__________________ Effective Management of Acute and Chronic Pain with Opioid Analgesics, 2nd Edition
NONDRUG APPROACHES Many nonpharmacologic and self-management treatment options have been found to be effective alone or as part of a comprehensive pain management plan, particularly for musculoskeletal pain and chronic pain [14]. Examples include, but are not limited to, psychological, physical rehabilitative and surgical approaches, procedural therapies (e.g., injections, nerve blocks), complementary therapies, and use of approved/ cleared medical devices for pain management. Primary care clinicians should know about the range of treatment options available, the types of pain that may be responsive, and when they should be used as part of a multidisciplinary approach to pain management. Clinicians should also be aware that not all nonpharmacologic options have the same strength of evidence to support their utility in the management of pain, and some may be more applicable for some conditions than others. MOVEMENT-BASED OPTIONS Movement therapies that may be helpful in patients with chronic pain include muscle-strengthening, stretching, and aerobic exercise (e.g., walking, aquatics). Recommended exercise programs typically occur one to three times a week for a total of 60-180 minutes per week, but any regimen must be carefully tailored to a patient’s existing level of physical conditioning, comorbidities, and cognitive status. WEIGHT LOSS Some pain syndromes, such as knee osteoarthritis, are worsened by obesity. For some patients, pain due to this condition is improved by reducing body weight because of reduced loads and physical stresses on the affected joints. The goal of body weight reduction is a baseline weight loss of 7%-10% by calorie reduction and increased activity using a balanced diet with less than 30% of calories from fat, 15%- 20% from protein, and 45%-60% from carbohydrates [15]. PASSIVE OPTIONS Acupuncture involves the stimulation of specific points on the body, most often involving skin penetration with fine metallic needles manipulated by hand but sometimes also including electrical stimulation or low-intensity laser therapy. Massage is the manual manipulation of the body to promote relaxation, reduce stress, and improve well-being. Handheld devices may also provide relief for some patients. Transcutaneous electrical nerve stimulation (TENS) machines generate mild electrical pulses that are applied cutaneously. The electrical stimulation from TENS may block or disrupt pain signals to the brain, reducing pain perception. TENS machines can be used at home or in conjunction with other interventions like physical therapy.
Recommendations for using a PDMP include: • Check the PDMP before starting anyone on opioid therapy. • Review the PDMP periodically throughout opioid therapy (at least every 3 months). • Look for prescriptions for other controlled substances, like benzodiazepines, that can increase risk of overdose death. • Review the total morphine milligram equivalent dose (MMED). Some states have specific requirements for PDMP use, such as requiring review prior to initial prescription or any time a specific prescription is written, such as for hydrocodone ER (Zohydro); clinicians should remain updated about the specific requirements of their state PDMPs. URINE DRUG TESTING Urine drug testing (UDT) is recommended before prescribing any opioid and at least annually thereafter [13]. Providers using urine drug screens should be familiar with the metabolites and expected positive results based on the opioid prescribed. If the prescribed opioid is not detected, discuss the finding with the patient and, if diversion is confirmed or suspected, reevaluate the pain management strategy or taper the opioid. If the patient tests positive for unprescribed drugs, schedule more frequent follow-up visits, consider opioid discontinuation, offer naloxone, or refer for treatment for substance use disorder. Decision tools and help with interpreting urine drug testing results are available at http://mytopcare.org/udt-calculator/ interpret-opiates-test-result. PAIN MANAGEMENT OVERVIEW Many pharmacologic and nonpharmacologic approaches to treating pain are available to primary care providers. These options should be employed using the following general principles: • Identify and treat the source of the pain, if possible, although pain treatment can begin before the source of the pain is determined. • Select the simplest approach to pain management first. This generally means using nonpharmacologic approaches as much as possible and/or trying medications with the least severe potential side effects and at the lowest effective doses. • Establish a function-based, individualized treatment plan if therapy is expected to be long- term.
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