Thoughtful prescribing

Friday, September 01, 2017 12:22 PM
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Using the most effective treatments for chronic pain

by Kathryn Mueller, MD, MPH, FACOEM

According to the Institute of Medicine, chronic pain affects an estimated 100 million American adults – more than the total affected by heart disease, cancer and diabetes combined. Thus a patient presenting with chronic pain is a common occurrence for many physicians, especially in primary care settings.

Opioids are the most powerful analgesics, and their use in acute pain and moderate-to-severe cancer pain is well accepted. However, their use in chronic pain is controversial due to limited effectiveness and documented rates of overdose and death. A study on chronic nonspecific low-back pain offers strong evidence that the short and intermediate term reduction in pain intensity of opioids, compared with placebo, falls short of a clinically important level of effectiveness1. In fact, opioids may not be the most effective medication for many chronic pain patients, and understanding this can change physicians’ prescribing patterns and shape their conversations with patients.

In chronic pain situations, the physician faces the challenge of establishing a care plan that addresses the many available treatment combinations and the individual patient’s specific goals for improvement. When considering pain management options, active therapy is an essential component. Regular exercise, especially outdoors, is shown to decrease both depression and chronic pain. Most chronic pain patients suffer from some level of anxiety or depression, and sleep deprivation. It is important to identify these issues during the initial assessment and address them as part of the treatment plan. Cognitive behavior therapy is effective for depression and anxiety as well as sleep disorders. The physician can then look to other options such as mindfulness, acupuncture or yoga, all of which have some evidence supporting their use – depending on the interest of the patient2. Helping the patient choose appropriate physical and cognitive activities is important for recovery.

It is essential that the patient and provider understand the type of pain the patient is experiencing and how the pain affects his or her daily activities. The goal is to get the patient active again and participating in his or her life. Some patients with chronic pain avoid exercise and physical activity because they are concerned about the pain it initially causes. The physician may wish to provide some examples of how pain can lead to successful physical performance. For example:

“If you wanted to learn to ski, what would you do? You would get up and practice. Then what would happen? Your muscles would hurt but that would show you that you are making progress toward your goal, and eventually, as you become more successful, the pain would decrease. Perhaps you are having pain in your back and there are some age-related changes to your back on X-ray. Some people with those changes have pain and others do not. It is likely that when you increase the muscle strengthen in the areas supporting your spine, your back pain will decrease. However, to do that you will naturally have some pain in your muscles as you strengthen them.”

If the physician adds medication to the management plan, neuropathic pain much first be ruled out as opioids are less effective. If the pain is primarily non-neuropathic pain and other non-opioid medications and treatment have been ineffective, a physician may decide to try opioids. An opioid trial should be set up like any other drug trial. The initial conversation is extremely important to avoid problems later. Be up front and honest.

  • Explain that opioids do not work for many people and that use of opioids leads to side effects such as constipation, sexual dysfunction and sleep apnea. Most studies show that only around 50 percent of patients tolerate opioid side effects and receive an acceptable level of pain relief. As long as the patient demonstrates objective functional benefits, such as ability to work, assist their family and/or participate in recreational activities, you will continue to prescribe medication and work to decrease the side effects of the opioid.
  • Explain that there are precautions against driving and that the patient cannot work in a job that requires driving during initiation of the trial or while escalating doses. The patient should also not use opioids if he or she works in a safety-sensitive job such as operating a forklift or roofing.
  • Establish reasonable expectations, telling the patient that if the opioid does not work to improve function, he or she will be gradually tapered from the opioid as in any other medication trial. The end point is not total absence of pain but rather returning to function in life. If he or she isn’t getting more out of life and is sleeping excessively or not exercising, that is not an outcome you can prescribe for and it will be time to switch.
  • Explain that your job as a physician is not to manage the opioid; the goal is to make the patient healthier. Opioids are a small factor in this equation and do not work for all patients in this situation.
  • There is no magic pill; a combination of therapies is needed to address chronic pain.

Most patients will cooperate with the treatment plan if they haven’t been introduced to opioids before, aren’t specifically seeking them and have a guided discussion with the doctor as outlined above.

When confronted with a “problem patient” who may be opposed to trying other options or reluctant to stop an opioid that isn’t working, the physician can continue to focus on their job to make the patient healthier. Thus evidence that the opioid isn’t beneficial will require a change of course. These patients may be inherently harder to manage, especially if their initial introduction to opioids was managed poorly.

Continue to work to change the patient’s mindset, explaining that the problem is that chronic pain is preventing him or her from enjoying the things the physician and patient identified together as the patient’s chosen goals. This is the problem they will solve together.

There are a variety of reasons a physician might taper a patient off of an opioid and start over, especially in cases where a patient has become less functional than would be expected for the injury involved. If you plan to taper the opioid, explain that you want to get the right plan in place and figure out what’s best for the patient. Many people who cease taking an opioid never go back because they feel much better off of opioids. Once the patient is off of opioids and compliant with the other elements of chronic pain treatment, the physician must decide if he or she is willing to put the patient back on the same or a different opioid or if the other elements of treatment are sufficiently successful without the use of opioids. All of these are acceptable treatment patterns.

The main goal is promoting shared decision-making and helping patients identify their goals. They should have verbalized actionable items to which they are attached and that can be used as treatment goals. To stay home and to not have pain are not realistic treatment goals!


1. Abdel Shaheed, C., Maher, C. G., Williams, K. A., Day, R., & McLachlan, A. J. (2016). Efficacy, Tolerability, and Dose-Dependent Effects of Opioid Analgesics for Low Back Pain: A Systematic Review and Meta-analysis. JAMA Intern Med, 176(7), 958-968. doi:10.1001/jamainternmed.2016.1251

2. Draft Chronic Pain guidelines:

Posted in: Colorado Medicine | Initiatives | Prescription Drug Abuse


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