WHO SHOULD READ THIS?
Any physician assistant who provides care to patients with chronic non-cancer related pain.
WHY IS THIS IMPORTANT?
Fifty million Americans suffer from chronic pain each year, and chronic pain is the most common cause of long-term disability in the United States. Still, research suggests that three out of four chronic pain sufferers do not receive appropriate therapy.1 Opioids offer effective pain control, and opioid use in the United States increased markedly between 1997 and 2006, especially for morphine (184%), fentanyl (450%), oxycodone (899%), and methadone (1,129%).2 Despite this large increase, many providers continue to feel that pain in any form is undertreated.
HOW IS PAIN CLASSIFIED?
Pain can be classified into three general categories: acute, chronic, and cancer related. Acute pain is a normal response to tissue damage and usually resolves when the damage heals. Cancer-related pain is associated with tumor growth, metastatic disease, and side effects of treatment. Chronic pain is defined as pain that lasts longer than expected for healing, persistent pain not controlled by nonopioid methods, pain associated with nonmalignant disease, or pain where healing may never occur.3,4 Pain may also be defined as nociceptive (resulting from tissue damage) or neuropathic (caused by damage or dysfunction of the central or peripheral nervous system).
WHAT GUIDELINES EXIST FOR OPIOID USE?
Despite growing evidence that opioids are useful in managing chronic pain, limited studies exist regarding ideal dosing regimens and duration of use.5,6 Most studies are small, limited to a single study in the area, or limited to nonexperimental descriptive studies. Clearly, more studies need to be done in order to guide clinicians in prescribing opioid therapy for patients with chronic pain.
The American Pain Society and the American Academy of Pain Medicine has issued evidence-based guidelines for the management of chronic pain based on an expert review of the literature.7 Another source of guidelines; assessment algorithms; recommendations based on type of pain; and multifactorial, comprehensive care plan management can be found at the National Guidelines Clearinghouse.8
Opioid therapy should be considered if other treatment modalities fail to provide effective analgesia and the benefit of using opioids exceeds the risks. The therapy, its side effects, and issues relating to tolerance and addiction should be discussed with the patient, and applicable regulations should be reviewed.9 The general recommendation is to start at the lowest dose possible and gradually increase until pain control is obtained.
For a sample controlled substance agreement, please click here.
WHAT ARE THE TREATMENT MODALITIES FOR CHRONIC PAIN?
Initial treatments for acute and chronic pain may include medications such as NSAIDs, acetaminophen, antidepressants, and anticonvulsants. Alternative therapies may also include core-strengthening activities, physical therapy, occupational therapy, psychiatry, counseling, dietary changes, and weight loss, as well as nontraditional therapies such as acupuncture, healing touch, massage, and other behavioral techniques.3 Therapies should be selected as appropriate to the patient's needs, comorbidities, and physical ability.