HOW DO I INITIATE
OPIOID THERAPY FOR CHRONIC PAIN?
When the patient and provider determine that opioid therapy could be beneficial, a standardized approach should be used that includes the following: an initial, comprehensive medical history and physical examination; establishment that nonopioid therapy has failed; establishment of agreed-on goals for treatment; discussion of the true benefits and risks of long-term opioid use and documentation of the discussion; limitation of prescribing to one provider and pharmacy (when possible); and a requirement for comprehensive follow-up. Screening for a history of or risk for substance abuse should be done initially and during follow-up visits. During follow-up, there should also be regular review of the goals being achieved, monitoring for signs of abuse, assessment of side-effects, and drug screening if needed; adjunctive therapies and the end of opioid treatment should be considered if goals are not being met.10
PAs should also use a controlled substance agreement, which outline patients' and clinicians' responsibilities and the treatment limitations.3,4,6 A sample agreement is provided with the online version of this article. Potential items to include in the agreement are limitation to one prescribing clinician and designated pharmacy, drug screening for at-risk patients (including a screening schedule and responsibility for cost), a refill policy, and a therapy discontinuation policy.
WHAT ARE THE BEST
OUTCOMES?
Patients with chronic pain do best when they participate in interdisciplinary pain management programs where the team may include a pain management clinician, psychologist, nurse specialist, physical therapist, vocational counselor, and pharmacist. Such team support provides patients not only with medication therapy but also with additional strategies for coping with their condition.3 A written plan of treatment is tailored to fit the patient's abilities and expectations, and it includes measureable treatment goals and requirements for continued treatment. Such agreements might require continued use of counseling, traditional and nontraditional therapies, and other active coping practices. Early referral to a pain clinic for interdisciplinary pain management is recommended for patients with difficult to treat acute or chronic pain. Patients who have significant comorbid psychological conditions such as depression or substance abuse or who have complicated medical conditions may benefit most from early consultation with pain medicine specialists.
WHAT ARE THE MOST COMMON CONCERNS?
Practitioners, patients, and others are very concerned about the potential for addiction and its consequences, drug-seeking behaviors, escalating drug doses, and drug diversion. Practitioners are concerned about regulation of prescribing privileges as well as about regulatory investigation and threats to licensing. While addiction and licensure are concerns, they should not prevent clinicians from providing appropriate care to their patients—especially if they are following the suggested guidelines for opioid therapy. A recent evidence-based review has noted that the risk of addiction is negligible in appropriately selected patients.11
Physical dependence is a predictable neural adaptation, called tolerance, that occurs in all patients receiving continuous opioid therapy.9 Although tolerance can result in the need for larger or more frequent doses of medication to control pain—and it may increase such unwanted side effects as sedation, central depression, and nausea—tolerance is not the same thing as addiction.
Addiction is distinguished from tolerance by a persistent pattern of dysfunctional behaviors that are focused on the possession of medications, including a preoccupation with obtaining opioids despite having adequate analgesia, increased use of the drugs despite side effects that can lead to harm, loss of control in use, and aberrant behavior leading to drug possession.9 Addiction can be difficult to distinguish from tolerance or pseudoaddiction (a misinterpretation of relief-seeking behavior that resolves upon institution of effective analgesic therapy). The use of contracts and screening for these criteria will help clinicians distinguish tolerance from addiction. Referring difficult-to-treat patients to a pain specialist can increase the chance for treatment success.
Providers have a limited or poor understanding of the state and federal laws and regulatory guidelines regarding the proper prescribing practice of opioids for chronic pain.7 The stigma and fear associated with substance use disorders may also contribute to the inadequate treatment of chronic pain. While these are valid concerns, they should not prevent PAs from providing appropriate care to their patients, especially if they are following the recommended guidelines in initiating opioid therapy. JAAPA
This article was written by Anthony E. Brenneman, MPAS, PA-C. Contributors included the other members and staff of CSAC 2009-2010: Daniel L. O'Donoghue, PhD, PA-C, Chair; Gilbert A. Boissonneault, PhD, PA-C; Alison C. Essary, MHPE, PA-C; Frank Fortier, PA-C; Michelle Lynn Heinan, EdD, PA-C; Marie-Michèle Léger, MPH, PA-C; and Thomas Moreau, PA-C, MS. The manuscript was edited by Sarah Zarbock, PA-C.
REFERENCES
1. American Pain Society. Pain: current understanding of assessment, management, and treatments. http://www.ampainsoc.org/ce/downloads/npc/npc.pdf. Accessed February 2, 2010.
2. Manchikanti L, Singh A. Therapeutic opioids: a ten-year perspective on the complexities and complications of the escalating use, abuse and nonmedical use of opioids. Pain Physician. 2008;11:S63-S88.
3. Asburn MA, Staats PS. Management of chronic pain. Lancet. 1999;353:1865-1869.
4. Trescon AM, Boswell MV, Sairam LA, et al. Opioid guidelines in the management of chronic non-cancer pain. Pain Physician. 2006;9:1-40.
5. Pergolizzi J, Boger RH, Budd K, et al. Opioids and the management of chronic severe pain in the elderly: consensus statement of an international expert panel with focus on the six clinically most often used World Health Organization step iii opioids. World Institute of Pain. 2008;8(4):287-313.
6. Trescot AM, Helm S, Hansen H, et al. Opioids in the management of chronic non-cancer pain: an update of American Society of the Interventional Pain Physicians' (ASIPP) guidelines. Pain Physician. 2008;11:S5-S62.
7. American Pain Society-American Academy of Pain Medicine Opioids Guidelines Panel. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009;10(2):113-130.
8. National Guidelines Clearinghouse. Assessment and management of chronic pain. http://www.guideline.gov/summary/summary.aspx?doc_id=12998&nbr=006693&string=pain+AND+management. Accessed February 2, 2010.
9. McCarberg BH, Barkin RL. Long-acting opioids for chronic pain: pharmacotherapeutic opportunities to enhance compliance, quality of life and analgesia. Am J Therapeutics. 2001;8:181-186.
10. Ballantyne JC, Mao J. Opioid therapy for chronic pain. N Engl J Med. 2003;349:1943-1953.
11. Fishbain DA, Cole B, Lewis J, et al. What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuse/addiction and/or aberrant drug-related behaviors? A structured evidence-based review. Pain Med. 2008;9(4):444-459.