Table 3. Opioid dose recommendations for post-procedural pain 126 Procedure
Number of oxycodone 5 mg tablets (or equivalent)
Dental extraction
0 5 5 5
Thyroidectomy
Breast biopsy or lumpectomy
Lumpectomy plus sentinel lymph node biopsy
Hernia repair (minor or major)
10 10 10 15 15 15 15 20 20
Sleeve gastrectomy
Prostatectomy
Open cholecystectomy
Cesarean delivery
Hysterectomy (all types)
Cardiac surgery via median sternotomy
Open small bowel resection
Simple mastectomy with or without sentinel lymph node biopsy
Total hip arthroplasty
30
Total knee arthroplasty
50 MANAGING CHRONIC NON-CANCER PAIN
Management of chronic non-cancer pain begins by establishing individualized treatment goals, exploring non-opioid treatment options, and addressing comorbid depression and anxiety, if present. Pain management goals may include both pain and functional targets, with the understanding that being 100% pain free is not realistic. Functional goals should focus on activities that are meaningful to the patient and attainable based on the severity of the painful condition. Multi-modal approaches that include non- drug (procedures, integrative treatments) and drug interventions are recommended. 28 Be aware that comorbid conditions such as depression and anxiety can impact pain management. (In a study of 250 patients with chronic pain and moderate depression, using antidepressant therapy reduced pain levels before analgesic interventions were added. 127 ) Establishing a written treatment agreement Written documentation of all aspects of a patient’s care, including assessments, informed consent, treatment plans, and provider/patient agreements, are a vital part of opioid prescription “best practices.” Such documentation provides a transparent and enduring record of a clinician’s rationale for a particular treatment and provides a basis for ongoing monitoring and, if needed, modifications of a treatment plan. 104 Many computerized systems are now available for the acquisition, storage, integration, and presentation of medical information. Most offer advantages that will benefit both patients and prescribers, such as maintaining up-to-date records, and providing instant
For patients with intractable, moderate-to-severe chronic noncancer pain unresponsive to non-opioid treatment options, a trial of opioids may be indicated guided by the following principles (each detailed below): ● Discuss risks and benefits of opioid use ● Establish a written treatment agreement ● Check or monitor opioid use with the prescription drug monitoring program ● Use caution with dose escalation ● Prescribe naloxone if at risk for overdose ● Screen for opioid misuse or abuse using history and, ideally, a validated questionnaire, as well as urine drug testing ● Taper or discontinue opioids when possible availability of information relevant to prescribing or treatment. Although automation can help, clear documentation is not dependent on electronic record- keeping; it merely requires a commitment to creating clear and enduring communication in a systematic fashion. Good documentation can be achieved with the most elaborate electronic medical record systems, with paper and pen, or with dictated notes. Clinicians must decide for themselves how thoroughly, and how frequently, their documentation of a patient’s treatment should be.
Book Code: MDAZ1124
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