For almost 30 years, common medical wisdom held that most individuals experiencing chronic pain would benefit from daily doses of opioids. Medical knowledge has matured, and our understanding of the risk/benefit of chronic opioid use has changed, such that we now know the risks of chronic use are significant, and the benefits are often modest.14 Most patients with chronic non-cancer pain can be managed with non-opioid modalities or occasional opioid use.
The problem we now face is the “legacy patients,” those who have been on high-dose daily opioids for years, sometimes passing from provider to provider. Many primary care practitioners care for these patients, though they may not have initiated the opioid treatment regimen. These individuals deserve compassionate care and may sincerely believe that they could not cope without continuing their medication regimen. However, current best practice suggests that a slow-dosage reduction will improve the quality of life for the majority of patients.
The characteristics that contribute to dose escalation for chronic pain patients are the same as those which predispose to addiction. When appropriate screening, safe monitoring, and dose reduction are instituted, some of these individuals will be found to have the true diagnosis of substance-use disorder. Co-occurring mental health disorders related to trauma, depression, and anxiety may be revealed, as well. Management of these emerging disorders may require a shift in treatment modalities or a specialty-care referral. A strong partnership with behavioral health experts is essential to managing these patients.15
Involvement in daily activities and improved quality of life are the goals of chronic pain treatment. Monitoring function, rather than simply measuring the perception of pain, is the method of assessing patient improvement. Many patients do better after tapering and are grateful to “have their lives back” despite their initial fears of dose reduction.
Categorization of Chronic Pain Patients
It may be helpful to think of chronic pain patients as having pain belonging to one of three broad categories: peripheral (nociceptive), neuropathic, and central (non-nociceptive).
- Nociceptive pain: Pain whose etiology is ongoing peripheral inflammation or damage. This pain may be responsive to medications or procedures.
- Neuropathic pain: Pain resulting from trauma to peripheral nerves. This pain may be responsive to pharmacotherapy.
- Central pain: This phenomenon has many names, such as “pain amplification,” “brain pain” and “non-nociception pain.” Fibromyalgia syndrome is the classic example of this type of chronic pain. Psychotropic and other non-opioid therapies, including behavioral therapies, can be beneficial. Opioids are contraindicated with central pain etiologies.
All three pain types may coexist and may benefit from non-medication pain-management strategies: cognitive behavioral therapy (CBT), movement therapy, and education.
Nociceptive and Neuropathic Pain
Historically, almost all chronic non-cancer pain (CNCP) was thought to be either nociceptive or neuropathic. In this model of CNCP, the underlying cause of pain was believed to result from stimulation of peripheral pain or sensory nerve fibers located within the painful anatomic region. In this pain schema, peripherally directed therapies such as topical treatments, injections, opioids, and surgery are believed to be helpful. Examples of peripheral nociceptive pain include osteoarthritis, rheumatoid arthritis, and cancer pain. While examples of peripheral neuropathic pain include diabetic neuropathic pain and post-herpetic neuralgia.
However, over the past decade, a body of evidence has accumulated to suggest that a third type of pain, centralized pain, is likely to be much more prevalent than either nociceptive or neuropathic pain amongst working-age adults with CNCP. This distinction is very important to make as centralized pain, unlike nociceptive and neuropathic pain, is not responsive to peripherally directed therapies or opioids.16
Central Pain or Central Sensitization (CS)
The prototypical central pain state is fibromyalgia syndrome. But current research suggests that centralized pain is a spectrum disorder, which includes a large family of common chronic non-cancer pain diagnoses. Chronic low back pain, chronic headaches, and fibromyalgia are highly associated with CS.16,17,18
Screening for centralized pain syndromes is essential both for successful treatment and to avoid the unnecessary harms of over-medicalization with repeated scans, injections, surgeries, and opioids. Because the examination, imaging, and labs are often unremarkable in centralized pain syndromes, diagnosis rests upon a careful history, review of symptoms, and the use of validated CS screening instruments. Moreover, given the high co-occurrence of depression, anxiety, PTSD, and addictive disorders within individuals with CS, it is recommended that screening for these co-morbidities is also included in the initial evaluation.
If we treat centralized pain syndromes with drugs alone, we will fail. This is akin to treating diabetes with insulin or drugs alone, without any corresponding attempt to modify diet or weight.
Assessment for Chronic Non-Cancer Pain
Prior to assuming responsibility for prescribing for these patients, you should obtain and review the following:
- Prior medical and psychiatric records and (ideally) personal communication with the previous prescriber. It may be important to know why a patient left the previous practice.
- A complete physical exam, including:
- Past medical and psychiatric history, longitudinal pain history, family pain history, substance use history, laboratory, and imaging as appropriate.
- Specific ROS (review of systems) related to CS spectrum: difficulty sleeping, fibromyalgia, headaches, inflammatory bowel syndrome, pelvic pain, memory problems, TMJ, sensory descriptors of pain, i.e., numbness, tingling, pins and needles, etc., and of course, history of childhood trauma.
- Physical exam: A thorough exam will typically rule out undiagnosed nociceptive or neuropathic pain. Physical findings, imaging, and labs are typically unremarkable in controlled substance spectrum disorders.
- A query of the PDMP.
- UDS (POC [in-office point of care] will provide results at the time of the visit)
- Substance-abuse risk screening.
- Mental health screening, for example, adverse childhood experiences (ACEs), PTSD, anxiety, and depression.
- Respiratory disease risk screening.
- Pain and, most important, functional assessment to evaluate progress with treatment over time. (Oswestry, Low Back Pain Intensity, Visual Analog Scale, PEG 3-item scale for pain tracking).
- Rarely will it be possible to prescribe on the first visit. Once you have decided to assume prescribing responsibility for opioid treatment, you should do the following:
- Discuss the material risk notice with the patient, and have it signed in your presence. Many providers also use a controlled substances agreement.
- Consider a lowering of their opioid dose, as many patients will benefit from a dose reduction. If the patient presents with a total MED over 90mg, a taper plan needs to be discussed with the patient, with the understanding that opioid risk is dose related. The safest regimen is the absence of opioids.
- Co-prescribe a naloxone rescue kit. This will require a visit with the patient’s loved ones. Most insurance will pay for this modality, and the drug comes as a nasal spray, is easy to use, carries no substantial risks, and has been proven to save lives. (See Naloxone, page 51.)
- Ongoing monitoring should be instituted as clinic policy for all patients. Everyone is at increased risk with opioids, not just the ones you identify as problem patients or high-dose patients. Risk stratification (see elsewhere in this document) may have some, albeit limited, usefulness. Monitoring should include episodic evaluation of functional improvement, UDS, PDMP query, callbacks with pill counts, and documentation of any other changes in behavioral or physical conditions that would influence your prescribing decision.
- Opioids and benzodiazepines should not be co-prescribed as they can produce a synergistic effect resulting in respiratory arrest.20
- Methadone use should be avoided, and, if prescribed, doses should be kept below 30mg/d because of its high lethality mg for mg.21 Other rapidly acting opioids, such as fentanyl, are highly addictive.
- Contraindications for opioid treatment:
- Concurrent use of benzodiazepines and other sedative hypnotics (alcohol, muscle relaxants, sleeping medications)
- Increased risk of respiratory depression: severe COPD, sleep apnea, etc.
- Substance-use disorder. Past abuse requires increased scrutiny if any prescribing is undertaken.
- Illegal activities regarding medications.
- Lack of functional improvement while taking opioids.
- Violation of an opioid treatment agreement with another prescriber in the previous 12 months (documented).
- A pain rehabilitation program is strongly recommended as an adjunct to treating chronic pain patients. Such programs often include education, movement therapies, behavioral modalities, and peer-to-peer support. Patients should be educated about pain management techniques, rather than expecting pain elimination. This is a strategy common to all chronic disease states (diabetes, hypertension, etc.).
- Attendance in a rehabilitation program can be effectively linked to a dose-reduction regimen. A patient agreeing to supportive treatments is likely to succeed with a slow opioid taper. Resistant patients may need to be tapered more rapidly to assure an appropriate risk/benefit balance in a timely manner.
- Over-the-counter pain medications as well as intermittent, brief opioid regimens may be beneficial in selected patients when exacerbations of the chronic state occur.
- Dose instructions need to be clear. PRN prescribing may lead to inadvertent large doses (e.g., hydrocodone/acetaminophen 5/325 one to two every three to six hours can be as much as 50 mg. MED a day, even though each pill represents a small dose of opioids.)
- The following should be a part of patient/family education concerning opioids:
- Safe storage to prevent children and others from obtaining the medication.
- Safe disposal when they are no longer needed.
- Clinic policy regarding inappropriate behaviors. Many clinics have patients sign a patient contract. Those disallowed behaviors often include: early refills, lost or stolen prescriptions, Friday and weekend refill requests, obtaining controlled substances elsewhere without disclosure, use of illicit drugs, alcohol abuse, and concomitant marijuana use (some providers do not allow).
- Many legacy patients are likely to react negatively to a discussion of tapering. Preparation for these difficult conversations can be very helpful, and a section of the guidelines is dedicated to that subject.
- Tapering strategies are discussed elsewhere in this document.
- It is essential that patients be provided resources to assist them with the discomfort and anxiety that often accompanies tapering. Learn what local community resources are available to you.
- Many patients are on both opioids and benzodiazepines simultaneously. It is inappropriate to have patients on both of those drugs, even if you are not the prescriber for both. Patients may be tapered off both simultaneously, but many prefer to taper off one and then the other. Since opioids are more dangerous regarding overdose, and can be tapered more rapidly; recommendation is to start with opioids and then taper the benzodiazepines.
- When patients are exhibiting active addiction behaviors (e.g., use of illicit drugs like heroin) an immediate cessation of prescribing may be indicated and accompanied by an addiction treatment referral.
- Secondary Gain: Disability payments, legal actions, and illicit financial incentives can complicate the treatment of pain. Practicing safe and appropriate medicine, with thorough documentation, will serve as a starting point, with specialty referral being necessary at times.
- Suicidality: Individuals whose lives have revolved around opioids for decades may have significant and legitimate concerns about dose reduction. These individuals need patience and behavioral support. Be sure to ask about suicidal thoughts and provide referrals to counseling when needed.
- Addiction (opioid-use disorder): It is sometimes hard to distinguish between patients who take opioids to relieve pain and those who are taking medication obsessively to relieve cravings or to achieve a pleasurable effect. Individuals who have an unnatural focus on their medications and respond poorly to opioid treatment may be identified as either having ineffectively treated pain or having an opioid-use disorder.
You may have patients to whom you were prescribing opioids for the treatment of pain, but who over time showed evidence of addiction. Ideally, if you prescribe opioids for chronic pain, you also have the capability to prescribe buprenorphine (or refer to others with that capability) for your patients who you feel have a substance-use disorder. Regardless of the terminology you use, some patients would be safer being prescribed buprenorphine rather than pure mu agonists.
An in-depth knowledge of your community addiction services is an important component of chronic pain treatment.