__________________ Effective Management of Acute and Chronic Pain with Opioid Analgesics, 2nd Edition
PATIENT-PROVIDER AGREEMENTS A written agreement between a clinician and a patient about the specifics of their pain treatment with opioids can help clarify the plan with the patient, the patient’s family, and other clinicians who may become involved in the patient’s care. Such agreements can also reinforce expectations about the appropriate and safe use of opioids. Caution must be exercised, however, to ensure that patient/provider agreements are not used in a coercive way to unethically place patients in the position of having to agree to its terms or else lose an important component of their treatment (or even lose all treatment). CASE STUDY 2 Inessa is 72 and lives in an urban area, having immigrated from Russia as a young woman. She grew up on a farm and worked in the fields or tending animals starting as a child. She blames these early labors for the arthritis she now has in her hands and wrists and for the pain she feels in her lower back. Although Inessa lives alone, following the death of her husband from a heart attack 5 years ago, she relies on a young man who lives in a small apartment attached to her house for help with activities of daily living and simply for company. According to Inessa, the pain medication she was prescribed for her arthritis (short-acting hydrocodone/acetaminophen) is no longer working, and she has come to you asking for either a different medication or a higher dose of the existing medication. Despite her reported pain, Inessa is ambulatory and appears cognitively intact. She takes a range of herbal supplements including St. John’s wort, turmeric, and a “joint support” supplement, the ingredients of which she is unsure. She has a very insistent, demanding personality and is convinced she needs the new, or higher-dose, opioid medication. Case study questions: 1. How would you respond to Inessa’s request? 2. What alternatives to an opioid analgesic could you offer to Inessa? 3. If you end up prescribing an opioid analgesic for Inessa, would you require that she sign a patient/provider agreement? If so, what specific caveats would you include in the agreement? 4. Would it be prudent to include the young man who cares for her in discussions about treatment?
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. 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. Even relatively modest reductions in pain can translate into significant functional improvements as pain rating declines. 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, nonadherence 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 noncancer 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.
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