How to care for patients suffering from chronic pain
From the June ACP Observer, copyright © 2006 by the American College of Physicians.
By Deborah Gesensway
PHILADELPHIA— Prescribing opioids comes with definite challenges, including the need to track the drugs' use. But physicians shouldn't let such challenges stop them from appropriately prescribing these powerful drugs for certain patients suffering from chronic nonmalignant pain.
“The challenge of using opioids lies between the argument that the undertreatment of pain in our society is a moral outrage and the evidence of the dramatic increase over the last decade in prescription drug abuse,” said Matthew F. Hollon, MD, assistant professor of medicine at the University of Washington in Seattle, who spoke at Annual Session.
Matthew F. Hollon, MD, says internists need to balance appropriate pain treatment with the 'dramatic increase' in prescription drug abuse.
Evidence for using opioids for chronic nonmalignant pain is reasonable, but "limited both by selection bias and the duration of the studies. Studies show you can reduce pain by 30%”—from 6 to 4 on a pain scale—"although the evidence is less good on whether the drugs improve functional status,” he explained. Methadone tends to be a good choice to treat chronic pain because of its unique receptor activity, long half-life and low cost.
Nearly 50 million Americans suffer from chronic pain, and its prevalence in primary care settings is estimated at between 5% and 33%, Dr. Hollon pointed out. These patients comprise about 10% of his practice.
But opioids are not for everyone, he said during a session entitled “Managing Chronic Nonmalignant Pain: The General Internist’s Perspective.” If you apply the selection criteria used in randomized trials of opioids for chronic pain, only one out of 10 chronic pain patients are good candidates for opioids.
In practice, only patients who meet certain criteria—those with clear goals for improving functional status, and who have failed at adequate trials of other therapies and have a low risk of drug abuse—should be considered for long-term opioid therapy. Physicians should look for red flags signaling abuse, including frequent requests for early refills and a history of substance abuse.
“It’s OK to say 'no,' ” he said. As a precaution, he never prescribes opioids on a patient's first visit—a clinic policy he can show to patients.
When he does prescribe opioids, he does so cautiously, requiring everyone starting on these medications to sign an agreement. (The agreement not only documents informed consent but, among other stipulations, grants permission for regular urine tests.) He also expects patients on opioids to be in psychiatric care or on treatment for depression, “because opioids are neurodepressants.”
And Dr. Hollon advised physicians to clearly document the role that opioids are playing in the treatment plan. Documentation at every visit should include the location, intensity and cause of the pain; the effect on functional status; the dose, frequency and quantity prescribed; and the specific follow-up plan.
A different approach
Chronic nonmalignant pain—commonly low back pain, or pain caused by osteoarthritis, spinal stenosis, injury or diabetic neuropathy—correlates poorly with physical findings or diagnostic tests. Consequently, managing these patients requires a slightly different take than managing other types of pain, such as cancer or acute pain.
Opioids are only one approach, Dr. Hollon said. Others include:
Patient education. Teach patients that the goal of treatment is to relieve pain enough to allow them to live with it, not eliminate it completely. "We won’t be able to get rid of the pain," Dr. Hollon said he tells patients, “but we will be able to move it out of the driver’s seat of your life and put it in the back seat.”
Set treatment goals. During the initial visit, have a detailed conversation about the patient’s treatment goals. Dr. Hollon writes these down and gives a copy to the patient. He also asks the patient to pick the one goal that is most important to him so he can refer back to it during frequent follow-up visits.
When treating chronic nonmalignant pain, negotiate stopping drugs and make a conscious decision about which one or ones to restart.
Take a 'clean slate' approach to polypharmacy. Negotiate stopping drugs and make a conscious decision about which one or ones to restart, focusing on medications to improve functional status.
Put pain in a biopsychosocial context. Chronic pain is frequently accompanied by psychiatric comorbidity and social stressors. Consequently, Dr. Hollon recommended treating depression and other psychiatric illnesses concomitantly and acknowledging the impact the pain has on an individual’s life.
Discuss non-pharmacological therapies. He talks to patients about everything from acupuncture and massage to physical therapy. The non-pharmacological approach with the best track record, he said, is exercise.
Consider other drugs. Many antidepressants including tricyclic antidepressants and venlafaxine have the added advantage of analgesic properties. Topical agents, such as capsaicin cream, can help 10-15% of patients. There is good evidence that anticonvulsants, such as gabapentin, can help relieve neuropathic pain. Anti-inflammatory drugs, on the other hand, appear to be of limited use due to ceiling analgesic properties and gastrointestinal side effects.
Build trust. Many chronic pain patients enter the doctor’s office extremely distrustful of the medical profession. Dr. Hollon said physicians need to address this roadblock upfront.
He speaks to that distrust directly by saying, “'I understand that you are in pain and I want to help you.' You have to say it explicitly because they expect the opposite," he said. "These patients come with a shield."
Deborah Gesensway is a freelance health care writer in Toronto.
The information included herein should never be used as a substitute for clinical judgment and does not represent an official position of ACP.
A national patient safety organization has posted a comprehensive list of commonly misinterpreted medication abbreviations that should never be used.
The list, compiled by the nonprofit Institute for Safe Medication Practices (ISMP), contains more than two dozen common medical abbreviations. The institute said the abbreviations should never be used in either internal communications about medications or in transmitting prescription information to pharmacies or computer physician order entry systems.
The list includes the suspect abbreviation, its intended meaning, how it is misinterpreted and the correct abbreviation or language that should be used instead. For many of the abbreviations, the ISMP recommends that physicians instead spell out the word or phrase being abbreviated.
The list was compiled from errors reported to the ISMP, which is a national nonprofit organization dedicated to medication error prevention and patient safety. The ISMP and the FDA intend to launch an intensive educational campaign in June to convince providers to stop using confusing medical abbreviations and dose designations.
The ISMP list flags those abbreviations that have been singled out by the JCAHO on its "do not use" list, but it goes beyond JCAHO requirements in reporting other abbreviations that should be avoided. The list is online.
Internist Archives Quick Links
Not an ACP Member?
Join today and discover the benefits waiting for you.
ACP offers different categories of membership depending on your career stage and professional status. View options, pricing and benefits.
A New Way to Ace the Boards!
Ensure you're board-exam ready with ACP's Board Prep Ace - a multifaceted, self-study program that prepares you to pass the ABIM Certification Exam in internal medicine. Learn more.