Effective Management of Acute and Chronic Pain with Opioid Analgesics, 2nd Edition _ ________________
Prescribers should evaluate benefits and harms of continued opioid therapy with patients every three months or more frequently. If benefits do not outweigh harms of continued opioid therapy, prescribers should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids [7]. Recommendation 8.3: Adjust and Prescribe Medication During Clinic Visit Medication adjustments, if necessary, should be made and prescriptions provided during a clinic visit. Face-to-face follow-up visits should occur at least every 2-4 weeks during any period when dosages are being adjusted. More frequent follow-up visits may be advisable when prescribing opioid medication to a patient with a known addiction problem, suspected aberrant behavior, or co-existing psychiatric or medical problems. Options for medication adjustments include reducing medication or rotating opioid medication. Opioid rotation can be an effective means of reducing opioid dose, reducing adverse side effects or improving efficacy. However, when switching from one opioid to another, extreme caution is required due to incomplete cross-tolerance among various opioids. Refer to opioid rotation guidelines before attempting an opioid switch (opioid rotation). When it is documented that the patient is compliant In general, if the patient’s underlying medical condition is chronic and unchanging and if opioid- associated problems (hyperalgesia, substantial tolerance, important adverse effects) have not developed, it is recommended that the effective dose achieved through titration not be lowered once the patient has reached a plateau of adequate pain relief and functional level [10].. CHRONIC PAIN RECOMMENDATION 9: MULTI- DISCIPLINARY APPROACH Recommendation 9.1: Obtain a Second Opinion or Consultation Prescribers should obtain a consultation for a patient with complex pain conditions or serious comorbidities. Reasons to refer patients include: • The prescriber has reached a limit of what he or she feels comfortable prescribing. • The treatment needs a multi-disciplinary approach. • The pain has progressed to a complex level. • Significant risk factors for substance use disorder are identified. • There is a need to re-evaluate the patient’s diagnosis and/or confirm the continued diagnosis. A multidisciplinary approach for chronic pain may result in a better outcome compared to medical management alone. The results generally indicate a reduction in pain, better functional
restoration, reduced healthcare costs, higher return-to-work rates, and reduced disability costs. Patients with serious comorbidities may benefit from a Palliative Care consultation if the goal is to improve a person’s quality of life while living with chronic or serious illness. These patients usually have exhausted other traditional therapies for their illnesses (congestive heart failure, COPD, advanced cancer) or live with a high symptom burden during treatment of their illness. They are not hospice eligible, because they live longer than a traditional hospice patient or may have aggressive medical goals. Patients that receive palliative care may have less frequent hospitalizations, improved quality of life, and improved physical function [11]. Recommendation 9.2: Refer to a Substance Use Disorder Specialist for Treatment Patients at high risk for Substance Use Disorder (SUD) or those exhibiting behaviors of abuse, diversion, or addiction should be referred to a SUD specialist for treatment. Find Substance Abuse Agencies by county at dsamh.utah.gov/ substance-use-disorders/. Also, see the Tools and Resources section for a list of Opioid Use Disorder Providers.
Recommendation 9.3: Offer Medication-Assisted Treatment
Prescribers should offer or arrange evidence-based treatment for a patient with opioid use disorder, which usually includes medication-assisted treatment with buprenorphine, naltrexone, or methadone in combination with behavioral therapies. The prescriber may consider opioid medication for pain when monitoring is performed during the titration and maintenance phase and the patient understands and consents to the risks, even if the patient has a self-reported or documented previous problem with opioids. Opioid treatment in this case requires more structured ongoing assessment for loss of control and nonadherence. Co- management with or a referral to an addiction medicine specialist is recommended. The specialist is required to have a special registration to provide medication- assisted treatment; otherwise, there is a provision in the Utah Controlled Substance Act in which the provider may apply to receive a waiver of the special registration requirements to treat with buprenorphine. This can be done through the Substance Abuse Mental Health Services Administration Buprenorphine Waiver Management at www.samhsa.gov/medication-assisted- treatment/buprenorphine-waiver-management. RECOMMENDATION 9.4: REFER TO MENTAL HEALTH SERVICES Patients with co-existing psychiatric disorders should receive ongoing mental health support and treatment while being treated for chronic pain. Unless the prescriber treating the patient is qualified to provide the appropriate care and evaluation of the coexisting psychiatric disorder, consultation should be obtained to assist in formulating the treatment plan and establishing a plan for
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