________________________________ Substance Use Disorders and Pain Management: MATE Act Training
In patients who are opioid-naïve, start at the lowest pos- sible dose and titrate to effect. Dosages for patients who are opioid-tolerant should always be individualized and titrated by efficacy and tolerability [125; 127; 132]. When starting opioid therapy for chronic pain, clinicians should prescribe short-acting instead of extended-release/long-acting opioid formulations [125; 127]. The need for frequent progress and benefit/risk assessments during the trial should be included in patient education. Patients should also have full knowledge of the warning signs and symptoms of respiratory depression. Prescribers should carefully reassess evidence of benefits and risks when increasing the dosage to ≥50 mg morphine milligram equivalents (MME) per day. In its 2016 guideline, the CDC recommended that decisions to titrate dosage to ≥90 mg MME/day should be avoided or carefully justified [125; 133]. This recommendation does not appear in the 2022 revision [127]. Prescribers should be knowledgeable of federal and state opioid prescribing regulations. Issues of equianalgesic dosing, close patient monitoring during all dose changes, and cross- tolerance with opioid conversion should be considered. If necessary, treatment may be augmented, with preference for nonopioid and immediate-release opioids over long-acting/ extended-release opioids. Taper opioid dose when no longer needed [134]. Palliative Care and Pain at the End of Life Unrelieved pain is the greatest fear among people with a life- limiting disease, and the need for an increased understand- ing of effective pain management is well-documented [135]. Although experts have noted that 75% to 90% of end-of-life pain can be managed effectively, rates of pain are high, even among people receiving palliative care [135; 136; 137; 138]. The inadequate management of pain is the result of several factors related to both patients and clinicians. In a survey of oncologists, patient reluctance to take opioids or to report pain were two of the most important barriers to effective pain relief [139]. This reluctance is related to a variety of attitudes and beliefs [135; 139]: • Fear of addiction to opioids • Worry that if pain is treated early, there will be no options for treatment of future pain • Anxiety about unpleasant side effects from pain medications • Fear that increasing pain means that the disease is getting worse • Desire to be a “good” patient • Concern about the high cost of medications Education and open communication are the keys to overcom- ing these barriers. Every member of the healthcare team should reinforce accurate information about pain management with patients and families. The clinician should initiate conversa- tions about pain management, especially regarding the use of
opioids, as few patients will raise the issue themselves or even express their concerns unless they are specifically asked [140]. It is important to acknowledge patients’ fears individually and provide information to help them differentiate fact from fic- tion. For example, when discussing opioids with a patient who fears addiction, the clinician should explain that the risk of addiction is low [135]. It is also helpful to note the difference between addiction and physical dependence. There are several other ways clinicians can allay patients’ fears about pain medication: • Assure patients that the availability of pain relievers cannot be exhausted; there will always be medications if pain becomes more severe. • Acknowledge that side effects may occur but emphasize that they can be managed promptly and safely and that some side effects will abate over time. • Explain that pain and severity of disease are not necessarily related. Encouraging patients to be honest about pain and other symptoms is also vital. Clinicians should ensure that patients understand that pain is multidimensional and emphasize the importance of talking to a member of the healthcare team about possible causes of pain, such as emotional or spiritual distress. The healthcare team and patient should explore psy- chosocial and cultural factors that may affect self-reporting of pain, such as concern about the cost of medication. Clinicians’ attitudes, beliefs, and experiences also influence pain management, with addiction, tolerance, side effects, and regulations being the most important concerns [135; 137; 139; 141]. A lack of appropriate education and training in the assessment and management of pain has been noted to be a substantial contributor to ineffective pain management [139; 141]. As a result, many clinicians, especially primary care physicians, do not feel confident about their ability to manage pain in their patients [139; 141]. Clinicians require a clear understanding of available medica- tions to relieve pain, including appropriate dosing, safety profiles, and side effects. If necessary, clinicians should consult with pain specialists to develop an effective approach. Strong opioids are used for severe pain at the end of life [136; 137]. Morphine, buprenorphine, oxycodone, hydromorphone, fentanyl, and methadone are the most widely used in the United States [142]. Unlike nonopioids, opioids do not have a ceiling effect, and the dose can be titrated until pain is relieved or side effects become unmanageable. Patients who are opioid- naïve or who have been receiving low doses of a weak opioid, the initial dose should be low, and, if pain persists, the dose may be titrated up daily until pain is controlled.
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