, which was 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 its self in an extended-release form. The combination pill has a short-acting version of hydrocodone and is dosed 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 very 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) enhance 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 with caution in breastfeeding and the combination pill has been shown to enter the breast milk and its use is not recommended.

Tramadol

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 and/or 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 dose of 200 mg a day). In those with severe liver impairment, the immediate release form should be given at a maximum of 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, and sweating.

Patients may experience withdrawal symptoms from tramadol that may include 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 who are 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 other drugs that lower the seizure threshold. The risk may also be increased in those who have seizures or are at risk for seizures, such as those who have 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 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 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 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 the breast milk and is not recommended in lactating women.

Other Medications

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 is used (Opana® ER) and 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 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, therefore, 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 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 who have 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 to lead 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 a day. Methadone should be used for severe pain that has not been responsive to other agents and only by clinicians with specific training in the use of methadone. Methadone is also used in detoxification.

Tapentadol (Nucynta, Nucynta ER) is used for acute moderate to severe pain and started 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 rates of central nervous system toxicity.

Oral Opioids: Adult Dosing

DrugInitial Dose (Treatment Naïve)Duration of Effects (in hours)Notes

Morphine

Immediate-release

10-30 mg every 3-4 hours as needed3-6  

Controlled-release ((MS Contin, Oramorph SR)

15 mg two times a day8-12 

Sustained-release 
(Kadian)

30 mg one to two times a day12-24 

Extended-release 
(Avinza)

30 mg once a day24 

Hydromorphone

Immediate-release

2 - 4 mg every 3-4 hours as needed3-6  

Extended-release 
(Exalgo)

8 mg every 24 hours  

Oxycodone

Immediate-release

5-15 mg every 4-6 hours3-6

Often combined with acetaminophen or aspirin

Controlled-release (OxyContin)

10 mg two times per day8-12 

 

Extended-release  (with acetaminophen) (Xartemis XR)

15 mg oxycodone with 650 mg acetaminophen every 12 hours8-12  

Hydrocodone

Immediate-release

5-10 mg every 6 hours4-8 

Combined with acetaminophen or ibuprofen

Extended-release (Zohydro ER)

10 mg every 12 hours12  

Fentanyl

Fentanyl patch

25 mcg per hour changed every 72 hours48 to 72 (12 hours after removal)    

 naïve patients, or acute pain; onset 12-24 hours

Oxymorphone

Immediate-release (Opana)

5-20 mg every 4-6 hours4-6 

Extended-release (Opana ER)

5 mg two times a day12  

Methadone

2.5 mg every 8-12 hoursFirst dose 4-8 hours, up to 48 hours with repeated doses

High risk for overdose partly due to the long half-life; prescribed only by a trained prescriber

Tapentadol

Immediate-release (Nucynta)

50 - 100 mg every 6 hours3-6 

Extended-release (Nucynta ER)

50 mg every 12 hoursunsure 

Tramadol

Immediate-release (tramadol)

50-100 mg every 4-6 hours4-6 

Max dose 400 mg/day

Extended-release (Ultram ER, ConZip)

100 mg once a dayunsure

Max dose: 300 mg/day

Follow Up

Regular follow up is important and should occur at a minimum of every three months. When assessing the pain patient, include the five A’s, which are: analgesia, addiction, activities of daily living, adherence, and adverse effects. Part of follow up should be urine drug testing to detect medication adherence as well as 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, which should be used between prescribers and patients when controlled substances 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.

Points Commonly Seen in Opioid Agreements
  • Early refills will generally not be given
  • Patient will not seek controlled substances from another provider
  • Patient will use only one pharmacy
  • Permission for the prescriber to speak freely with other healthcare providers, pharmacists and family members regarding opioid use
  • Patient will submit to urine drug test
  • The patient will safeguard the medications
  • Common side effects of the medication will be discussed

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. If a patient has an undisclosed prescription for controlled substances, it is prescription drug misuse.
When abuse/misuse is detected, how should the clinician respond? If it is alone, minor deviation from counseling along with 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 removal of the prescription is likely the best course. If a substance abuse disorder is suspected, a referral to an addiction specialist is recommended.

Clinician Response

How should the clinician respond when abuse or misuse detected? If it is a singular, minor deviation, then counseling, along with 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 removal of the prescription is likely the best course. If a substance abuse disorder is suspected, recommend a referral to an addiction specialist.

Tips to Reduce Iatrogenic Harm

  • 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 52
  • 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 in use.
  • The greatest risk of opioid use is respiratory arrest and death, and this risk is greatest when the therapy is started or the dose increased. Opioid-induced respiratory depression manifests by the reduced desire to breathe and reduced respiratory rates. The patient will be breathing shallow, 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 more than 100 mg of morphine or morphine equivalents per day is used, the risk of accidental overdose is high.
  • Pay attention to drug-to-drug and drug-to-disease interactions.

Patient Education on Opioid Medications

Patient education is crucial as it will reduce the risks associated with these medications and result in improved 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, as well as 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 and/or an 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 overestimation of 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 got 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).46

Patient education should also include information on misuse. Many patients will misuse medications because they are seeking 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 result in immediate termination of 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 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 and/or the package insert every time they get a new prescription.
  • Teach about abuse, addiction, misuse, and diversion.
  • Risks of overdose and/or death if dose not taken exactly as prescribed or someone else takes the medication.
  • Pain medications may impair breathing.
  • Do not give the medication to anyone else.
  • If anyone else takes the medication, to contact emergency services.
  • Swallow pills whole that are meant to be swallowed – do not crush, snort, chew, inhale, or take by 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 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 may affect driving ability or safety at work, especially if operating heavy equipment.
  • Opioids should be stored safely and away from family members, acquaintances, and friends.
  • Medications should be locked up in a drawer, cabinet, or safe so no one else will get them.
  • Educate patients that it is illegal and dangerous to give away or sell their medications to others.
  • 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.

Termination Strategies for Chronic Therapy

Discontinuation of opioid therapy may be considered if problematic patterns are noticed, opioid therapy is not effective, 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, at which time a 5% reduction every 2-4 weeks may be done.

Offer Individuals who have shown aberrant behavior other non-opioid options. For 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.

Case Study

Jack C is a 38-year-old male with chronic back pain due to three herniated discs and spinal stenosis, which was first diagnosed after a motor vehicle accident three years ago. He currently rates the severity of his back pain as a 9/10 and has been unable to work as a plumber due to his pain. He describes the pain as dull and constant with occasional sharp exacerbation in the low back with the pain increasing with bending, prolonged standing, and walking. The patient denies any loss or change of bowel/bladder control, history of IV drug use, recent infection, progressive neurological complaints, night pain, night sweats, weight loss, or fever. The pain radiates into the right leg to the knee, and he describes this pain as burning and tingling. The patient can do all his activities of daily living but does report poor sleep at night.

He has a past medical history of hyperlipidemia. His only current medication is atorvastatin to control his cholesterol.

He has had multiple treatment modalities, including four rounds of physical therapy, chiropractic treatment, and multiple medications. He tried to control his back pain on acetaminophen, ibuprofen, and topical non-steroidal anti-inflammatory agents without relief. The patient experienced significant tremors and an increase in blood pressure while on tramadol. A series of epidural injections did not help. The patient refused surgery as an option when discussed.

Jack is married and has one daughter who lives over 500 miles away with her biological mother. He has limited financial means and lives paycheck to paycheck. He has a prior history of alcohol abuse but has not had a drink in five years, and is currently a smoker. He denies any history of substance abuse, and there is no family history of alcohol or substance abuse.

Physical exam showed a patient with a slow, deliberate gait, a limited range of motion in the spine with no obvious deformity, swelling, or erythema. There is mild tenderness on the right side of the spine from the area of L4 to S1 as well as tenderness in the right sacroiliac joint. Normal reflexes, normal sensation, normal strength, and no atrophy noted in the lower extremities. The straight leg raise test is normal.

An MRI performed one year ago showed a herniated disc at the L5/S1 level and mild spinal stenosis.

The Opioid Risk Tool was administered and determined that the patient is at moderate risk for opioid abuse. He signs a written opioid treatment agreement that outlines the conditions of opioid therapy. His past medical records were verified, suggesting he is not lying.

After the state’s PDMP was accessed, it was determined that he had not gotten any controlled substances for the last two years. The patient is prescribed hydrocodone/acetaminophen 5 mg/500 mg, two tablets every six hours as needed (56 tablets) for one week.

He returned to his primary provider, who was uncomfortable prescribing him long-term opiates, so he was referred to a pain specialist. The pain specialist continued the hydrocodone/acetaminophen two tablets every six hours as needed for pain. At the same time, he was started on gabapentin 100 mg three times a day, and then after one week, the dose was increased to 300 mg three times a day to manage the neuropathic pain. He is also started on a lidocaine patch. The patient was told to follow up in two weeks to assess effectiveness. After two weeks, the patient reports he is more functional, and the pain is improved. The dose of the gabapentin was increased to 600 mg three times a day. After two more weeks, he reports he is feeling better and wants to stop the hydrocodone/acetaminophen. He continues the gabapentin and lidocaine patch and uses a combination of acetaminophen and naproxen for breakthrough pain.

Case Study

Ms. L is a 46-year-old female with a history of bilateral knee pain; she currently rates the pain as an 8/10 in her right knee and 5/10 in her left knee. She takes MS Contin 60 mg every 12 hours with an immediate-release tablet of morphine dosed 15 mg every 8 hours as needed (she averages one dose a day) and has been using this regime for the past six months. However, over the last month, she has not been getting adequate relief from her pain and has been progressively disabled and has stopped exercising.

The pain is attributed to osteoarthritis and has been progressively worsening over the last 1-2 years. She has a past medical history of anxiety and depression but does not take any medication for these conditions. She has a past-surgical history of a hysterectomy approximately three years ago and takes no other medications. She has no known allergies.

She has no history of alcohol, drug, or substance abuse. She has a strong family network, including a supportive husband of 25 years and two sons who live within twenty miles of her home.

The physical exam is significant for obesity (BMI of 34). She has crepitus to both of her knees and is unable to reach full extension of the right knee due to pain

An x-ray demonstrates moderate arthritic changes in both knees. The patient is unwilling to consider the surgery of her knees.

After the state’s PMPD was accessed, it was determined that he had not gotten any controlled substances other than the morphine for the last two years. A urine drug screen was positive for morphine, but no other substances.

The prescriber offers meloxicam and a knee injection in her right knee. She is agreeable to a follow up in two weeks, which at that point, there is a noted improvement in her pain level as well as the amount of enjoyment she gets out of life. She reports she has not used any breakthrough morphine dosing. The nurse practitioner increases the dose of meloxicam and gives her an injection in her left knee and has a conversation about weaning the morphine dosing. The patient is agreeable to weaning dose of morphine by 10 mg every 1-2 weeks with frequent follow-up to assess pain control. Over the next year, she can wean off morphine while continuing the meloxicam. In addition to the meloxicam, she was able to lose 20 pounds, which she attributes to her improved quality of life and improved ability to function.

Overdose

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.

Can Narcan Reverse Acute Opioid Overdose? 25,48,53

Yes, Narcan (naloxone) can reverse an acute opioid overdose, when given in time. The timing issue is so important that our current United States Surgeon General issued a rare national advisory in April 2018, urging more citizens to have Narcan on hand in order to help those they find overdosing on opioids.

Naloxone is an opioid antagonist that binds to opioid receptors in the body, preventing and reversing the effects of opioid medications. Positive effects of restoring breathing last from 30 to 90 minutes, precious time in which medical assistance can be initiated.

Narcan/ Naloxone comes in three forms:

  • Injectable, which requires some professional training to give
  • Auto-injection devices, where prefilled doses can be administered by families, office personnel, or first responders
  • Nasal spray, (approved by FDA fast-track in 2015) is a needle-free prefilled device that can be sprayed into one nostril while the person in need is on their back

NOTE: Once Narcan is given, turn the person onto one side if it is safe to do so. Narcan administration can provoke vomiting, and it is never good to risk emesis entering the lungs

Remember that any Narcan administered will wear off, so observation for at least two hours after the last dose is given is crucial, lest any opioids still present in the person’s system places them once more into an overdose situation.

Abuse and Misuse

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, in fact, 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 used as or in prescription medication are taken.

Opium, and to a greater or lesser extent, all of the “opioids,” are able to 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.9 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.4 The longer opioids are used, the less and less 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.

Risk Factors for Opiate Abuse

  • To prevent prescription drug abuse, the clinician needs to assure:
  • Patients are assessed and reassessed
  • Treatment agreements in use
  • Prescription monitoring occurs
  • The practice of safe prescription methods

Patients' risk should be assessed, with contraindications immediately identified. Contraindications to opioid treatment include those who have erratic follow up, suffer from current untreated addiction, or have poorly controlled mental illness.

The health care industry should shoulder some of the burdens of the opioid epidemic. The 1990s were a time when pharmaceutical companies aggressively marketed pain medications. Healthcare providers, encouraged by the Joint Commission, were encouraged to assess pain and manage it appropriately. The combination of intense assessment and pharmaceutical companies marketing pain medication was partially responsible for the increased use of opioid pain medications. Also, support was given to multiple medical organizations, including the American Pain Society, the Federation of State Medical Boards, and the American Academy of Pain Medicine that lobbied for aggressive identification and management of pain.49

Research from 2015 showed that six times more opioids were dispensed in counties with high prescribing rates versus counties with low prescribing rates. Certain characteristics make prescribing controlled substances more likely. The CDC reported risk factors for counties at higher risk for prescribing more controlled substance including a higher percentage of white people, more patients with diabetes, arthritis, or disability, when a higher percentage of people were unemployed or uninsured, counties with more dentists or primary care physicians, and counties with small cities or large towns.38

There are many known risk factors for opioid abuse, misuse, diversion, addiction, and overdoses.50 Evaluating these risk factors remain an important aspect of the evaluation of a patient. Factors that increase the risk of problematic opioid use include:

  • A prior history of misuse or abuse
  • Younger age
  • Untreated psychiatric disorder
  • Living in a social and/or family environment that encourages misuse
  • Genetics
  • Physical, sexual or emotional abuse
  • Using nicotine, alcohol or other drugs at an early age
  • Substance use/abuse in the family or among friends
  • Stress
  • Access to addictive substances
  • Highly impulsive personality
  • Family or personal history of drug/alcohol abuse and mental health issues including depression, anxiety, eating disorders, or personality disorders
  • History of legal trouble/incarceration
  • White race

Prescription drug misuse is the use of prescription medication in a method or intent inconsistent with its prescription; this includes using medication to get high, selling or sharing it with other (diversion), overuse, having multiple prescribers, and concurrent use of alcohol or other illicit substances. Misuse is necessary but not solely enough of a criterion for a substance use disorder.

Susceptible individuals are at risk in the misuse of medications that stimulate the reward center of the brain, which may include opioid analgesics, stimulants, benzodiazepines, or tranquilizers.

Opioid Crisis Interventions

Yes, some practices have been shown to be successful in both bringing users back from their opioid misuse, and keeping others from wandering into the trap of overuse and addiction. For preventing opioid misuse, for instance, encouraging clients in some safe practices and prescribers in some positive actions are useful.55,56

  • 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 as53;

  • 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, a decrease in their everyday coping skills.
  • Physical changes – constricted pupils, drowsiness, slurred speech, constipation, slowed breathing, malnutrition, even an increase in skin and other infections.

Case Study: Frederick

Frederick (call me Fred) is a 32-year-old bricklayer who fell from scaffolding seven months ago. During his three-month recuperation, he became opioid-tolerant, developed a dependence, and subsequently continued using opioids after his injuries had healed, and he was released from medical care. As Fred puts it in a return-to-treatment interview session, “Bricking is an unforgiving occupation. When I can’t concentrate, I make mistakes. Mistakes get me injured or fired.”

Fred attempted to wean himself off opioids. When that failed, he went “cold turkey,” trying to stop using abrupt withdrawal. However, the intense symptoms of withdrawal and constant cravings proved too much for him. He has subsequently entered a formal medication-based treatment program for opioid abuse.

In his first six weeks of the treatment program, Fred is switched from his drug of choice, OxyContin, on buprenorphine, a partial opioid agonist used to diminish physical dependence to opioids.57 The treatment produces a lack of cravings, and urine testing shows that Fred is staying opioid-free. The buprenorphine is gradually lowered to a maintenance amount, and Fred returns to full-time work.

Eventually, feeling cured of his cravings, Fred stops going to treatment and stops the buprenorphine. A few months go by, and another injury brings Fred into contact with oxycodone prescribed at the urgent care clinic he visits. The use of prescription pain medication quickly increases, and he finds himself with thoughts focused on the next dose of medication. Having experienced some of the downsides of opioid dependence, as well as the benefits of regaining control, Fred presents himself to the opioid treatment center to get control of his life back again.

Prevention of Misuse

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

  • 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, the frequency of use, and the 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 substances 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 for 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 low, moderate, or high risk to abuse 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 asking about family and personal history of substance abuse (alcohol, prescription drugs or illegal drugs), age (risk is 16-45 years old), psychological disease, and a 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 in low, moderate, or high risk.

Regular follow-up is important and should occur at 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 as well as illicit and non-prescription drug use. It is critical that the clinician adequately document any and all 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.

Conclusion

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. Having 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.

It is the role of the health care team to perform a good initial pain assessment and an on-going assessment of pain. Proper pain management requires a team approach in the assessment and treatment of 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 lead to many social and legal problems, including overuse and diversion.

The health care team also has the responsibility to partner 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.

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References

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