3. Using language that is stigmatizing, dominating, or pejorative 4. Using coercion in any way 5. Imposing limitations for the clinician’s convenience without clear and substantial benefit for the patient. 6. Insisting on behaviors unrelated to actual use of medications Using the term “fired” to describe termination of treatment. 7. Threatening abandonment or suggesting that patients will not have continued access to non- opioid pain-relieving treatments if opioids are terminated To be effective, written agreements must be clearly understood by the patient. This may require the provision of agreements in multiple languages. All agreements should be written at the sixth- to seventh-grade level or even lower. 129 Translators may need to be provided for speakers of other languages to ensure patient understanding and effective informed consent. A patient who does not fully understand the potential risks and benefits of a treatment cannot be truly “informed” as required by the legal and ethical guidelines for medical practice. Time must be allowed for patients to ask questions, and for prescribers to ensure patients understand what they are being told. Some, or all, of these tasks may be handled by trained personnel (or staff members) rather than clinicians. Although the term “agreement” is generally perceived as being more patient-friendly than the word “contract,” clinicians should understand that, from a legal standpoint, any written or oral agreement between a prescriber and a patient may be considered a binding “contract.” 130 Clinicians should ensure that the terms in any agreement are understood by the patient, and are acceptable, attainable, and consistent with high-quality practice. BEFORE MOVING ON THE NEXT SECTION, PLEASE COMPLETE CASE STUDY 4 ON THE NEXT PAGE. Creating individualized function-based pain treatment plans Once a patient has been assessed and accepted as a candidate for chronic opioid therapy, and after informed consent has been obtained for such treatment, a written plan for implementing the treatment should be drafted. Such plans typically include a statement of the goals of therapy. These goals should be written carefully in light of the inherent subjectivity of pain. Since pain itself cannot be measured objectively, framing treatment goals solely in terms of pain relief means that such goals cannot be objectively confirmed. Although a patient’s subjective pain and suffering are obviously important factors, only the functional impact of the pain can be measured
and used to create objective treatment goals. This impact takes many forms, but typically chronic pain erodes foundations of daily life, such as physical activity, concentration, emotional stability, interpersonal relationships, and sleep. This can, in turn, degrade functioning at work or in the home, which can lead to depression, anxiety, insomnia, and even suicide. Clinicians should know that even relatively modest reductions in pain can translate into significant functional improvements as pain rating declines. 104 A 20% reduction in a pain score (i.e., roughly two points on the standard 0-10 pain scale) may be acceptable if it produces significant functional benefits for a patient. Framing treatment goals in terms of improved patient functioning, rather than merely pain relief, offers two primary advantages to clinicians: • Prescribing decisions (or decisions to terminate treatment) are based on outcomes that can be objectively demonstrated to both clinician and patient (and, possibly, to the patient’s family) • Individual differences in pain tolerance become secondary to the setting and monitoring of treatment goals, since subjectively perceived levels of pain are not the primary focus in determining functionality. Basing treatment plans on functional goals is especially valuable in the context of prescribing opioid pain medications, because such goals may help determine whether a patient has an opioid use disorder because patients with OUD often have decreased functioning, while effective pain relief typically improves functioning. Functional decline itself may result from a range of problems, including inadequate pain relief, non-adherence to a regimen, function-limiting side effects, or untreated affective disorders. Sometimes impaired functioning is the result of OUD, and these objective results may shed valuable light on an otherwise confusing presentation of a patient’s pain symptoms. Functional treatment goals should be realistic. Progress in restoring function is usually slow and gains are typically incremental. Chronic non-cancer pain is often marked by long-standing physical and psychological deconditioning, and recovery may require reconditioning that may take weeks, months, or years. It is much better to set goals that are slightly too low than slightly too high. Raising goals after a patient has “succeeded” in achieving them is far more motivational and encouraging than lowering goals after a patient has “failed.” Table 4 illustrates some simple functional goals and ways they might be verified.
The responsibility for obtaining evidence of success in meeting a functional goal lies with the patient and should be made explicit in the prescribing agreement. If a patient is unable to document or achieve the progress outlined in a treatment plan, this may suggest a need for goal readjustment. Initiating therapy When initiating a trial of opioids, start with immediate-release formulations because their shorter half-life reduces the risk of inadvertent overdose. Prescribe low doses on an intermittent, as-needed basis. For elderly patients who have comorbidities, start at an even lower dose (25-50% of usual adult dose). Long-term opioid use often begins with treatment for acute pain, and research shows that opioids are often over-prescribed for acute pain. For example, a study of 1,416 patients in a 6-month period found that surgeons prescribed a mean of 24 pills (standardized to 5 mg oxycodone) but patients reported using a mean of only 8.1 pills (utilization rate 34%). 125 For acute pain, only enough opioids should be prescribed to address the expected duration and severity of pain from an injury or procedure (or to cover pain relief until a follow-up appointment). Several guidelines about opioid prescribing for acute pain from emergency departments 131,132 and other settings 133,134 have recommended prescribing ≤ 3 days of opioids in most cases, whereas others have recommended ≤ 7 days, 135 or ≤ 14 days. 136 CDC guidelines suggest that for most painful conditions (barring major surgery or trauma) a 3-day supply should be enough, although many factors must be taken into account (for example, some patients might live so far away from a health care facility or pharmacy that somewhat larger supplies might be justified) and clinician judgment is an important factor in determining the supply. 31 Monitoring opioid use Follow-up appointments should occur one to four weeks after initiation of opioids or with dose changes; maintenance therapy visits should occur at least every three months. Each visit should include an assessment using a pain and function tool, questions about side effects, evaluation of overdose risk, and discussions about how the medication is being used. 34 Many strategies to monitor opioid use and ensure patient safety have been recommended. However, simply asking patients how they are using the medication, how often they take it, how many pills they take at one time, and what triggers them to take the medication, can identify patients who may be misusing opioids or need changes to their pain management plan.
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