Introduction

For the past few decades, a conceptual shift has taken place regarding the treatment of chronic pain. Opioids have been encouraged for the treatment of all types of pain. In particular, chronic non-cancer pain was suggested as a treatable condition necessitating long-acting medications, without solid scientific evidence supporting that practice. As a society, we are reaping the consequences of that change in prescribing habits with an increase in opioid dependency, accidental drug overdoses, and heroin use. The expectation on the part of the public that there is a pill to be prescribed for any discomfort is harder to quantify but no less important.1,2,3

The community consequences of excessive opioid prescribing are manifest. In addition to the mortality and quality-of-life consequences previously mentioned, we are facing an increase in communicable diseases associated with substance-use disorders (HIV, hepatitis, syphilis), strains on the court system and treatment programs, and a “lost generation” of patients dependent upon opioids who are a challenge to treat humanely and effectively.

The message embodied in this document is that opioids are powerful drugs that can create calm and relief when used wisely but can cause great harm when prescribed injudiciously. Every encounter with a patient in pain will require the same analysis, and patient safety should guide all treatment recommendations.

  • What is the etiology of the pain, and would non-opioid treatment suffice?
  • Are there risk factors present that would make the use of opioids unsafe for this patient?
  • What is the usual expectation for pain for this condition? Is my patient’s response outside that expected range?
  • Is there a medical justification for this dose of opioid, for this length of time, for this condition, in this patient?

Practicing outside those parameters puts your patient, or your patient’s family, or the community at large, at risk. Too many pills prescribed for a given situation can create dependency in your patient, or if they are stolen or diverted, can feed the illicit habit of others.

This is an iatrogenic public health crisis, and all of us in the healthcare profession have to assume responsibility in fixing it.4

To achieve genuine and lasting practice change, our entire community has to be educated concerning our current understanding of the appropriate management of pain. All of us need to understand the science that underlies current best-practice recommendations. Our patients and families need to hear the same message. We felt the best approach would be to promote a grassroots effort, achieving regional, broad support for these guidelines. Providers would share common understanding, our patients would hear a consistent message, and the community at large would support these efforts.

OPG Guidelines Authors and Contributors

Our goal in the development of these treatment guidelines is to provide real world tools and advice to practicing clinicians as they seek to comply with this excellent national guidance document. These guidelines have been influenced by the work of the Washington State Medical Directors Group,6 the CDC, and many other leaders in the state of Oregon and nationally in the field of safe opioid prescribing. We have created these guidelines for everyone who manages patients with pain: prescribers, behavioral professionals, those who dispense pain medications, and those who pay for them. Credit for the creation of these guidelines belongs first to the members of the Southern Oregon OPG group who developed a series of guidelines over several years that reflected agreed community standards of care.

The major drafters of these guidelines are: Jim Shames, MD, Medical Director and Health Officer of Jackson County Health and Human Services; John Kolsbun, MD, Medical Director of AllCare Health, and Mark Stephens, a healthcare consultant. Other significant contributors were Laura Heesacker, LCSW; Sara Smith, RN; Rachel Vossen, PharmD; Mark Kantor, RPh; and Paul Coelho, MD; as well as other members of the OPG group who added additional content. Other experts in “Pain” have reviewed and commented on these guidelines as well. We are very grateful for all the contributors who helped produce these guidelines.

CDC Guidelines

In March 2016, the CDC issued new guidelines on opioid prescribing.5 The importance of these guidelines cannot be overstated as they establish national recommendations for the use of opioids for treatment of chronic pain. We completely support and endorse these new guidelines. These Pain Treatment Guidelines are aligned with and incorporate explicitly, the CDC Guidelines.