(0–7 Days Following Trauma or Surgery)

In most cases, acute pain can be treated effectively with non-opioid or non- pharmacological options (e.g., elevation, ice) With more severe acute injury (e.g., significant trauma, fracture, crush injury, postoperative pain, extensive burns), short-term use of opioids may be appropriate Initial opioid prescriptions should not exceed seven days for most situations, and two to three days of opioid medication will often suffice. If an individual needs medication beyond three days (or beyond the average expected time for initial healing) a reevaluation of the patient should be performed prior to further opioid prescribing Physical dependence on opioids can occur within only a few weeks of continuous use, so great caution needs to be exercised during this critical recovery period.

Assessment

  • Review medical history, including records from previous providers, when available.
  • Administer a physical exam to determine diagnosis and appropriate care. Document baseline function and baseline pain.
  • Determine whether the injury can be treated without opioids or if the severity of the injury justifies the risks of opioid therapy.

Non-Opioid Treatment

  • Help patients set reasonable expectations concerning recovery from the injury. Educate them about the healing process and the benefits of appropriate activity.
  • Reassure the patient that some pain is to be expected and that it will subside in time. Over-the-counter (OTC) medications will provide significant relief from pain in many situations and can be relied upon for ongoing pain relief a after the acute period is over.
  • Patients should improve in function and pain and resume their normal activities in a matter of days to weeks, depending upon the diagnosis. Reevaluate those who do not follow the normal course of recovery.

Opioid Treatment

  • If the severity of the injury indicates that limited opioid treatment is appropriate, before prescribing, you:
    • Should perform a simple screen for substance abuse (e.g., ORT). Individuals in active recovery are at high risk of being “triggered” by even small amounts of opioids, and you can inadvertently put them in harm’s way with your prescription. Those with a history of attempted suicide or overtaking opioids should be prescribed the least amount of medication necessary.
    • Should identify other prescribed medications or conditions that would preclude co-prescribing opioids. Benzodiazepines have a synergistic effect with opioids.12
    • Must inform the patient about the risks and side effects of opioids. Many young people who became dependent on opioids say they never were informed of its risks.
    • May want to have the patient sign a treatment agreement if the patient returns requesting a re ll of opioids. A urine drug screen and PDMP query should be performed prior to writing the second prescription. Continued prescribing might indicate the need for the patient to sign a treatment agreement.
  • Opioid prescriptions should be for the shortest appropriate period of time, usually two to three days of treatment post injury or surgery, followed by over-the-counter treatments if further medications are indicated.
  • Opioid overprescribing puts your patients at risk. Four out of five recent heroin initiates (79.5 percent) previously used prescription pain killers.13
  • Some major surgeries, injuries, and certain disease states may require longer periods of opioid treatment. Justification for prescribing outside the guidelines should be documented in the patient record.
  • If pain continues, a reevaluation is usually indicated because:
    • Pain beyond the expected timeframe may indicate a complication (e.g., infection, re-injury, displacement, dehiscence).
    • Complaint of ongoing pain may indicate an unrecognized substance-use disorder, which may require greater scrutiny and an alternative treatment modality.
  • At each follow-up visit, assess and document pain and function, educate the patient on the importance of self-management and appropriate activity.

Patient Instructions

  • Dosage instructions need to clear. PRN prescribing should be only as liberal as necessary, as it can 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—a lot of medication for an opioid-naïve individual).
  • The number of pills you prescribe sets up “dosing expectations” for the patient. Prescribing #40 pills for a time-limited painful experience may send an inadvertent message to the patient, giving permission for the casual use of opioids.

Tools

  • Screening tools for substance abuse: ORT (Appendix A), and SOAPP-R (Appendix B)
  • Screening tools for function: Oswestry Disability Index (ODI) (Appendix M) and PEG-3 (Krebs et al 2009) (Appendix N)
  • Screening tools for co-occurring mental health conditions: PHQ-4, GAD-7
  • Prescription Drug Monitoring Program (PDMP) (See http://www.orpdmp.com/PDMP_2015v02262015.pdf, page 15)

Pain Lasting More Than Three Months

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).

Opioid Treatment

  • 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).

Non-Opioid Treatment22,23,24,25

  • 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.

Patient Instructions

  • 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).

Tapering

  • 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.

Additional Concerns

  • 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.

A patient’s trauma history, mental health, family, and social situation all can affect the perception of pain. This is why chronic pain is described as a bio-psycho-social phenomenon. Without addressing those behavioral issues, opioid management of chronic pain will not provide the level of relief the patient is seeking, and dose escalation, with its concomitant morbidity and mortality, will often occur.

Studies show that opioids are only moderately successful in relieving pain and, in fact, are inferior to sleep restoration, mindfulness training, and physical exercise in providing long-term benefit.

 

Treatment Comparisons

Source: David Tauben, MD, Chief of Pain Medicine at the University of Washington.

Non-Opioid Treatment Options

The following table lists various non-opioid treatment options, including behavioral, movement, and pharmacological treatments. This is not meant to be an exhaustive list but, rather, is intended to show the many empowering ways our patients can use readily accessible resources to help manage their pain.

Behavioral Treatment Options

Cognitive behavioral therapy (CBT)

›     What is CBT?  CBT is a form of psychotherapy that emphasizes the importance of the causal relationship between our thinking and our feelings and behaviors. The cognitive, or thinking part of our experience, very much affects the behavioral, or action part of our experience. With training, we can change the way we think to affect the way we feel and behave, even if the situation has not changed. CBT has an educational focus and teaches rational self-counseling skills.

›     What does the research say about CBT for the treatment of chronic pain?  Studies show that a patient’s report of chronic pain intensity is far more about that individual’s capacity to manage his or her pain than it is about stimulation of nociceptors.26 Additional studies show that patients experience between 30% to 60% reduction in pain intensity by learning and applying CBT techniques. This compares favorably to the estimated efficacy of 30% for chronic opioids.

›     What are some of the key components of CBT for patients with CNCP?  In general, CBT for chronic pain works to reduce patients’ pain, distress, and pain behavior while improving their daily functioning. Components of CBT may include helping patients to decrease negative emotional responses to pain and perceptions of disability while increasing their acceptance of pain as well as orientation toward self-management. CBT helps patients change the way they relate to pain so they can experience life more fully.

›     What is the goal of CBT for patients with CNCP?  Two fundamental concepts are at play in this strategy. One is that a person must accept the aspects of the pain that cannot be changed, including all the difficult thoughts, feelings, and bodily sensations that come with it. The second is that this acceptance allows for the possibility of the patient opening to the pain and committing to acting in ways that make the patient feel vital and energized. Learning to accept pain to live life is often referred to as “victory by surrender.”

Living Well with Chronic Pain

This program is one of a group of validated syllabus-based programs developed at Stanford University for the purpose of empowering individuals living with chronic pain. It is available in many communities around the country and teaches self-management skills concerning the management of chronic diseases, including pain.

Shared medical appointments

One approach for a busy practice to incorporate peer support, education, and behavioral treatment into the office visit is to use a shared medical appointment. The prescriber and a facilitator, often a nurse, can meet with patients as a group to discuss common issues, while simultaneously taking individual patients aside for brief patient-specific evaluations. Many insurance companies will pay for this treatment approach.

Peer-to-peer meetings

Trained peer educators can facilitate groups of pain patients to share successes, set goals, and help overcome common obstacles. Peer educators can work under the auspices of a licensed practitioner or enroll patients independently. Such programs can work in parallel with the other modalities mentioned in this section.

Pain, in all its manifestations, is an aspect of most illnesses, as well as a normal part of the aging process. As such, its treatment is an essential component of primary care. The treatment of pain, especially acute pain, may at times require the use of opioids, which have significant risks in addition to their benefits. After years of misguided provider education, millions of patients in our healthcare system are on opioids for inappropriate diagnoses and at inappropriate doses (legacy patients or the lost generation). Even the most skilled providers may at times need specialty care to assist in the management of these complex patients. This guideline will address the following questions:

What kinds of patients are most appropriate for specialty care?

What is the screening and evaluation expected for these high-risk patients?

What kind of oversight should exist to assure consistent and safe management of these patients?

Who is a pain specialist?

What kind of services should constitute a specialty-care clinic?

What are the expectations and long-term goals for such patients?

Patient Selection for Pain Specialty Care

  • Patients on high doses (>90 mg MED) or unsafe drug combinations (e.g., benzodiazepines + opioids) who either refuse dosage reduction, exhibit substance-use disorder behaviors, or have significant behavioral conditions beyond the scope of the provider, may require referral to a pain specialty program or substance abuse program for evaluation or ongoing care.
  • Any chronic pain patient beyond the expertise of the primary care provider.
  • The Oregon Medical Board (or similar state boards), UW “Tele-Pain” (or similar regional peer education), can be excellent resources for helping manage difficult patients in lieu of specialty referral.

Screening and Evaluation

All patients being prescribed chronic opioids need screening for behavioral, respiratory, and other psychosocial risks because, by definition, the specialty-referral clients are at higher risk. A more thorough evaluation of such patients is to be expected:

  • Ongoing functional evaluation: PEG, Oswestry or similar, monitored over time.
  • Respiratory: S T O P   B A N G or similar, with appropriate referral or further evaluation as necessary.
  • Central sensitization screening including but not limited to Central Sensitivity Index, Pain Catastrophizing Scale (PCS), PHQ-15, etc.
  • Validated addiction-screening tests such ORT/SBIRT/DAST-28, appropriate for age and history.
  • Query of the PDMP initially and episodically.
  • Evaluation for possible unforeseen sources of nociception, such as identification of ongoing
    tissue destruction.

Oversight

Pain specialists, accredited, self-identified, or working under the license of others, can succumb to lack of time and inadequate resources resulting in a loosening of appropriate safeguards in the management of chronic pain. A process of peer review can provide feedback at the expert level (and can be an educational resource for primary care) to assure quality and consistent care for complex, high-risk patients. This may include:

  • Regularly scheduled multi-disciplinary meetings of healthcare professionals, including behavioral specialists, addiction counselors/specialists, pharmacy, case management, and more to facilitate case discussions. Review of treatment data (MED, functional improvement, adherence to risk stratification) in a transparent fashion by the participants is an expected component.
  • A committee that could serve as a “brain trust” for others providing pain management in the community.

Pain Specialty

It is clear from the latest research that chronic pain is often, if not largely, a disorder of nociceptive perception and dysregulation.27 Chronic pain patients often represent a subset of the population with specific bio-psycho-social characteristics. This means that a pain specialty clinic needs to have a foundation of understanding and resource accessibility to care for individuals with historical trauma, substance-use disorder, catastrophizing, as well as an understanding of the pharmaco-dynamics of opioids. Chronic pain is often best viewed through the lens of chronic disease management rather than cure. Therefore, to be considered a pain specialty clinic for the purposes of referral and reimbursement, items 1 through 6 will need to be provided by the clinic staff.

Services

A pain specialty clinic should include the following:

  1. Clinicians willing to be transparent and share de-identified treatment data.
  2. An organization with deeply embedded behavioral health experts to provide evidence-based counseling, education, and substance-use disorder treatment.
  3. Prescribers specifically educated concerning the use and abuse of opioids, or who can demonstrate their expertise through an objective testing process.
  4. The ability to provide buprenorphine to appropriate patients for the treatment of opioid-use disorder.
  5. The ability to provide referral and expert care for complex chronic pain patients. It should be the goal of pain specialty to develop and establish a treatment plan and return the patient to primary care. In extremely complex patient situations, pain specialty should provide direct care until exceptional care needs are addressed, managed, and a care plan is established; at which point the patient should be returned to primary care. It is expected that all providers participating in a patient’s care will employ common treatment goals and communicate regularly amongst themselves.
  6. The previously listed components are essential for quality chronic pain care. If they are not offered on site, then close collaboration, integration, and management of such services is expected.

Long-Term Management Goals

The evidence supporting long-term benefits of opioids is lacking, while the risks and harms are evident. Tapering opioids after long-term use can be challenging and may elicit preexisting conditions. Patients with underlying trauma, mental health disorders, co-existing benzodiazepine use, and substance-use disorders can be exceptionally challenging when tapering, and specialty care can provide additional structure, expertise and support.

  • The OPG guidelines, including < 50 MED for most patients, with an absolute MED maximum of < 90 MED, are appropriate for patients managed by pain specialty, as well.
  • It is understood that these complex patients may require additional services, support, and time to achieve those goals. Specialty care, by definition, will provide that level of expertise and care.

It is increasingly recognized that childhood trauma and PTSD affect not only the quality of life of many individuals but also their physical health. Research has increasingly demonstrated that trauma can lead to neurobiological dysregulation, altering the functioning of catecholamines, the hypothalamic-pituitary-adrenocorticoid axis, endogenous opioids, thyroid and immune function, and neurotransmitter systems. It is not surprising, therefore, that exposure to traumatic stress is associated with increased health complaints, health-services utilization, morbidity, and mortality.

Trauma and Chronic Pain

The prevalence of trauma is substantially elevated in patients with chronic pain. A current PTSD prevalence of 35% was seen in a sample of chronic pain patients,28 compared to 3.5% in the general population.29 In a study of patients with chronic low back pain, 51% of the patients evidenced significant PTSD symptoms.31 Daniel Claw and others have found a strong association between trauma, childhood sexual abuse in particular, and central sensitization (CS) syndromes.30 Emotional pain can amplify physical pain perception, and pain itself can actually serve as a reminder of the traumatic event, and thus put the patient at risk for dose escalation.

Screening and Referral Overview

  • PTSD symptom screening is an important addition to routine preventive health screening in primary healthcare settings because:
    • Patients are unlikely to report trauma history or symptoms unless directly asked.
    • Trauma exposure is associated with many problems—emotional and physical—that affect health.
    • Patients with long-lasting PTSD are unlikely to achieve significant improvement in symptoms without behavioral health treatment.
  • Gather a thorough bio-psycho-social history and assess the individual for medical and psychiatric problems. Do a risk assessment for suicidal and homicidal ideation. Also ask about substance abuse.
  • Assess for PTSD symptoms. There are a number of screening tests that have been designed for use in primary care and other medical settings. See PTSD Screening and Referral: For Health Care Providers for more information.
  • Make appropriate referrals for PTSD, depression, other psychiatric disorders, or significant spiritual issues. Likewise, help build up or stabilize the patient’s social support network, as this will act as a buffer against the stress they are experiencing.

Trauma-Informed Treatment

  • Research suggests that providing CBT treatments to address PTSD symptoms in patients with chronic pain may lead to improvements in pain-related functioning.32
  • Other useful treatment methods include behavioral regulation methods (imagined or actual exposure to feared activities or circumstances) and physiological strategies (relaxation-response training; movement therapy) that overlap substantially with many aspects of cognitive behavioral therapy used in the treatment of chronic pain.
  • Multimodal pain programs, which are trauma informed, also provide a good referral resource for those suffering from PTSD and persistent pain.

What Can Healthcare Providers Do

Healthcare providers can increase the chances of improved health outcomes for their patients by following these steps:

  • Identify behavioral health professionals in the healthcare system or community who work with patients who have PTSD
  • Screen for trauma
  • Discuss the results openly with your patient
  • Provide a referral when appropriate
  • Provide educational materials
  • Follow up with the patient

Further information can be found on:  U.S. Department of Veterans Affairs website

Tools

See Primary Care PTSD Screen (PC-PTSD) in Appendix D.

The use of opioids to treat pain in infants and children presents challenges. First, with rare exceptions, opioids have not been labeled for use in individuals under 18 years of age. There is a dearth of quality studies on pharmacokinetics, pharmacodynamics, safety, and clinical effectiveness. Acute pain problems in pediatrics have many characteristics in common with adult presentations. Persistent, recurrent, and chronic pain in infants, children, and adolescents are often qualitatively different from chronic pain problems in adults. Treatment approaches may vary accordingly.

Assessment

  • Review medical history, including records from previous providers, when available. Be sure to elicit family history of chronic pain syndromes.
  • Perform a physical exam to determine diagnosis, baseline function, and pain.
  • Carefully assess the degree of injury and the normal healing expectations regarding pain and improved function. Determine the need for opioids versus non-opioid therapies (see Acute Pain section in this document).

Non­-Opioid Treatment

  • Describe the nature of the injury or disease to the patient and the parent. Be sure to describe the expected course of recovery and convey that some pain is to be expected and that activity and exercise can often provide some pain relief and may improve healing.
  • Explain that OTC or over-the-counter pain medications can be highly effective, and be sure they understand dose and frequency recommendations.
  • Patients who experience pain extending beyond the expected time of recovery should be reevaluated.

Opioid Treatment

  • Only those who understand the differences in pharmacokinetics and pharmacodynamics between children and adults should prescribe opioids for pediatric patients.
  • Opioids should be avoided for the vast majority of chronic non-cancer pain in children and adolescents as evidence of safety and efficacy is lacking.
  • Opioids are indicated for a small number of persistent, painful conditions, including those with clear pathophysiology and when an endpoint to usage may be defined, such as post-surgical pain and trauma (including burns). Every attempt should be made to limit opiate use to fewer than seven days.
  • Opioids may be indicated for some chronic conditions where there is no definable endpoint (like osteogenesis imperfecta or epidermolysis bullosa) or for end-of-life care. Such patients are best treated in a specialty-care setting.
  • Put safety first when prescribing opioids to younger patients. Limit the total dispensed and educate parents about dosing, administration, storage and disposal to minimize risks of diversion or accidental ingestion. Adolescents should undergo similar screening for risk of substance-use disorder that one would conduct with adults.

Tools for Adolescents

  • Screening tools for substance abuse: ORT, SOAPP-R
  • Screening tools for co-occurring mental health conditions: PHQ-9, GAD-7
  • Prescription Drug Monitoring Program
  • Age and developmentally appropriate screening tools for children such as NIPPS, FLACC, or Bieri-Modified

Pain in the elderly patient may be more difficult to assess because of the patient’s cognitive and physical impairments. Traditional approaches to pain management may need to be modified because of a sometimes-elusive diagnosis, altered patient physiology, and the risk of more prominent side effects.

The goals of therapy are to decrease pain while increasing function and enhancing quality of life.

Because chronic non-cancer pain can be reduced but not eliminated, ongoing pain reporting is common in patients with dementia.

Chronic Pain in the Elderly Population

  • Persistent pain (three to six months) is present in 25–50% of older adults, and increases with age. Nursing home patients may have prevalence as high as 45–80%.33
  • Chronologic markers for old age are arbitrary; however, various factors such as socioeconomic impacts, health-style choices and medical comorbidities may all factor into a patient’s physiologic age.

Evaluation of the Elderly Patient

  • Identify the source of the pain and the impact that pain is having on the patient. Assess previous consultations, workups, and imaging studies. Be suspicious of increases in pain above baseline as pathologic pain promoters are much more likely with advanced age.
  • Cognitive impairment resulting from delirium, dementia, or other mental health conditions may make both the assessment and management of symptoms more difficult.
  • In a patient with complicated emotional issues, they may describe the pain in imprecise, inconsistent terms.
  • Poly-pharmacy is common. Be aware of potential adverse effects from multiple medications.
  • Imaging should be symptom and examination driven. Avoid duplication of previous testing.
  • The management of symptoms in the older patient follows the same principles as that in younger persons. However, the elderly are more sensitive to medication side effects.34

Goals of Treatment

  • The goals of treatment are modulated pain; ability to perform valued activities; improved function; to feel well enough to socialize; to have additional freedom from chronic, painful conditions; and enhanced quality of life.35
  • Persistent pain is multifactorial. It is a treatable but not curable condition. Let the patient know that although pain may not be eliminated, substantial improvement in function is a realistic goal.

Non-Pharmaceutical Approach

  • Often beneficial, with low cost and minimal side effects.
  • Includes physical therapy, occupational therapy, acupuncture, chiropractic, and massage therapy. When ordering therapies, be sure to specify what conditions you want targeted and your goals of treatment. Monitor the modalities to ensure that they are being applied appropriately (positioning, hot/cold).
  • Behavioral – Cognitive behavioral therapy and meditation along with patient education.
  • Localized therapy – Joint injections and trigger-point injections.
  • Continue these treatments when introducing medications to minimize medications and their side effects.

Pharmaceutical Approach

Non-opioids

Non-opioids are preferred over opioids. Used primarily for nociceptive pain (post-op pain, mechanical low back pain, injuries/trauma, arthritis). Involve a pharmacist for help in reviewing side effects and concomitant medications (including supplements) for drug-drug/supplement interactions.

  • Acetaminophen is the first-line approach to mild, persistent pain:
    • Acetaminophen lacks inflammatory activity; therefore it’s effects may be limited in the long-term treatment of inflammatory conditions.
    • Beware of potential drug interactions and drug-dosing limits (determine the doses of all acetaminophen-containing products).
    • Reasonable prescribing: 3 grams/24 hours OR fewer than 2 grams in frail patients, those more than 80 years old or those who use alcohol on a regular basis.
  • Non-steroidal, anti-inflammatory drugs (NSAIDs)
    • Start at low doses in the elderly.
    • Use briefly; no more than one to two weeks during periods of increased pain.
    • Tailor the medication to the patient’s cardiac and GI risk factors.
    • For those at risk for GI complications, add a gastro-protective agent.
    • There is a potentially lower GI risk with non-acetylate salicylate or COX-2 inhibitors.
  • Antidepressants-for chronic neuropathic pain (postherpetic neuralgia, neuropathic back pain, polyneuropathy, trigeminal neuralgia). All have increased side effects in the elderly.36
    • TCAs – Tricyclic antidepressants have been shown to have effectiveness preventing migraine and tension headaches and in treating chronic pain. Common side effects are sedation, cognitive dysfunction, and orthostatic hypotension. Watch for drug interactions.
    • SNRIs – Selective noradrenalin reuptake inhibitors (e.g., duloxetine, venlafaxine) are frequently used in treating neuropathic pain.
    • SSRIs – Selective serotonin reuptake inhibitors (e.g., paroxetine, citalopram) have been used in the treatment of neuropathic pain. These agents may be particularly useful in elderly patients because of their favorable side-effect profiles.
  • Anticonvulsants – gabapentin, pregabalin and carbamazepine may be effective for neuropathic pain. Use of these medications is frequently limited because of dizziness, somnolence, fatigue and weight gain. Tolerance improves over time. Side effects and potential for drug-drug interactions limit their utility in older adults.37
    • Start at low doses, titrate slowly upward, and taper off when stopping the medication.
  • Transdermal lidocaine can be useful in the elderly to treat neuropathic and localized, nociceptive pain and has a low incidence of side effects.
  • Muscle relaxants should be avoided in individuals older than 65 because of intolerance to side effects.

Opioids – General Considerations

  • Opioid analgesics are the mainstay for the treatment of moderate to severe pain in patients with advanced illness. Long-acting or sustained-release analgesic preparations should be used for continuous pain. Breakthrough pain should be identified and treated by the use of fast-onset, short-acting preparations.
  • Elderly are more sensitive to the effects of the opioids, due to age-related physiologic changes (e.g., decreased renal or hepatic function and altered body-fat distribution) as well as comorbid medical conditions.
  • Always consider if there is an alternative therapy that is likely to have an equal or better therapeutic benefit for pain control, functional restoration, and improvement in the quality of life.
  • Consider whether the patient (or caregiver) is likely to manage use of the opioid responsibly.
  • Patients may require other forms of medication other than pills. These may be liquid, patch or injections. Try to stay with the least-complicated mode of treatment to help with compliance.
  • Opioids can cause mental clouding, which may clear over time. However, there may be persistent sedation, cognitive and psychomotor impairment, hallucinations, dreams and nightmares while on the medication.
  • Never initiate opioid therapy with patches or other long-acting opiates in opioid-naïve patients.
  • Reasonable dosing recommendations should start at 30% to 50% of the recommended starting dose at the same dosing intervals, and then titrate doses upward in 25% increments for comfort and side-effect tolerance. There is substantial individual variation in the response to the different opioids, and the drug with the most favorable balance between analgesia and side effects cannot be predicted.
  • Potential medication choices:
    • Morphine, oxycodone, hydrocodone +/- acetaminophen, hydromorphone, tramadol, fentanyl, buprenorphine. Avoid meperidine and methadone. When choosing a medication, identify the targeted goal of treatment, the preferred route of administration, the patient’s frailty and comorbid conditions along with your clinical experience.
    • Opioid side effects:
      • Constipation – There is little adjustment to this side effect over time. Constipation is predictable, so start prophylactic laxative therapy when initiating narcotics.
      • Balance/Falls
    • Particularly in patients taking poly-pharmacy, who are deconditioned, or who have vision difficulties.
    • If there is evidence of risk for falls, consider avoiding use of opioids.
    • Consider a possible referral for PT and mobility aids prior to initiating treatment.
    • Ensure a safe environment for the patient with impaired mobility. Consider a home safety evaluation through the appropriate agency.
    • Respiratory
    • Sleep apnea and sleep-disordered breathing are seen with narcotic use.
  • The exaggerated respiratory depression seen with opioid use can be minimized by starting at low doses and with appropriate titration. Use significant caution when increasing doses, especially in elderly individuals with risk factors for sleep apnea.
    • Nausea is common. Nausea can be minimized with a slow titration upward in the opioid dosing.
    • Depression – Opioids may precipitate or worsen depression, which is a treatable condition that may respond to therapy.
    • Opioids affect the functioning of the hypothalamic-pituitary-adrenal axis, resulting in increased levels of prolactin, decreased levels of sex hormones and, rarely, secondary adrenal insufficiency.

Pain Treatment in Patients with Dementia

  • Because chronic, non-cancer pain is more likely to be reduced than eliminated, ongoing pain reporting is common.
  • In those with advanced dementia who may be unable to communicate verbally about their pain, you may need to evaluate their condition (and their response to treatment) by facial expressions, verbalizations, body movements, changes in interpersonal interactions, activity patterns and routines such as sleep disruption and appetite suppression. Multiple questionnaires have been developed with variable success rates in eliciting pain levels in persons with dementia, with no general consensus on which one is superior.38
  • Patients may also exhibit striking out, refusing medications, agitation, delirium, increased restlessness, and social withdrawal. Rule out other potential infectious, metabolic, medication-related, and social-situation changes as possible causes for acute decline.
  • Prescribe a trial of scheduled medications (be cautious with scheduled NSAIDs). Use a stepwise approach.
    • Start low, go slow, be aware of possible under treatment.
    • Monitor the patient carefully to balance the risks and benefits of the treatment.
  • Be alert to herbal and dietary supplements taken by older patients who may not volunteer this information. They may be prone to drug-supplement interactions.
  • Patients who don’t respond to one medication may respond to another.

Pain control for cancer and palliative care is used when pain and symptom control is important for quality of life. An integrated model of care to address the entire patient, body and mind, is the best approach. This may serve as a bridge to hospice care.

What Is Palliative Care

  • Palliative care employs an interdisciplinary team to focus on relieving suffering in all stages of disease and is not limited to end-of-life care. This care may occur at the same time as curative or life-prolonging treatments.
  • Palliative care is not hospice and doesn’t need to have a six-month-terminal-condition prognosis.
  • The basic goal of palliative care is symptom management. The care team can typically better manage symptoms of pain, anxiety, shortness of breath, nausea, emesis, constipation, and diarrhea than the busy, multitasking provider.
  • Palliative care providers continually strive to clarify the goals of treatment interventions and determine whether they are consistent with the values and decisions of the patient and with the reality of the disease process.
  • Palliative care improves quality of life for the patient and their family.
  • After serious illnesses, the primary care providers, friends, family members, nursing facilities, specialists, and also hospitalists refer patients to palliative care.
  • For patients who have a terminal cancer condition and transition from palliative care onto hospice, the goal of treatment for cancer pain is to improve comfort (compared to the goal for treatment of CNCP to improve function). Escalating doses and high MEDs are not unusual in these circumstances. The risk/benefit balance is not the same as it would be in a patient with the expectation of years of productive life. Care must still be taken to ensure that your medication is going to your patient, and not being diverted.

Why Is Palliative Care Important

  • Primary care management of pain and symptom relief in the pre-terminal and terminal patients may vary considerably between provider offices.
  • PCPs may not have the training or experience to feel comfortable with symptom management, and their offices may not have the dedicated resources for integrated services.
  • Palliative care teams are responsive to the questions and needs of the patient and families, and can serve as the eyes and ears for the provider.
  • Palliative care can serve as a seamless transition to hospice care during the last six months of life. This benefits everyone.

Palliative Care Approaches

  • Non-pharmacologic treatments may include electrical nerve stimulation and TENS units, therapeutic exercise, splints, and nerve blocks.
  • Alternative or complementary therapies for pain may include psychological therapies (e.g., guided imagery, cognitive interventions), acupuncture, music therapy, massage, rehabilitation, and physical therapy, along with other mind-body approaches.
  • Pharmacologic approaches to pain include the same medications as mentioned above in Pain Control in the Elderly, page 32.
  • Novel uses of medications to manage a wide spectrum of symptoms may also be effective.
  • Major depression is a treatable condition, even in terminally ill patients.
  • Opioids are the mainstay of treatment for pain at the end of life.

There are many factors that make opioid use in pregnancy a unique issue, requiring special understanding and careful treatment.39 Beyond the obvious—that you are treating two patients, the fetus and the mother—there are other considerations.

  • These are by definition young patients whose appropriateness for chronic pain treatment and risk factors for abuse are different from older adults.
  • Opioid withdrawal involves a number of possible serious prenatal consequences including preterm labor, abruption, and fetal demise.40
  • Guilt and shame may create a situation whereby the patient downplays the seriousness of her opioid use. Providers may be misled into believing they are dealing with occasional use, when they are in fact dealing with an opioid-use disorder.41
  • Metabolic changes may occur during pregnancy that reduce the effect, and thereby the dose, of opioids needed to prevent withdrawal.
  • Neonatal abstinence syndrome (NAS) is common after prolonged opioid use, and is best treated when anticipated prior to delivery.42
  • Buprenorphine and methadone are the drugs of choice for treating opioid-use disorder in pregnancy. Such treatments should be provided by professionals familiar with the special dosing considerations for this population. Methadone has been used successfully for decades, though it has a higher rate of NAS and opioid-related risks. Buprenorphine is safer for the mother and baby and may be the preferred treatment in selected women.

The Oregon Chapter of the American College of Emergency Physicians has created a set of guidelines regarding the use of opioids in a hospital emergency department (ED). The following is a modified summary of those guidelines. Emergency medical providers (EMPs) should be supported and should not be subject to adverse consequences by any regulating bodies when respectfully adhering to these guidelines.

  1. Only one medical professional should provide all opioids to treat a patient’s chronic pain, to the
    extent possible.
  2. The administration of intravenous and intramuscular opioids in the ED for the relief of acute exacerbations of chronic pain is discouraged.
  3. EMPs should not provide replacement prescriptions for controlled substances that were lost, destroyed,
    or stolen.
  4. EMPs should not provide replacement doses of methadone for patients in a methadone treatment program.
  5. Long-acting or controlled-release opioids (e.g., oxycodone, fentanyl patches, and methadone) should not be prescribed by EMPs.
  6. EMPs are encouraged to access EDIE (emergency department information exchange) and/or the
    state PDMP.
  7. EMPs should exercise caution when considering prescribing opioids for patients who present to the ED without a government-issued photo ID.
  8. Primary care and pain-management physicians should make patient pain agreements accessible to local EDs and work to include a plan for pain treatment in the ED.
  9. EDs should coordinate the care of patients who frequently visit the ED, using an ED care coordination program, to the extent possible.
  10. The administration of meperidine in the ED is discouraged.
  11. ED prescriptions for opioid pain medication for acute injuries should be no more than 10 pills. For more serious injuries (fractured bones), the amount prescribed should be an amount that will last until the patient is reasonably able to receive follow-up care for the injury. In most cases, this should not exceed 20 tablets.
  12. EMPs are encouraged to ask patients about past or current substance abuse prior to the EMP prescribing opioid medication for acute pain. Prescribe opiates with great caution in the context of substance abuse.
  13. EMPs are required by law to evaluate an ED patient who reports pain to determine whether an emergency medical condition is present. If an emergency medical condition is present, the EMP is required to stabilize the patient’s condition. The law allows the EMP to use his or her clinical judgment when treating pain and does not require the use of opioids.