Table 4: Example of functional goals and evidence used to assess progress 104
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.
Table 4: Example of functional goals and evidence used to assess progress 104 Functional Goal Evidence Begin physical therapy Letter from physical therapist Sleeping in bed as opposed to lounge chair
Report by family member or friend (either in-person or in writing)*
Participation in pain support group Increased activities of daily living
Letter from group leader
Report by family member or friend
Walk around the block
Pedometer recordings or written log of activity
Increased social activities Resumed sexual relations
Report by family member or friend
Report by partner
Returned to work
Pay stubs from employer or letter confirming the patient is off of disability leave Gym attendance records or report from family member or friend
Daily exercise
* Involving other persons requires explicit permission from the patient, and this permission should be documented. 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 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
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 opioids or need changes to their pain management plan. Other ways to objectively monitor opioid use are checking prescription drug monitoring programs, completing urine drug tests/oral fluid tests, or random pill counts. Relatively infrequent urine monitoring may be appropriate for low-risk patients on a stable dose of opioids (i.e., 1-2 times a year). More frequent or intense monitoring is appropriate for patients during the initiation of therapy or if the dose, formulation, or opioid medication is changed. Patients who may need more frequent or intense monitoring (i.e., 4-6 times a year) include: 104
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Book Code: MDAZ1124
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