Pain Treatment Guidelines
Upcoming Pain Treatment Guidelines
Upcoming Pain Treatment Guidelines
Upcoming Pain Treatment Guidelines
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.
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.
Upcoming Pain Treatment Guidelines
Upcoming Pain Treatment Guidelines
Introduction
Primary care providers soon recognize that management of low back pain is common and complex. Low back pain is one of the most common reasons for physician visits in the United States and about one-fourth of all US adults report low back pain in the last three months. Furthermore, acute low back pain complaints oftentimes become chronic ones. Fortunately, our understanding of the physiology of pain and its treatment has increased dramatically in recent years. For example:
- We now know that the use of opioids for chronic non-cancer back pain is counterproductive.
- We know that advanced imaging of patients without dangerous “red flag” symptoms and signs is counterproductive.
- We know that keeping a patient with low back pain active is essential.
Many tools have recently been developed to assist providers as they approach their patients with back pain. The goal of this clinical update is to help introduce members of health care teams to these resources.
SPACE: The final frontier
Opioids show no benefit over non-opioids for function or pain
- Randomized controlled trial comparing opioid vs. non-opioid medication therapy in chronic low back pain and hip/knee osteoarthritis
- Primary outcome was pain-related function, main secondary outcome was pain intensity
- At 12 months there was no difference between the two groups for either outcome
- The opioid group had significantly more side effects
- For Chronic Pain, opioids offered no benefit over non-opioid medications for function or pain intensity and had significantly more side effects
The significance of this study is that for chronic pain, opioids didn’t provide any benefit over non-opioid in terms of function or pain intensity and carry significant risks. All decisions in medicine involve balancing risk and benefit. The SPACE trial showed that when it comes to opioids and chronic low back and degenerative hip and knee pain, there is no benefit, only risk.
Key points to remember
- Opioids are not a first line treatment
- Routine imaging is rarely helpful for most back pain
- Keep your patients active!
- Improved function is the goal
References and Resources
- Opioids are not a first line treatment
- Diagnosis and Treatment of low back pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society http://annals.org/aim/fullarticle/736814/diagnosis-treatment-low-back-pain-joint-clinical-practice-guideline-from Ann Intern Med. 2007;147(7):478-491 (Step by step recommendations for work-up and treatment of low back pain)
- Noninvasive Treatments for Acute, Subacute, and Chronic Back Pain: A Clinical Practice Guideline from the American College of Physicians http://annals.org/aim/fullarticle/2603228/noninvasive-treatments-acute-subacute-chronic-low-back-pain-clinical-practice Ann Intern Med. 2017;166(7):514-530 (Implementing a selective approach to low back imaging would provide better care to patients, improve outcomes, and reduce costs)
- Editorial: Management of Low Back Pain: Getting from Evidence-Based Recommendations to High-Value Care: http://annals.org/aim/fullarticle/2604103/management-low-back-pain-getting-from-evidence-based-recommendations-high Ann Intern Med. 2017;166(7):533-534. (Editorial comment on the 2 articles above)
- SPACE TRIAL: Effect of Opioid vs. Non-opioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip and Knee Osteoarthritis Pain, The SPACE Randomized Clinical Trial JAMA 2018; 319: 872-882 https://jamanetwork.com/journals/jama/article-abstract/2673971 (Opioids are no better for chronic low back pain than non-opioid approaches)
- Oregon HERC (Health Evidence Review Commission) Guideline Note 60: “Opioids for conditions of the back and spine” http://www.oregon.gov/oha/HPA/CSI-HERC/SearchablePLdocuments/Prioritized-List-GN-060.docx (Guidelines regarding the use of opioids for back pain with Oregon Health Plan patients).
- Routine imaging is rarely helpful for most back pain
- Diagnostic Imaging for Low Back Pain: Advice for High-Value Health Care from the American College of Physicians Ann Inter Med 2011; 154: 181-189 http://annals.org/aim/fullarticle/746774/diagnostic-imaging-low-back-pain-advice-high-value-health-care (Addresses implementing a selective approach to low back imaging)
- Oregon HERC Guideline Note D4: “Advanced Imaging for Low Back Pain”. http://www.oregon.gov/oha/HPA/CSI-HERC/SearchablePLdocuments/Prioritized-List-GN-D004.docx (Guidelines regarding recommendations for Initial Diagnostic Work-up and Potentially Serious Conditions-so called “Red Flags”)
- Keep your patients active!
- Providence Persistent Pain Program. https://oregon.providence.org/our-services/p/providence-persistent-pain/persistent-pain-toolkit/ (A Toolkit designed to help both health care professionals and patients and their families with resources for understanding and quieting pain)
- Oregon HERC Guideline Note 56: “Non-Interventional treatments for the back and spine”. http://www.oregon.gov/oha/HPA/CSI-HERC/SearchablePLdocuments/Prioritized-List-GN-056.docx (Tools to stratify patients into “Risk levels” for poor functional prognosis based on psychosocial indicators. Use of PT, OT, DC, Acupuncture, Cognitive Behavioral Therapy, yoga, massage, supervised exercise therapy).
- Improved function is the goal
Upcoming Pain Treatment Guidelines
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
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Treatment | Reduction in Pain Intensity |
Physical fitness | 30–60% |
CBT/Mindfulness | 30–50% |
Sleep restoration | 30–40% |
Opioids | <30% |
Tricyclics | <30% |
Anti-epileptics | <30% |
Cannabis | 10–30% |
Acupuncture | >10% |
Source: David Tauben, MD, Chief of Pain Medicine at the University of Washington.
Non-Opioid Treatment Options
The following list shows 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.
Patient Lifestyle
- Healthy sleep management
- Weight reduction
- Diet/Nutrition
- Stress reduction
- Exercise
Physiotherapy Interventions
- Functional therapies
- Physical therapy (PT)
- Occupational therapy (OT)
- Passive modalities
Behavioral Interventions
- Educational groups
- Preventive
- Support
- Peer-to-peer/Living Well workshops
- Shared medical appointments
- Psychotherapy
- Individual counseling
- Group therapy
- Cognitive behavioral therapy
- Supportive care
- Case management
- Substance-abuse treatment
- Residential
- Outpatient
- Medication-assisted treatment referral
- Trauma-informed care
- PTSD screening
- Domestic violence screening
- Child abuse screening
Medical Interventions
- Non-opioid medications that may aid in chronic pain management
- NSAIDS, acetaminophen
- Tricyclic antidepressants (neuropathic pain)
- Anti-epileptics (neuropathic pain)
- Topical medications
- Minimally invasive surgical procedures
- Nerve blocks, steroid injections
- Interventional treatments: ablations, restorative injections, stimulators, implantable devices
- Surgical treatment
- Complementary and alternative treatments
- Manipulative therapy
- Acupuncture
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.
Upcoming Pain Treatment Guidelines
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.
Upcoming Pain Treatment Guidelines
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.
Upcoming Pain Treatment Guidelines
Pain management is routinely required for some dental procedures. Patients must receive respectful care and appropriate management of dental pain. Most often, dental pain management is for acute or episodic situations, requiring short-term prescribing. For many conditions, ibuprofen, acetaminophen, or a combination of the two will suffice for dental pain. In other circumstances, a very small amount of narcotic medications followed by OTCs will provide appropriate pain relief.
- Prescribe opioids cautiously to those with a substance-abuse history. Be aware that such use can trigger relapse behaviors in susceptible individuals.
- Ask if patients are getting medications from other doctors, and use the PDMP prior to prescribing opioids whenever possible.
- Do not prescribe opioids to patients in substance-abuse treatment programs without consulting the program’s medical staff.
- Do not offer prescriptions with refills. Use caution if replacing prescriptions that were lost, destroyed, or stolen.
- Prescribing over the phone is discouraged, especially with patients you have not met, except in rare cases involving known invasive surgery.
- The use of non-combination opioids is discouraged.
- Prescribe opioid pills only in small dosages, which in most cases should not exceed three days or 10 tablets.
- When prescribing an antibiotic with the opioids, stipulate that the narcotic must be filled with the antibiotics at the pharmacy.
- Inform patients how to secure medication against diversion and how to dispose of leftover medication.
- Opioids should not be prescribed more than seven days after the last appointment. In most cases, three days of medication will suffice. It is strongly recommended that the patient be assessed in the clinic prior to providing refills.
- A second refill (same or different opioid) request should require patient assessment in the dental clinic and only be provided once a supporting diagnosis is established to continue with narcotic pain management.
- Third refills are strongly discouraged (except in unusual clinical circumstances that are well documented, such as osteonecrosis management); consider the need for chronic pain management by physician.
- Prolonged pain management (while awaiting specialty care) should be managed by and/or coordinated with the patient’s primary care provider.
Dental Section
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Upcoming Pain Treatment Guidelines
Sleeping Pills (Z Drugs and Others)
The Z drugs—zolpidem, zaleplon, eszopiclone—are indicated for the short-term treatment of insomnia. These medications are not benzodiazepines, but they do act on the same receptors and though they have a somewhat different risk profile (reduced seizure risk with withdrawal, for example) they share many of the adverse effects of benzodiazepines such as drowsiness, memory impairment, reduced coordination, depression, and sleep disturbances. Benzodiazepines are also commonly prescribed for insomnia, namely temazepam and lorazepam. As noted, there are many adverse effects associated with use, with little long-term efficacy.
There is an increase in all of these effects with elderly and pediatric patients. Using any of the Z drugs, benzodiazepines, alcohol, or opiates in any combination increases the risks of impairment and overdose. It is easy to become dependent on these medications, and it can be difficult to return to normal unaided sleep when discontinuing use. There are safer medical alternatives as well as non-pharmacological options that can be explored.
When considering prescribing these medications for insomnia:
- Avoid combinations of Z drugs, benzodiazepines, opioids, or stimulants
- Use the lowest dose possible:
- Avoid prescribing these for children and adolescents
- Use cautiously and at the lowest doses in the elderly
- Prescribe for only short intervals (7–10 days)
- Consider alternatives:
- Trazodone
- Amitriptyline
- Melatonin
Tramadol and Tapentadol
These are opiate-like analgesics used to treat moderate to severe pain. In addition to binding to mu opioid receptors, tramadol weakly inhibits norepinephrine and serotonin reuptake and tapentadol inhibits norepinephrine reuptake. Many of the risks associated with opioids are true for tramadol and tapentadol. Tramadol is now a Schedule IV drug and has been shown to increase the risk of precipitating a seizure. Both of these medications can cause physical and psychological dependency.
We recommend that tramadol be treated as other true opioids when evaluating risks and benefits of
opioid treatment.
Carisoprodol
Carisoprodol is a muscle relaxant with properties and risks similar to benzodiazepines including similar habit-forming properties. This medication should be used cautiously, if at all, especially in combination with opioids. It has been removed from the market in a number of countries worldwide, and the EU recommends it not be used for the treatment of low back pain. In patients experiencing severe pain from spasticity, consider alternatives such as tizanidine or baclofen.
Meperidine
Meperidine is a narcotic analgesic with sedative properties and is not recommended for outpatient treatment of acute or chronic pain. Additionally, meperidine is included in the 2015 AGS Beers Criteria as a potentially inappropriate medication to be avoided in patients 65 years and older because of potentially higher risk for delirium (neurotoxic metabolite), and lack of analgesia when taken orally. Furthermore, the American Pain Society does not recommend its use as an analgesic.
Long-Acting Opioids
Long-acting opiates consist of ER/LA formulations such as oxycodone, morphine ER, fentanyl patches, and methadone, among others.
Long-acting opiates carry the same risks as short-acting formulations. However, the risks of addiction, abuse, misuse, overdose and death are much greater, especially in opiate-naïve patients. For this reason, the use of long-acting opiates should be reserved for the management of pain severe enough to require daily, around-the-clock, long-term opioid treatment and for which alternative modalities (both pharmacologic and non-pharmacologic) have been maximally tried and subsequently failed.
Methadone
Methadone has unique metabolic properties making it particularly dangerous to prescribe outside of a closely managed methadone clinic. Overdoses are greatly increased with methadone compared to other opioids. Most guidelines recommend dosing at fewer than 30 mg/day or not at all.
As the dose of methadone increases, the potency of the drug in relation to other opioids increases in an exponential fashion. For making safe medication switches from methadone to other opioids and vice versa, see the Opioid Conversion Calculator.
Gabapentin
Gabapentin and pregabalin have a role in the treatment of neuropathic pain, but also have potential for misuse and abuse. These agents are perceived on the street as a substitute for most common illicit drugs. Overdoses have been fatal because of CNS depression, especially when combined with opioids, alcohol, or other CNS depressants.
Gabapentin and pregabalin are structurally related to GABA. They reduce the release of excitatory neurotransmitters as well as increase the effects of the dopaminergic reward system. This is responsible for the sedative and dissociative/psychedelic effects that can occur at higher doses. Pregabalin is a Schedule V controlled substance in the U.S. It may have a higher addiction potential than gabapentin resulting from its rapid absorption, faster onset of action, and a greater affinity for binding sites. The bioavailability of pregabalin does not change with higher doses, but bioavailability of gabapentin decreases by nearly 50% when the dose is increased from 900 mg/day to 3,600 mg/day. As a result, gabapentin doses greater than 1,800 mg/day don’t appear to provide additional neuropathic pain relief.
Gabapentin may help attenuate withdrawal symptoms from alcohol or opioids, and abusers will often “bridge” with gabapentin until they can obtain a supply of illicit drugs. However, it is important to note that individuals may also experience withdrawal symptoms from gabapentin itself. Consider alternatives such as tricyclics (TCAs) for neuropathic pain as an alternative to high-dose gabapentin.