create objective treatment goals. This impact takes many forms, including reductions or dysfunctions in physical activity, concentration, emotional stability, interpersonal relationships, and sleep. These impacts, in turn, degrade functioning at work or in the home, which can lead to depression, anxiety, insomnia, and even suicide. Even relatively modest pain reductions can lead to significant functional improvements. 10 A 20% reduction in a pain score (i.e., roughly two points on the standard 0-10 pain scale) may be acceptable if it produces significant functional benefits for a patient. Function-based treatment goals, rather than pain relief goals, offer two primary advantages to clinicians: • Treatment decisions 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. Function-based treatment plans are especially valuable in the context of prescribing opioid pain medications, because such goals may help determine whether a patient has an opioid use disorder, but they serve many useful purposes even when treatments do not involve opioids. Functional decline itself may result from a range of problems, including inadequate pain relief, non-adherence to a regimen, function-limiting side effects, or untreated affective disorders. Sometimes impaired functioning is the result of an opioid use disorder (OUD), and these objective results may shed valuable light on an otherwise confusing presentation of pain symptoms. It’s important to set realistic functional goals. Progress in restoring function is usually slow, irregular, and gains are typically incremental. Chronic non-cancer 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. Raising goals after a patient has “succeeded” in achieving them is far more motivational and encouraging than lowering goals after a patient has “failed” (although one should not use the word “fail” or “failed” in actual practice). Treatment initiation A central tenet of pain management, whether for acute or chronic pain, is to aim for a tolerable level of pain that allows the patient maximum physical and emotional functioning with the lowest risk of side effects, progression to chronic pain, or misuse or abuse. 10 This requires a careful balancing of patient-related factors (e.g., comorbidities, medical
history, risk of abuse) and drug-related factors (e.g., potency, mechanism of action, expected side effects). A commonly-recommended way to achieve this balance is with multimodal analgesia, in which several therapeutic approaches are used, each acting on different pain pathways, which can reduce dependence on a single medication and may reduce or eliminate the need for opioids and attendant risks/side effects. 11 Multimodal analgesia can produce synergistic effects, reduce side effects, or both. One example of multimodal analgesia is the use of both an NSAID and acetaminophen, plus physical approaches (e.g., cold, compression, or elevation) to manage postoperative pain. Demonstrated benefits of multimodal analgesia include earlier ambulation, earlier oral intake, and earlier hospital discharge for postoperative patients, as well as higher levels of participation in activities necessary for recovery (e.g., physical therapy). 11 The many pharmacologic and non- pharmacologic approaches to treating acute and chronic pain should be employed using the following general principles: • Identify and treat the source of the pain, if possible, although pain treatment can begin before the source is determined • Use the simplest approach to pain management first. This generally means using non-pharmacologic approaches as much as possible and/or trying medications with the least severe potential side effects, and at the lowest effective doses • Create individualized treatment plans if therapy is expected to last longer than a week • Reserve opioid analgesics for moderate-to- function-based, severe acute pain unresponsive to non-opioid therapies or moderate-to-severe chronic pain in patients who have been assessed for risk of abuse or dependence and for whom previous trials of both drug and non-drug approaches have failed to provide an adequate response. Managing patient expectations Patients in pain are understandably worried that the pain will persist or get worse with time. Physicians can reduce such fears and set realistic expectations for treatment effectiveness and healing with clear, compassionate communication couched in terms patients can easily understand. It can be helpful, for example, to share with patients the fact that most forms of acute pain (e.g., nonspecific low back pain) are self-limiting, subside within weeks, and do not require invasive interventions. (In a systematic review of 15 prospective cohort studies, 82% of people who stopped work due to acute low back pain returned to work within one month.) 12
Introduction Across specialties, physicians are concerned about opioid pain medication misuse, they find managing patients with chronic pain stressful, express concern about patient addiction, and say they have insufficient training in prescribing opioids. 1 It is increasingly understood that although opioids can effectively control pain, addiction can be a consequence of prolonged use, and long-term opioid therapy is often overprescribed for patients with chronic non-cancer pain. 2 Many of the problematic issues surrounding the use of opioids for chronic pain are equally compelling and urgent in the treatment of acute pain. For example, a number of studies demonstrate an increased risk of new persistent opioid use in opioid-naïve patients after having been prescribed opioids for acute pain. 3-6 Physicians are constantly challenged to provide optimum pain relief for those suffering from acute and chronic pain in an era dominated by a profound opioid crisis. In 2020 an average of 252 people were dying every day from opioid-related overdoses. 7 In this context it is essential that clinicians become familiar with the wide array of non-opioid analgesic treatment options (both pharmacologic and non-pharmacologic) for acute and chronic pain conditions. Clinicians need to understand the relatively recent evidence showing that opioids may not be very effective for relieving chronic pain in the long-term and, in fact, may be associated with increased pain, reduced functioning, and opioid dependence. 8,9 This CME learning activity focuses on the evidence supporting the effectiveness of non-opioid therapies, suggests strategies for assessing and managing patients with both chronic and acute pain, and takes an in-depth look at non-opioid options for four common painful conditions: osteoarthritis, low- back pain, diabetic neuropathy, and fibromyalgia.
General strategies for pain management
The importance of function-based pain treatment plans Formal treatment plans are seldom needed for treating acute pain conditions, but they may be extremely valuable when treating patients with chronic pain, regardless of the specific treatment options being considered. The plans should include the goals of therapy and should be written carefully because pain is inherently subjective. Since pain cannot be measured objectively, framing treatment goals solely in terms of pain relief means that such goals cannot be objectively confirmed. Although a patient’s subjective pain and suffering are obviously important, only the functional impact of the pain can be measured and used to
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