● Patient and family history of mental health disorders (e.g., bi- polar, attention deficit disorder (ADD) / attention deficit hy - peractivity disorder (ADHD), depression, posttraumatic stress disorder). ● Patient and family history of substance use, addiction, or de- pendence. ● Determination of any history of physical, emotional, or sexual abuse and risk factors for substance abuse disorder; validated screening tools for substance abuse disorder help determine a patient’s risk level. ● Review of PDMP results. ● Monitoring of PDMP regularly throughout chronic pain man- agement follow-up to determine if the patient obtains other controlled substance prescriptions from other providers. ● Reasons a drug may be changed or discontinued; treatment may be discontinued without agreement from the patient, such as violations of the treatment agreement. ● Education for patients stating that complete elimination of pain should not be expected. (HHS, 2019a) Chronic pain treatment agreements that outline the responsibili- ties of the patient and the provider are indicated for long- term treatment with opioids or other medications with the potential for substance abuse disorder. The U.S. Department of Health and Human Services, Division of Indian Health Services, recommends that treatment agreements include the following tenets: ● Treatment goals are defined in terms of pain management, restoration of function, and safety. ● The patient is responsible for safe medication use (i.e., not taking more than prescribed; understanding the dangers of using in combination with alcohol, cannabis, benzodiazepines, or other CNS depressants unless closely monitored by the prescriber). ● The patient will ensure secure storage and safe disposal. ● The patient will obtain opioids from only one clinician or prac- tice. ● The patient will fill the opioids at only one pharmacy. ● The patient will agree to periodic drug testing (i.e., urine drug screening). ● The clinician is responsible for making themselves available or having a covering clinician available to care for unforeseen problems and to prescribe scheduled refills. (HHS, 2019a) Complete pain relief is often not achieved; a 30% reduction in pain is considered a good clinical response (Dowell et al., 2016). In a function-based treatment strategy for chronic pain, treatment efficacy is measured by the patient’s ability to achieve improved function rather than complete pain relief. These goals may include going to work, walking, achieving enhanced sleep, or improving social interactions. It may be beneficial to begin with more easily achievable goals and progress to more challenging ones after ini- tial successes. This approach can be much more motivating than a plan resulting in early treatment failure (HHS, 2019b). ing chronic pain treatment. For example, patients receiving other central nervous system depressants, especially benzodiazepines, require special attention because of an increased risk of adverse events, including increased sedation, confusion, difficulty driving or performing other tasks requiring high concentration levels, re- spiratory depression, and overdose. It is also necessary to assess how the patient uses work equipment that requires precise mo- tor control, heavy machinery, or chemical or biohazardous materi- als. Pregnant women also require an enhanced level of caution because chronic opioid use during pregnancy increases the risk of harm to the newborn, specifically neonatal opioid withdrawal syndrome. Further, these medications must be used cautiously in breastfeeding women because some opioids can be transferred
tions that could influence the decision to utilize opioid analgesics (AAFP, 2021). The assessment should include: ● Nature and intensity of pain. ● Past and current treatment regimens and responses, including adverse effects or reactions. ● How pain impacts physical and psychological function. ● How pain influences sleep, mood, work, relationships, leisure, and substance use. ● Identification of concurrent conditions that may increase the risk for adverse events (e.g., obesity, renal disease, sleep ap- nea, COPD). ● Review of current medications; identify interacting drugs and other CNS depressants. ● Social support, housing, employment, or recent military de- ployment.
Informed consent and treatment plans for chronic opioid treatment The patient-specific treatment plan should be developed and re - viewed regularly to ensure that both the clinician and patient agree on the goals of the therapy, treatment regimen, and options. Con- sider different treatment modalities, such as an interventional ap- proach, a formal pain rehabilitation program, physical medicine, psychological and behavioral strategies, or medications (nonopi- oids and opioids), depending upon the physical and psychosocial issues related to the pain. Opioid therapy is not the appropriate first-line treatment for most patients with chronic pain. It should be reserved for intractable chronic pain not adequately managed with more conservative or interventional methods. Other nonopi- oid medications, treatment modalities, and nonpharmacological therapy should be tried first. Practitioners should document the effectiveness or failure of these medications before initiating opi- oid therapy (CDC, 2022a; Dowell et al., 2016).
Suppose the prescriber determines that an opioid trial is an ap- propriate treatment option. In that case, the patient, caregiver(s), and family member(s) are informed of the risks and benefits of opioid analgesic therapy and the conditions under which the opi- oids are being prescribed. A trial implies that opioids are used for a short period (i.e., weeks or a couple of months), and continued use will be contingent upon demonstrated improvement in pain, physical function, and quality of life with no significant adverse reactions or aberrant behaviors (Kroenke et al., 2019). If the prescriber institutes long-term opioid therapy, a written informed consent and treatment agreement are recommended. The informed consent may address several issues, such as: ● Limited evidence of the benefit of opioids or other medica - tions in managing chronic pain (except for cancer). ● Potential risks and benefits of opioid therapy. ● Potential short- and long-term side effects of opioid therapy. ● The likelihood that tolerance to and physical dependence on the medication will develop. ● Risk of drug interactions and oversedation. ● Risk of impaired motor skills. ● Risk of substance abuse disorder, overdose, and death. ● The clinician’s prescribing policies (e.g., number and frequen- cy of refills, early refills, exceptions). Initiating opioid therapy for chronic noncancer pain When initiating opioid therapy for chronic pain, clinicians should start with immediate-release opioids and avoid extended- release formulations or long-acting opioids. Begin with the lowest effec- tive dosage. Evaluate patients within one to four weeks of start- ing opioid therapy or dose escalation. Clinicians should evaluate patients every three months to assess the continued benefit and the development of any adverse effects once the opioid dose is stabilized. If the patient no longer benefits from the opioid thera - py, the clinician should optimize the treatment regimen, including adding other treatment modalities or tapering off the opioid regi- men (CDC, 2022b). Some patient populations and patients with certain conditions re- quire closer monitoring and counseling before initiation and dur-
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